Savings with expanding use of the levonorgestrel intrauterine device and fewer benign hysterectomies

Daniel M. Morgan, Neil Kamdar, Dalton VK, Vanessa K. Dalton, Carolyn W. Swenson, Swenson CW, Michelle H. Moniz, Nallamothu B, Brahmajee K. Nallamothu
American journal of obstetrics and gynecology · 2018 · vol. 220(1) , pp. 116–118.e1 · doi:10.1016/j.ajog.2018.10.015 · PMID:30321528 · PMC6487885 · W2898025902
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Increasing levonorgestrel intrauterine device use correlated with decreased hysterectomies and endometrial ablations, resulting in an estimated $87 million in annual savings for commercially insured women aged 35-54.

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This retrospective cohort study used Health Care Cost Institute commercial claims data to examine women aged 35–54 from 2010–2014, assessing trends in levonorgestrel intrauterine device (LNG-IUD) insertions alongside utilization and spending for hysterectomy and endometrial ablation, and modeling cost-effectiveness. Annual LNG-IUD insertions increased while hysterectomies and endometrial ablations decreased, and the authors estimated that per 100 LNG-IUDs inserted there were 31.5 fewer hysterectomies and 45.3 fewer endometrial ablations, with overall spending savings of $87 million (−13.6%), with modeled cost-effectiveness if at least 61% avoided hysterectomy or ablation. A major limitation was inability to determine whether LNG-IUDs were inserted for contraception versus symptom control, and inability to track which women eventually underwent hysterectomy due to inadequate symptom control. Relevance to endometriosis: the introduction frames prior observed decreases in hysterectomy utilization for endometriosis (along with abnormal uterine bleeding and leiomyoma) during the same 2010–2013 period, though the analysis itself mainly tracks hysterectomy codes without definitively attributing outcomes to endometriosis.

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Study

This is a retrospective cohort analysis of women aged 35 to 54 with commercial insurance in the Health Care Cost Institute (HCCI)—an independent, non-profit research institute with claims data for over 50 million individuals nationwide. LNG-IUD insertion was identified with an ICD-9 procedure code for IUD insertion and a National Drug Code specific for an IUD containing levonorgestrel. Hysterectomies for bleeding and pain disorders were identified with ICD-9 procedure and diagnostic codes. Endometrial ablations were identified with ICD-9 procedure and Current Procedure Terminology codes. Quarterly utilization rates were adjusted for seasonal variation with autoregressive moving average modeling and for inflation with the medical consumer price index. Changes in utilization and spending for LNG-IUDs, hysterectomy, and endometrial ablation were assessed with generalized linear regression models. Change in number of hysterectomies and endometrial ablations per 100 LNG-IUD insertions was calculated. Cost effectiveness was modeled with a sensitivity analysis in which success rates for LNG-IUD in avoiding hysterectomy ranging from 50–100% were considered.

Results

Between 2010–2014, there were 6.82 and 6.48 million women aged 35 to 54 in the HCCI. Annual counts of LNG-IUD insertions increased (45,347 to 75,276) with concomitant decreases in hysterectomies (64,225 to 52,574) and endometrial ablations (33,435 to 18,575). Utilization rates and spending are illustrated in Figure 1 . Per 10,000 women, the annual utilization rate of LNG-IUD insertion increased from 16.8 to 28.0, while the rates for hysterectomy decreased from 23.7 to 19.9 and those for endometrial ablation decreased from 12.3 to 7.1. Annual spending for LNG-IUDs increased from $32 to $69 million; those for hysterectomy decreased from $500 million to $422 million; and those for endometrial ablation decreased from $111 million to $64 million. For every 100 LNG-IUDs inserted, there with 31.5 fewer hysterectomies and 45.3 fewer endometrial ablations with savings in spending of $87 million (−13.6%). A sensitivity analysis indicates cost effectiveness when hysterectomy and endometrial ablation are avoided in at least 61% of women ( Figure 2 ).

Objective

Due to the effectiveness of levonorgestrel intrauterine devices (LNG-IUDs) in managing menstrual bleeding and pelvic pain disorders, professional associations recommend their use before hysterectomy. 1 Among commercially insured women, we observed overall decreases in hysterectomy utilization of 9–17% for abnormal uterine bleeding, uterine leiomyoma, and endometriosis between 2010 and 2013. 2 We hypothesized that these decreases in hysterectomy utilization were associated with a concurrently increasing use of LNG-IUD and described financial implications of these changes.

Conclusion

Between 2010 and 2014, among commercially insured women who are 35–54 years old, there was an annual savings of $87 million related to increasing LNG-IUD use and decreasing use of hysterectomy and endometrial ablation. It is not possible to determine if a LNG-IUD was inserted for contraception, control of bleeding and pain, or both. Nonetheless, the medical and financial benefits of increasing LNG-IUD utilization are apparent. Fewer women resort to expensive, invasive treatment and savings are realized. We are unable to determine which women who received a LNG-IUD went on to hysterectomy due to inadequate symptom control. While this is a limitation of our analysis, there is evidence that spending related to hysterectomy and its complications are greater than those related to LNG-IUD use, even if hysterectomy is eventually needed. 3 In this population, assuming that all LNG-IUDs are inserted for menstrual disorders, LNG-IUDs are cost-effective if at least 61% are able to avoid hysterectomy or endometrial ablation.

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