Cost-effectiveness of saline-assisted hysterosonography and office hysteroscopy in the evaluation of postmenopausal bleeding: A decision analysis

Rationale and Objectives. The authors performed this study to evaluate whether hysterosonography (HSG) is a more cost-effective initial diagnostic examination than office hysteroscopy in the evaluation of postmenopausal bleeding (PMB). Materials and Methods. A computer model simulated the diagnosis and treatment of PMB in otherwise healthy women. The hypothetical patient who had one episode of PMB precipitating a clinic visit would undergo either HSG or office hysteroscopy as the initial examination. Algorithms were designed such that a finite number of false-negative and false-positive findings would be expected, and clinical decision making would rely on the reported results. Performance characteristics for diagnostic tests and other clinical probabilities were taken from the literature. Costs were based on actual 1997 Medicare reimbursements. The primary clinical outcome considered was the correct diagnosis of any anatomic abnormality that was amenable to definitive treatment. The primary cost outcome considered was the cost per abnormality detected. Sensitivity analysis was performed to examine the effect of varying performance characteristics for diagnostic techniques. Results. HSG and office hysteroscopy correctly depicted 68.1 and 67.6 anatomic abnormalities per 100 patients, respectively. The average cost per abnormality detected was $7,978 with HSG and $8,400 with office hysteroscopy. Conclusion. HSG depicted more abnormalities at a lower cost per abnormality, which suggests that it should be the preferred initial diagnostic examination in the setting of PMB.