The Cost of Screening for Synchronous Thyroid Disease in Patients Presenting With Primary Hyperparathyroidism

Abstract

To use decision analysis to compare the costs associated with minimally invasive parathyroidectomy (MIP) and bilateral neck exploration (BNE) in patients with primary hyperparathyroidism with regard to treatment of incidental synchronous thyroid disease. Design: We developed a decision tree model to evaluate the cost of managing thyroid pathology in primary hyperparathyroidism with the following 3 approaches: MIP, MIP with preoperative ultrasonography, and routine BNE with intraoperative thyroid evaluation. We tested the robustness of the optimal decision with sensitivity analyses. Setting: A tertiary care academic medical center. Main Outcome Measure: Total costs from a provider perspective. Results: Minimally invasive parathyroidectomy without an active search for thyroid abnormalities was determined to have the lowest expected cost ($5275 per patient). Parathyroid surgery with routine preoperative thyroid ultrasonography and further thyroid treatment as indicated had an expected cost of $5910 per patient. Bilateral neck exploration with intraoperative thyroid evaluation and treatment of the thyroid gland had an expected cost of $5916 per patient. Sensitivity analyses confirmed the robustness of the results across a reasonable range of surgical and imaging costs. Conclusions: Minimally invasive parathyroidectomy is not contraindicated on the basis of cost by an inability to screen for synchronous thyroid disease. In addition, ultrasonographic screening of the thyroid glands of patients undergoing MIP is not cost prohibitive and, in fact, is less costly than BNE. Ultrasonography has the added advantage of confirming the location of the offending parathyroid.

Preoperative Thyroid Ultrasound Is Indicated in Patients Undergoing Parathyroidectomy for Primary Hyperparathyroidism

“…8,12,13,14,15 More recent published studies report the coexistence of non-medullary thyroid cancer in 2-18% of patients operated on for pHPT. 5,8,16,17,18 Strichartz and Giuliano conducted a retrospective review of 308 patients who underwent an operation for hyperparathyroidism.…”

“…It has also been shown to be a cost-effective undertaking when utilized in conjunction with MIPS. 13 With these points in mind, the debate about the nature and extent of treatment for isolated well-differentiated thyroid carcinoma is entertained in an entirely different context when considered in combination with pHPT requiring surgical treatment. In line with national endocrine disease treatment center practice patterns, our adoption of MIPS for pHPT attributable to a localizing adenoma precludes exploration of the entire neck and careful examination of the thyroid gland at time of operation.…”

Preoperative Thyroid Ultrasound In All Patients Undergoing Parathyroidectomy?

“…Others have also shown that the use of ultrasound in conjunction with MIPS is not a cost prohibitive endeavor [19]. With these points in mind, the debate about the nature and extent of treatment for isolated papillary thyroid microcarcinoma takes on a different perspective when discussed in combination with pHPT requiring surgical treatment.…”

Preoperative imaging for parathyroid localization in patients with concurrent thyroid disease: A systematic review

“…Combining ultrasound with MIBI was also noted by Arciero et al to be cost‐effective when combined with minimally invasive parathyroidectomy. Furthermore, 2 recent cost analyses supported combined imaging for localization, as this decreased the rate of conversion to bilateral neck exploration, and was the most cost‐effective option overall …”