The cost-effectiveness of preference-based treatment allocation: the case of hysterectomy versus endometrial resection in the treatment of menorrhagia

Abstract

Typically, economic evaluation compares the costs and benefits of two or more interventions and seeks to identify the single superior option on the basis of relative cost-effectiveness. It is then anticipated that all patients will receive the more or most cost-effective option. This 'all or nothing' approach can be departed from when sub-groups of patient exist, defined on the basis of clinical or demographic characteristics which are considered to influence benefit, for whom an option is cost-effective whilst not being so for the population of patients as a whole. However, patients' preferences concerning the different process characteristics and outcomes of an intervention will also influence the benefit they derive from health care. This paper explores the concept of preference-based sub-group analysis in economic evaluation to assess the potential cost-effectiveness of using patients' preferences to determine treatment allocation. The clinical example used to explore these methods is the comparison of abdominal hysterectomy (AH) and transcervical resection of the endometrial (TCRE) for the treatment of menorrhagia.

"You can't always get what you want": from doctrine to practicability of study designs for clinical investigation in endometriosis

“…Whereas clinicians may be prone to recruit different types of women to the two study arms, allocation by the patients themselves should improve external validity. It has been suggested that preference-based treatment allocation may optimize cost-effectiveness of intervention [ 41 ], also because this research environment may be more similar to practical life conditions [ 33 ]. In case of functional outcomes, a comparison between two groups of participants who have chosen their treatment emphasizes patient satisfaction, thus representing the maximum possible effect size of the intervention [ 42 ].…”

Economic evaluation alongsiden-of-1 trials: getting closer to the margin

“…Sculpher investigated the application of individual health state valuations in women experiencing menorrhagia, and found that the objective of maximizing health gain was met most efficiently by the application of individualized cost-effectiveness analyses [8]. This study did not individualize costs and the health state valuations were collected prior to the women actually experiencing the symptoms.…”

“…Indeed, Sculpher's results indicated that treatment allocation by patient choice was potentially more cost-effective than allocation on an all-ornothing basis [8]. The improved understanding of the trade-offs between treatments informed by an involvement in n-of-1 trials could lead to more efficient allocation alone.…”

A survey of women's preferences regarding alternative surgical treatments for menorrhagia

“…Indeed, early modelling work has shown that allocating women with menorrhagia to a surgical treatment on the basis of their preferences has the potential to be more cost-eective than providing one treatment to all women. 19 Given the apparent inadequacy of existing information sources, it is perhaps not surprising that less than half the women in the survey had strong positive (43% overall) or negative (42%) preferences for speci®c treatments. These results are similar to Coulter et al's study, which found that 46% of women with menorrhagia consulting GPs had no positive treatment preference.…”