The impact of perioperative diagnostic tools on clinical outcomes and cost-effectiveness in parathyroid surgery: a health economic evaluation

Abstract

ObjectivesPre- and intraoperative diagnostic tools influence the surgical management of primary hyperparathyroidism (PHPT), whereby their performance of classification varies considerably for the two common causes of PHPT: solitary adenomas and multiglandular disease. A consensus on the use of such diagnostic tools for optimal perioperative management of all PHPT patients has not been reached.DesignA decision tree model was constructed to estimate and compare the clinical outcomes and the cost-effectiveness of preoperative imaging modalities and intraoperative parathyroid hormone (ioPTH) monitoring criteria in a 14-year time horizon. The robustness of the model was assessed by conducting a one-way sensitivity analysis and probabilistic uncertainty analysis.SettingThe United States healthcare system.PopulationA hypothetical population consisting of 5,000 patients with sporadic, symptomatic, or asymptomatic PHPT.InterventionsPre- and intraoperative diagnostic modalities for parathyroidectomyMain outcome measuresCosts, quality-adjusted life years (QALYs), net monetary benefits (NMB), clinical outcomesResultsIn the base-case analysis, four-dimensional (4D)-computed tomography (CT) was the least expensive strategy with $10,289 and 13.93 QALYs. Ultrasound and99mTc-Sestamibi single-photon-emission computed tomography/CT were both dominated strategies, while18F-fluorocholine positron emission tomography was cost-effective with a net monetary benefit of $264 considering a willingness to pay threshold of $95,958. The application of ioPTH monitoring with the Vienna criterion decreased the rate of reoperations from 10.50 to 0.58 per 1,000 patients. Due to an increased rate of bilateral neck explorations from 257.45 to 347.45 per 1,000 patients, it was not cost-effective.Conclusions4D-CT is the most cost-effective instrument for the preoperative localization of parathyroid adenomas. Due to an excessive increase of bilateral neck explorations, the use of ioPTH monitoring is not cost-effective in PHPT but leads to a significant reduction of reoperations.Strengths and limitations of the studyOur decision tree model is the most complete for parathyroidectomy; incorporating both solitary adenomas and multiglandular disease and ioPTH monitoring.In addition to cost-effectiveness, we present the impact of the interventions on the major clinical outcomes.Our study is limited to the United States and does not include a societal perspective.The model did not consider the potential institutional variations in the prevelance of multiglandular diseaseThere remains uncertainty for certain parameters for the model as they were derived from a limited number of single-institution studies