6.1 Introduction

The development process for this guideline has included explicit consideration of economic issues at each stage, as part of a pilot study being run by SIGN and the Scottish Health Economists' Network. This pilot study recognises that by taking account of the resource implications of guidelines the NHS can ensure that the quality of services is improved, while contributing to the goal of efficient use of scarce resources.

6.2 Methodology

The first stage of the process of incorporating economic considerations is to review the economics literature in addition to the clinical literature. Where high quality information is obtained from this review it is incorporated into the clinical recommendations. The second stage involves consideration of the economic implications of the guideline where no economic evaluations are available. This involves considering the following questions:

• Are the resource implications of implementation of the guideline likely to be significant
  nationally or locally, such that they cannot be absorbed within existing resource allocation?
• Will the guideline affect outcomes or resource use in other areas of the NHS (such as primary care, other clinical specialties, support departments)?
• Will the guideline affect outcomes or resource use in partner organisations (e.g. social work departments; the voluntary sector, etc.)?
• Will the guideline affect costs to patients, for example will they face additional visits to hospital/GP or have to spend longer in hospital?
• Will the guideline affect outcomes or resource use in future time periods?
• Will other groups benefit or be potentially disadvantaged by the recommendation / guideline?
• Are there disproportionate costs or outcomes for a particular group?

6.3 Results

The literature review found no high quality economic evaluations of the investigation of post-menopausal bleeding which could be used to inform the clinical recommendations. As a result, an economic analysis of the guideline was undertaken.

6.3.1 SIGNIFICANCE OF RESOURCE IMPLICATIONS?

What are the existing facilities for investigating PMB?

A telephone survey was undertaken of all 31 gynaecology and community gynaecology units in Scotland. Fourteen units have specialist clinics to which women with PMB can be referred. All but one unit have access to TVUS, although this did not necessarily mean that all women with PMB were referred for TVUS, nor that the service provision was adequate. In the unit where TVUS was not available on site, women could be referred to another hospital for TVUS. Outpatient hysteroscopy facilities are available in only 16 units in Scotland. Anonymised data for existing facilities for the investigation of PMB in gynaecology units within Scotland is available from the SIGN website.

There are, at present, no reliable data on the patterns of initial investigation for women with PMB referred to the above units. Data from a national audit of the care of endometrial cancer suggests that endometrial biopsy (Pipelle™ ), TVUS, hysteroscopy and D&C accounted for respectively 36%, 13%, 30% and 16% of initial investigations in 1996-7. Five percent of women received no investigation. These findings may not be representative of investigation of the current population of women presenting with PMB (most of whom will not have endometrial
cancer).

Will the number of women referred for investigation of post-menopausal bleeding change if the guideline is used?

At present there is no reliable estimate of the number of women referred each year for the investigation of post-menopausal bleeding. However, it is likely that the need for TVUS will increase overall if gynaecology units shift practice towards greater use of TVUS as recommended in this guideline. It is also likely that the number of women referred to secondary care will increase over the next few years as a result of demographic change and increased use of hormone replacement therapy.

Are additional facilities required?

If all women referred for post-menopausal bleeding were to receive TVUS with subsequent outpatient hysteroscopy for further investigation of those with positive findings, then there may be significant resource implications for the NHS, depending on the level and capacity of current provision. There may, however, be some saving in resource use (although this is unlikely to be reflected in financial savings because of the existence of fixed costs) associated with moving from current practice, as described above, to a policy of TVS and outpatient hysteroscopy. For example:

• In units which currently undertake TVUS on a routine basis and have access to outpatient hysteroscopy, there are unlikely to be significant resource implications, unless there is a significant increase in the number of women referred. This may require the purchasing of additional TVUS equipment and additional clinic slots
• In units currently offering TVUS, the threshold (cut-off point) for a 'positive' result influences the proportion of patients subsequently referred for further investigation. Therefore, any change in local policy towards the use of lower cut-off points will result in a greater number of
  patients being referred for further investigation. However, this cost may be offset by a potential reduction in cancers missed on initial investigation and reduced use of other first-line investigations
• The resource implications may be more significant for the one unit where TVUS is either not currently used or used for only a small number of patients. Additional resources required will include the purchase of ultrasound equipment and the provision of accommodation in which to undertake scanning and staff training.

Overall, it is likely that the recommendation of TVUS and outpatient hysteroscopy will have resource implications for each gynaecology unit in Scotland, but these will vary according to current provision of services, existing capacity and the existence of trained staff. This may be matched by a reduction in the use of other forms of investigation.

6.3.2 IMPACT ON OTHER AREAS OF THE NHS

It is unlikely that there will be a significant effect on other areas of the NHS in Scotland of implementing the guideline. Where the TVUS service is provided in the radiology department there may be an effect on waiting times for other radiological procedures.

6.3.3 IMPACT ON PARTNER ORGANISATIONS

It is unlikely that there will be significant impact of the guideline on partner organisations.

6.3.4 IMPACT ON PATIENT COSTS

There is unlikely to be a significant increase in the private costs faced by women under investigation for PMB and there may be a decrease if investigation is undertaken on an outpatient basis.

6.3.5 IMPACT OVER TIME

The guideline and increasing HRT use may result in more women being referred for investigation over time.

6.3.6 IMPACT ON OTHER GROUPS

If all women with PMB are referred then waiting list for other women to be seen may increase.