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

Daniel Batora, Rowan Iskandar, Juerg Gertsch, Reto M. Kaderli
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Abstract

Objectives Pre- 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. Design A 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. Setting The United States healthcare system. Population A hypothetical population consisting of 5,000 patients with sporadic, symptomatic, or asymptomatic PHPT. Interventions Pre- and intraoperative diagnostic modalities for parathyroidectomy. Main outcome measures Costs, quality-adjusted life years (QALYs), net monetary benefits (NMB), clinical outcomes. Results In the base-case analysis, four-dimensional (4D)-computed tomography (CT) was the least expensive strategy with $10,289 and 13.93 QALYs. Ultrasound and 99mTc-Sestamibi single-photon-emission computed tomography/CT were both dominated strategies, while 18F-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. Conclusions 4D-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.
甲状旁腺手术围手术期诊断工具对临床结果和成本效益的影响:一项健康经济学评估
目的术前和术中诊断工具影响原发性甲状旁腺功能亢进(PHPT)的手术治疗,因此它们对两种常见病因PHPT的分类表现差异很大:单发腺瘤和多腺疾病。对于使用这些诊断工具对所有PHPT患者进行最佳围手术期管理尚未达成共识。设计构建决策树模型来评估和比较14年时间范围内术前影像学方式和术中甲状旁腺激素(ioPTH)监测标准的临床结果和成本-效果。通过进行单向敏感性分析和概率不确定性分析来评估模型的稳健性。美国的医疗体系。人群由5000名散发的、有症状的或无症状的PHPT患者组成的假设人群。甲状旁腺切除术的介入和术中诊断方式。主要结果测量:成本、质量调整生命年(QALYs)、净货币效益(NMB)、临床结果。结果在基本病例分析中,四维(4D)计算机断层扫描(CT)是最便宜的策略,为10,289美元和13.93 qaly。超声和99mTc-Sestamibi单光子发射计算机断层扫描/CT都是主要的策略,而18f -氟胆碱正电子发射断层扫描具有成本效益,考虑到愿意支付95,958美元的门槛,净货币效益为264美元。采用维也纳标准的ioPTH监测将再手术率从每1000例10.50例降低到0.58例。由于双侧颈部探查率从每1000例患者257.45例增加到347.45例,因此不具有成本效益。结论4d - ct是甲状旁腺瘤术前定位最有效的工具。由于双侧颈部探查的过度增加,在PHPT中使用ioPTH监测并不具有成本效益,但可显著减少再手术。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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