Quantifying diagnostic and etiologic management costs of perimenopausal abnormal uterine bleeding and postmenopausal bleeding

Objectives: The evaluation of perimenopausal AUB and PMB for underlying neoplasia is not standardized and can vary widely among patients. Similarly, costs for workup and management of underlying cause may vary. This study aimed to quantify costs of perimenopausal AUB/PMB evaluation and treatment according to ultimate tissue-based diagnosis. Methods: Women ≥45 years of age presenting to a single institution gynecology clinic with abnormal uterine bleeding (AUB) or postmenopausal bleeding (PMB) for an office endometrial biopsy were prospectively enrolled from February 2013 to October 2018 for a lower genital tract biospecimen research study. Clinical workup of their AUB or PMB was per provider discretion. CPT and ICD-10 codes were abstracted retrospectively at a minimum of 90 days post enrollment. Medicare reimbursement rates were assigned to all professional billed services to estimate standardized costs with inflation adjustment to 2017 dollars. The study cohort was stratified based on final diagnosis as endometrial cancer (EC), atypical hyperplasia (AH), hyperplasia without atypia, polyp, benign or disordered proliferative endometrium (DPE), no biopsy preformed, and inadequate biopsy. Only disease related costs were considered in the analysis. Descriptive statistics of cost at 7 day, 30 day, and 90 day follow up timeframes were completed for each diagnosis. Results: In total, there were 1017 women included with 5.6% diagnosed with AH or EC. The patient demographics included mean age 55.2 years (standard deviation (SD) 7.9), mean body mass index (BMI) 30.3 (SD 8.0), 431 (42.4%) BMI greater than or equal to 30, 541 (53.2%) postmenopausal, 161 (15.8%) nulliparous, 253 (24.9%) with hypertensive disease, 73 (7.2%) with diabetes mellitus, and 212 (20.9%) with history of hormone replacement therapy or tamoxifen use. Within the full cohort, costs for perimenopausal AUB/PMB workup and management were as follows: 7 day median $628 (interquartile range (IQR) $333-2,298), 30 day median $1,959 (IQR $431-3,653), and 90 day median $2,279 (IQR $512-4,828). Among patients with a diagnostic biopsy, median 90 day costs ranged from $2,203 (IQR $499-3604) for benign/DPE diagnosis to $21,039 (IQR $19,084-24,536) for a diagnosis of EC. Among women with a non-diagnostic office-based endometrial biopsy, the median 90 day cost was $2205 (IQR $424-2972). Table 1 details 7-day, 30-day, and 90-day costs per office-based tissue diagnosis. Conclusions: The costs for diagnostic evaluation and management of perimenopausal AUB and PMB vary greatly according to ultimate tissue diagnosis. Even reassuring benign findings that do not require further intervention-the most common in this study's cohort-yield substantial costs. The development of sensitive, specific, and more cost effective diagnostic strategies is warranted. The evaluation of perimenopausal AUB and PMB for underlying neoplasia is not standardized and can vary widely among patients. Similarly, costs for workup and management of underlying cause may vary. This study aimed to quantify costs of perimenopausal AUB/PMB evaluation and treatment according to ultimate tissue-based diagnosis. Women ≥45 years of age presenting to a single institution gynecology clinic with abnormal uterine bleeding (AUB) or postmenopausal bleeding (PMB) for an office endometrial biopsy were prospectively enrolled from February 2013 to October 2018 for a lower genital tract biospecimen research study. Clinical workup of their AUB or PMB was per provider discretion. CPT and ICD-10 codes were abstracted retrospectively at a minimum of 90 days post enrollment. Medicare reimbursement rates were assigned to all professional billed services to estimate standardized costs with inflation adjustment to 2017 dollars. The study cohort was stratified based on final diagnosis as endometrial cancer (EC), atypical hyperplasia (AH), hyperplasia without atypia, polyp, benign or disordered proliferative endometrium (DPE), no biopsy preformed, and inadequate biopsy. Only disease related costs were considered in the analysis. Descriptive statistics of cost at 7 day, 30 day, and 90 day follow up timeframes were completed for each diagnosis. In total, there were 1017 women included with 5.6% diagnosed with AH or EC. The patient demographics included mean age 55.2 years (standard deviation (SD) 7.9), mean body mass index (BMI) 30.3 (SD 8.0), 431 (42.4%) BMI greater than or equal to 30, 541 (53.2%) postmenopausal, 161 (15.8%) nulliparous, 253 (24.9%) with hypertensive disease, 73 (7.2%) with diabetes mellitus, and 212 (20.9%) with history of hormone replacement therapy or tamoxifen use. Within the full cohort, costs for perimenopausal AUB/PMB workup and management were as follows: 7 day median $628 (interquartile range (IQR) $333-2,298), 30 day median $1,959 (IQR $431-3,653), and 90 day median $2,279 (IQR $512-4,828). Among patients with a diagnostic biopsy, median 90 day costs ranged from $2,203 (IQR $499-3604) for benign/DPE diagnosis to $21,039 (IQR $19,084-24,536) for a diagnosis of EC. Among women with a non-diagnostic office-based endometrial biopsy, the median 90 day cost was $2205 (IQR $424-2972). Table 1 details 7-day, 30-day, and 90-day costs per office-based tissue diagnosis. The costs for diagnostic evaluation and management of perimenopausal AUB and PMB vary greatly according to ultimate tissue diagnosis. Even reassuring benign findings that do not require further intervention-the most common in this study's cohort-yield substantial costs. The development of sensitive, specific, and more cost effective diagnostic strategies is warranted.