Medverd Jonathan R, Dubinsky Theodore J
Department of Radiology, University of Washington, Seattle, 98104-2499, USA.
Radiology. 2002 Mar;222(3):619-27. doi: 10.1148/radiol.2223001822.
To develop a cost minimization analysis model from the societal perspective of Medicare reimbursement to determine whether endometrial biopsy or transvaginal ultrasonography (US) is less expensive in evaluating peri- and postmenopausal women with abnormal vaginal bleeding and to assess whether this strategy is equally effective in populations at low and high risk for endometrial carcinoma.
Clinical algorithms were constructed that detailed diagnostic evaluation of the target population by using office-based endometrial biopsy versus transvaginal US as starting points. An economic model based on Medicare reimbursement and average wholesale drug price data and using disease prevalences and modality sensitivities from the scientific literature was then created to examine common bleeding causes in this population. All models included the cost of obtaining a tissue diagnosis for focal or diffuse endometrial thickening found at US. Modality sensitivities and prevalences of disease states were varied within the model to discover limits at which each modality became cheaper versus the other for assessing a population of women.
Population prevalence of neoplastic disease is the principal factor governing total cost between competing diagnostic algorithms. In populations with 31% or less combined prevalence of endometrial carcinoma/atypical adenomatous hyperplasia, algorithms utilizing transvaginal US as the initial test are most cost minimizing. At combined endometrial carcinoma/atypical adenomatous hyperplasia prevalence of 10%, savings of up to 11% and 16% over pathways initiated with endometrial biopsy are predicted. In populations with a high incidence of neoplastic disease (>31%), biopsy-based algorithms should become least costly.
Transvaginal US-initiated triage predicts substantial cost savings versus biopsy-based algorithms in evaluating typical populations of peri- and postmenopausal women with abnormal vaginal bleeding seen in clinical practice.
从医疗保险报销的社会角度开发一种成本最小化分析模型，以确定子宫内膜活检或经阴道超声检查（US）在评估有异常阴道出血的围绝经期和绝经后妇女时成本更低，并评估该策略在子宫内膜癌低风险和高风险人群中是否同样有效。
构建临床算法，详细说明以门诊子宫内膜活检与经阴道超声检查为起点对目标人群进行诊断评估的过程。然后创建一个基于医疗保险报销和平均批发药品价格数据，并使用科学文献中的疾病患病率和检查方式敏感性的经济模型，以研究该人群常见的出血原因。所有模型都包括对超声检查发现的局灶性或弥漫性子宫内膜增厚进行组织诊断的成本。在模型中改变检查方式的敏感性和疾病状态的患病率，以发现每种检查方式在评估女性人群时比另一种检查方式更便宜的界限。
肿瘤性疾病的人群患病率是决定竞争性诊断算法总成本的主要因素。在内膜癌/非典型腺瘤样增生合并患病率为31%或更低的人群中，以经阴道超声检查作为初始检查的算法成本最小化程度最高。在内膜癌/非典型腺瘤样增生合并患病率为10%时，预计比以子宫内膜活检为起始的检查路径节省高达11%和16%的成本。在肿瘤性疾病发病率高（>31%）的人群中，以活检为基础的算法成本应最低。
在评估临床实践中常见的有异常阴道出血的围绝经期和绝经后女性典型人群时，经阴道超声检查启动的分诊预计比基于活检的算法可大幅节省成本。
