تجزیه و تحلیل به حداقل رساندن هزینه فرسایش حرارتی های آندومتر در طول روز و یابه صورت سرپایی تحت رژیم های مختلف بیهوشی

Objective To evaluate the cost difference between a daycase endometrial thermal ablation performed under general anaesthesia and an outpatient endometrial ablation using local anaesthetic. Study design Calculations using real reported resource use in 20 daycase procedures and 16 outpatient procedures. Results The costs were 1865 euros for daycase procedure versus 1065 euros for outpatient procedure. Conclusion The cost of endometrial thermal ablation can be considerably minimised by taking the procedure out of the theatre and performing it under local anaesthetic instead of general anaesthesia. This setting makes endometrial thermal ablation cost-effective.

Heavy menstrual bleeding occurs in 25% of women [1] and in addition to the health problem, it consumes substantial health service resources. Hysterectomy is the final surgical treatment but it is associated with significant morbidity and expense. The levonorgestrel-releasing intrauterine system (LNG-IUS) is usually the first-line treatment in Finland, and it has been proved to be effective in avoiding hysterectomy at least in a short one-year follow-up [2]. Some women, however, do not prefer it for personal reasons, and some women experience adverse effects, including progestogenic side effects, which cause discontinuation rates up to 50% at 5 years [3] and [4]. Eventually after 5 years up to 42% of the women treated with the LNG-IUS end up with a hysterectomy [5]. Second-generation endometrial ablation devices provide endometrial destruction techniques which do not require hysteroscopy. They seem to be as effective as the LNG-IUS in controlling heavy menstrual bleeding [6] and [7], and are less costly than hysterectomy even when performed after failed treatment with the LNG-IUS [8] and [9]. There seem to be only slight or no differences between most second-generation devices in efficacy or cost-effectiveness [10] and [11], but there is a trend towards bipolar radiofrequency ablation having better response rates than balloon ablation [12]. Endometrial ablation has traditionally been performed as a day case procedure under general anaesthesia. With modern devices, which have shorter treatment times, it has become safe and well-accepted to perform the procedure under local anaesthesia [13], [14], [15], [16], [17], [18] and [19]. The ability to perform endometrial thermal ablation using local anaesthesia raises the possibility of moving the procedure into the outpatient environment, and thus decreasing the amount and the cost of hospital resources used. An outpatient procedure is associated with more rapid discharge and the patient feels well straight after treatment, which are important factors to the majority of women [20], [21] and [22]. When endometrial ablation is performed in an operating theatre, there are only minimal cost savings for the patient or health service from using local rather than general anaesthesia [23]. The aim of the present study was to evaluate the cost of a day case procedure performed under general anaesthesia in the operating theatre and an outpatient procedure performed using local anaesthesia. The selected economic evaluation method is cost-minimisation analysis, because the health outcomes of the compared alternatives are the same, and the cost-effective treatment option can be found by comparing the costs of the treatment alternatives.

This study demonstrates that endometrial thermal ablation performed as an outpatient procedure under local anaesthesia instead of a daycase procedure under general anaesthesia results in significantly reduced health service costs. The outpatient procedure was 800 euros cheaper than the daycase procedure for the health service provider. The difference is caused by lower costs of the hospital ward and anaesthesia, and partly by overhead costs. The outpatient procedure in the Finnish context is also cheaper for the patient. The day case price for patients is 83.90 euros versus an outpatient fee of 25.60 euros. This, however, cannot be used as an argument for the cost-effectiveness of the outpatient procedure, because the prices patients pay do not reflect the actual resource cost of the procedures. The alternative treatment option for endometrial thermal ablation after unsuccessful LNG-IUS treatment for menorrhagia is hysterectomy. The mode of operation in these cases is usually laparoscopic hysterectomy, because these patients have an anatomically normal uterus and no other indications, like prolapse, for hysterectomy. Costs of performing endometrial thermal ablation in theatre under general anaesthesia approach the costs of laparoscopic hysterectomy, but the risks of complications are less and sick leave is shorter in endometrial ablation (two days) than in laparoscopic hysterectomy (2–3 weeks). The main reason a woman chooses endometrial ablation over hysterectomy is that she prefers a minimally invasive intervention with a short hospital stay [24]. Because endometrial ablation is a very safe procedure with practically no risk of severe complications, it is possible to take the procedure out of the operating theatre. Choosing paracervical block over general anaesthesia is related to high tolerability and high patient satisfaction and leads to a shorter hospital stay, and paracervical block also decreases postoperative pain due to uterine contractions. Paracervical block does not seem to increase the time spent in the procedure. The limitation of this study is small number of cases, but endometrial thermal ablation with a second generation device is a highly repeatable procedure with a short learning curve, because it does not require hysteroscopy or great technical skills. The actual operating time is always the same, and it does not vary due to patient- or operator-related factors. The strength of this study is that it is based on real reported resource use, not a model. Earlier it has been shown that the mode of anaesthesia does not affect the costs of endometrial ablation very much [23], but that is the case when the procedure is performed in a theatre setting. While it is known that endometrial thermal ablation is effective, with at least 85% of women avoiding hysterectomy, and performing the procedure under local anaesthesia is highly acceptable, the fact that taking the procedure out of the operating theatre significantly reduces the costs makes endometrial thermal ablation also cost-effective.