Objective: To determine whether advanced imaging is cost-effective compared to primary bilateral neck exploration in the management of non-localizing primary hyperparathyroidism. Study Design: Cost-effectiveness analysis. Methods: Cost-effectiveness analysis based on decision tree model and available Medicare financial data using data from 347 consecutive patients having parathyroidectomy for primary hyperparathyroidism with either 1) positive, concordant ultrasound and sestamibi or 2) negative sestamibi and negative ultrasound. Results: Bilateral neck exploration (BNE) costs $9578 and has a success rate of 97.3%. Single photon emission computed tomography (SPECT) + minimally invasive parathyroidectomy (MIP) was modeled to have a total cost of $8197 with a success rate of 98.6%. SPECT/computed tomography (CT) + MIP was modeled to have a total cost of $8271 and a 98.9% success rate. Four-dimensional (4D)-CT + MIP was modeled to cost $8146 with a success rate of 99%. Incremental cost-effectiveness ratios (IECR) (as compared to BNE) were −536.1, −605.5, and −701.6 ($/percent cure rate) for SPECT, SPECT/CT, and 4D-CT respectively. One-way sensitivity analyses demonstrate the change in IECR and cutoff points (IECR = 0) for four major variables. Conclusions: In patients with non-localizing primary hyperparathyroidism, advanced imaging is associated with costsavings compared to routine bilateral neck exploration. Increased cost-savings were predicted with increased imaging accuracy and decreased imaging costs. Increasing time for BNE or decreasing time for MIP were associated with increased cost savings.

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