The Value of Intraoperative Parathyroid Hormone Monitoring in Localized Primary Hyperparathyroidism: A Cost Analysis

Abstract

BackgroundMinimally invasive parathyroidectomy (MIP) is the preferred approach to primary hyperparathyroidism (PHPT) when a single adenoma can be localized preoperatively. The added value of intraoperative parathyroid hormone (IOPTH) monitoring remains debated because its ability to prevent failed parathyroidectomy due to unrecognized multiple gland disease (MGD) must be balanced against assay-related costs. We used a decision tree and cost analysis model to examine IOPTH monitoring in localized PHPT.MethodsLiterature review identified 17 studies involving 4,280 unique patients, permitting estimation of base case costs and probabilities. Sensitivity analyses were performed to evaluate the uncertainty of the assumptions associated with IOPTH monitoring and surgical outcomes. IOPTH cost, MGD rate, and reoperation cost were varied to evaluate potential cost savings from IOPTH.ResultsThe base case assumption was that in well-localized PHPT, IOPTH monitoring would increase the success rate of MIP from 96.3 to 98.8%. The cost of IOPTH varied with operating room time used. IOPTH reduced overall treatment costs only when total assay-related costs fell below $110 per case. Inaccurate localization and high reoperation cost both independently increased the value of IOPTH monitoring. The IOPTH strategy was cost saving when the rate of unrecognized MGD exceeded 6% or if the cost of reoperation exceeded $12,000 (compared with initial MIP cost of $3733). Setting the positive predictive value of IOPTH at 100% and reducing the false-negative rate to 0% did not substantially alter these findings.ConclusionsInstitution-specific factors influence the value of IOPTH. In this model, IOPTH increased the cure rate marginally while incurring approximately 4% additional cost.

Imaging diagnostics for primary hyperparathyroidism

“…A bilateral exploration takes usually 109.3 ± 29 min., and a unilateral 49.29 min. [17][18][19][20].…”

The use of intraoperative parathyroid hormone monitoring in minimally invasive parathyroid surgery

“…7 In the UK, the number of centres offering MIP remains suboptimal, mainly as a result of costs and limited availability of IOPTH testing. 8 In the presence of concordant radiology (ultrasonography and sestamibi imaging), intraoperative frozen section and expert clinical opinion, some surgeons argue that IOPTH monitoring is unnecessary. The aim of this study was to identify whether the measurement of IOPTH in patients having MIP for pHPT alters their management.…”

“…It is claimed that IOPTH testing has avoided failure during MIP from missed multiglandular disease. 8,12 A prospective study with a cohort of 350 patients who underwent MIP based on concordant neck ultrasonography and sestamibi imaging observed that only 79% of patients were identified correctly as having single gland disease without IOPTH monitoring. 12 Further exploration showed that 15% of patients had multiglandular disease.…”

“…Currently, in the UK, the number of centres offering MIP remains suboptimal; this is mainly because of the costs and the limited availability of IOPTH testing. 8 Elimination of IOPTH measurement from the management of patients with pHPT could help increase the use of the MIP and the range of benefits it provides.…”

Intraoperative parathyroid hormone assay during surgery for secondary hyperparathyroidism: is it time to give up the chase at the hormone?

“…In fact, the method had an acceptable certainty of confirming in most patients that all of the hyperfunctioning parathyroid tissue in the neck had been removed, to the extent of defining it as a ''biochemical frozen section.'' Some of the limits of the technique became evident quite soon, because a limited but significant number of false-positive and false-negative results seemed to be unavoidable in every series that was reported, adding some uncertainty about the real effectiveness of the tool [2].…”