Is Less More? A Microsimulation Model Comparing Cost-effectiveness of the Revised American Thyroid Association's 2015 to 2009 Guidelines for the Management of Patients With Thyroid Nodules and Differentiated Thyroid Cancer

Abstract

Objective: To assess relative clinical and economic performance of the revised American Thyroid Association (ATA) thyroid cancer guidelines compared to current standard of care. Background: Diagnosis of thyroid cancer in the United States has tripled whereas mortality has only marginally increased. Most patients present with small papillary carcinomas and have historically received at least a total thyroidectomy as a treatment. In 2015, the ATA released the revised guidelines recommending an option for active surveillance (AS) of small papillary thyroid carcinoma and thyroid lobectomy for larger unifocal tumors. Methods: We created a Markov microsimulation model to evaluate the performance of the ATA's 2015 guidelines compared to the ATA's 2009 guidelines. We modeled a cohort of simulated patients with demographic and thyroid nodule characteristics representative of those presenting clinically in the United States. Outcome measures include life expectancy, quality-adjusted life years, costs, and frequency of surgical adverse events. Results: In our base case analysis, the ATA 2015 strategy dominates the ATA 2009 strategy. The ATA 2015 strategy delivers greater discounted average quality-adjusted life years (13.09 vs 12.43) at a lower discounted average cost ($14,752 vs $20,126). Deaths due to thyroid cancer under the 2015 strategy are higher than the 2009 strategy but this is offset by a reduction in surgical deaths, leading to greater average life expectancy under the ATA 2015 strategy. The optimal strategy is sensitive to patients who experience a greater decrement in quality of life while undergoing AS. Conclusions: The ATA 2015 Guidelines represent a cost-effective strategy regarding AS and extent of surgery.

American Association of Clinical Endocrinology And Associazione Medici Endocrinologi Thyroid Nodule Algorithmic Tool

“…In the United States, well over 500 000 fine-needle aspirations (FNAs) of thyroid nodules are performed per year, with as many as 200 000 of them being unnecessary. 3 Similarly, in European countries, such as Germany and France, with well-functioning National Health Services, the vast majority of thyroidectomies performed for nodular thyroid disease have benign histopathology, 4,5 while the minority that proves to be malignant is predominantly composed of low-risk thyroid cancers. 6,7 Guidelines from the American Association of Clinical Endocrinology (AACE), Associazione Medici Endocrinologi (AME), American Thyroid Association (ATA), and American College of Radiology 8e10 provide recommendations for reducing the collective burden of evaluating and treating thyroid nodules and lowrisk thyroid cancers.…”

Cost-Effectiveness Analysis of Active Surveillance Compared to Early Surgery in Small Papillary Thyroid Cancer: A Systemic Review

“… Notes : a White et al 24 estimated disutility and summed it into the patient’s total lifetime utility score. Abbreviations : RLN, recurrent laryngeal nerve; FNA, fine needle aspiration; RAI, radioactive iodine; LND, lymph node dissection; TT, total thyroidectomy.…”

Differentiated Thyroid Cancer: A Health Economic Review

“…Cost of care tends to not be considered at all or to be an afterthought years after the implementation. A recent study used a microsimulation model to compare the cost-effectiveness of the revised 2015 ATA guidelines to the 2009 guidelines [ 99 ]. One of the aims of these revised guidelines was to reduce the number of total thyroidectomies and surgical complications and, therefore, potentially cost.…”

“…One of the aims of these revised guidelines was to reduce the number of total thyroidectomies and surgical complications and, therefore, potentially cost. The study illustrates that the ATA 2015 guideline patient generated greater average QALYs (13.09 vs 12.43) at a lower average cost per patient (£10,612 vs £14,386) [ 99 ].…”