Surgery versus medical follow-up in patients with asymptomatic primary hyperparathyroidism: a decision analysis

Abstract

Objectives: To examine the cost-effectiveness of strategies for management of primary asymptomatic hyperparathyroidism: surgical strategies and medical follow-up versus surgery. Design: We used a Markov state-transition decision-analytic model for an hypothetical cohort of 55-year-old women to compare with a lifetime horizon costs and effectiveness of bilateral neck exploration (BNE), unilateral neck exploration (UNE), video-assisted parathyroidectomy (VAP) and lifelong medical follow-up shifting for either BNE or UNE in case of disease progression. Methods: Data on localization tests, complications and treatment efficacies were derived from a systematic review of the literature. Outcomes were expressed as quality-adjusted life years (QALY). Costs (€2002) discounted at 3% yearly were estimated from the health care system perspective. Results: In the base-case analysis, VAP strategy (VAPS) was the most effective and BNE strategy (BNES) was the least costly. UNE strategy (UNES) had an incremental cost-effectiveness ratio of €2688/QALY versus BNES and VAPS of €17 250/QALY in comparison with UNES. Surgical management was more effective than medical follow-up with acceptable incremental cost-effectiveness ratios. VAPS became less effective than UNES over 71 years. Differences between UNES and VAPS were sensitive to success and complication rates, quality-of-life weights and procedural costs. Medical follow-up strategies became the most effective if quality-of-life weight for this condition was higher than 0.99. Conclusions: Surgery is more effective than medical follow-up at a reasonable cost and can be preferred except in patients choosing medical follow-up. Minimally invasive surgery is cost-effective compared to the traditional surgical approach.

Cost-effectiveness of scan-directed parathyroidectomy

“…Similar financial benefits were highlighted in the analysis of the first 100 consecutive MIP performed by same authors, in which the mean hospital charge for MIP was less than 40% of that associated with traditional exploration [11]. In an analytic model comparing the cost of different strategies of management for asymptomatic PHPT in France, it was estimated that scan-directed unilateral neck exploration would cost 3,766€ while BNE without would cost 3,537€, with the incremental costs for quality-adjusted life expectancy in favour of minimally invasive surgery [22]. In contrast with these studies, we found that the expense of radiological tests was not off-set by the savings on the length of hospital admission.…”

Is surgery necessary for ‘mild’ or ‘asymptomatic’ hyperparathyroidism?

“…A targeted approach is more cost-effective compared to traditional surgical bilateral exploration (17).…”

“…In France, it was shown that the cost of surgery and of monitoring are nearly equal, but the costeffectiveness ratio tends to favor surgery for patients between the ages of 40 and 80 years (17). In the USA, the cost of surgery is also somewhat high, but the surgery was slightly more effective.…”

Faut-il opérer une hyperparathyroïdie primaire asymptomatique ?

“…Cette question n'est pas que théorique puisque 30 à 80 % des patients sont actuellement considérés comme ayant une HPT « asymptomatique ». La recherche bibliographique dans les bases de données factuelles a permis de retrouver outre les études épidémiologiques, deux études randomisées [7,8], 12 études prospectives [1,[9][10][11][12][13][14][15][16][17][18][19] et deux étu-des coût-efficacité [20,21].…”

“…Deux études coût-efficacité très récentes ont évalué les résultats de la stratégie chirurgicale versus surveillance pour les patients asymptomatiques (et n'ayant aucun critères du NIH) [20,21]. La première conclut que la chirurgie est plus efficace que la surveillance médicale sauf si les patients n'attachent pas de diminution de qualité de vie au fait d'être surveillé [20].…”