Kyle Zanocco

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

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

How should age at diagnosis impact treatment strategy in asymptomatic primary hyperparathyroidism? A cost-effectiveness analysis.

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

A Cost-efficacy Decision Analysis of Prophylactic Clip Placement After Endoscopic Removal of Large Polyps

12,000 (compared with initial MIP cost of

Cost-effectiveness analysis of repeat fine-needle aspiration for thyroid biopsies read as atypia of undetermined significance

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.

Cost Effectiveness of Intraoperative Pathology Examination during Diagnostic Hemithyroidectomy for Unilateral Follicular Thyroid Neoplasms

BACKGROUND The National Institutes of Health consensus conference on asymptomatic primary hyperparathyroidism (PHPT) recommended several criteria for parathyroidectomy (PTX), including age <50 years. We hypothesized that a cost-effectiveness analysis would show PTX to be the optimal strategy for asymptomatic patients >50 years of age. METHODS A Markov model was constructed comparing operative, observational, and pharmacologic treatments. Costs were estimated from a third-party payer perspective. Outcomes were weighted with utility adjustment factors, yielding quality-adjusted life-years (QALYs). Future costs and QALYs were discounted at 3%. Threshold analysis identified the optimal strategy at life expectancies ranging from 6 months to 75 years. Multivariate sensitivity analysis was completed with Monte Carlo simulation. RESULTS PTX was optimal when life expectancy reached 5 years for outpatient PTX and 6.5 years for inpatient PTX. Observation was the optimal strategy at all shorter life expectancies considered. The pharmacologic treatment strategy was not optimal at any life expectancy. CONCLUSION PTX is the optimal strategy for many patients with asymptomatic PHPT who are >50 years of age. PTX is cost effective for patients with a predicted life expectancy of 5 years (outpatient) or 6.5 years (inpatient). For patients with a shorter life expectancy, observation is the most cost-effective strategy.

The management of aldosterone-producing adrenal adenomas—does adrenalectomy increase costs?

BACKGROUND & AIMS Delayed bleeding after lower endoscopy and polypectomy can cause significant morbidity. One strategy to reduce bleeding is to place an endoscopic clip on the polypectomy site. We used decision analysis to investigate the cost-effectiveness of routine clip placement after colon polypectomy. METHODS Probabilities and plausible ranges were obtained from the literature, and a decision analysis was conducted by using TreeAge Pro 2011 Software. Our cost-effectiveness threshold was an incremental cost-effectiveness ratio of

Is subtotal thyroidectomy a cost-effective treatment for Graves disease? A cost-effectiveness analysis of the medical and surgical treatment options.

100,000 per quality-adjusted life year. The reference case was a 50-year-old patient who had a single 1.0- to 1.5-cm polyp removed during colonoscopy. We estimated postpolypectomy bleeding rates for patients receiving no medications, those with planned resumption of antiplatelet therapy (nonaspirin), or those receiving anticoagulation therapy after polypectomy. We performed several sensitivity analyses, varying the cost of a clip and hospitalization, number of clips placed, clip effectiveness in reducing postpolypectomy bleeding, reduction in patient utility days related to gastrointestinal bleeding, and probability of harm from clip placement. RESULTS On the basis of the reference case, when patients did not receive anticoagulation therapy, clip placement was not cost-effective. However, for patients who did receive anticoagulation and antiplatelet therapies, prophylactic clip placement was a cost-effective strategy. The cost-effectiveness of a prophylactic clip strategy was sensitive to the costs of clips and hospitalization, number of clips placed, and clip effectiveness. CONCLUSIONS Placement of a prophylactic endoscopic clip after polypectomy appears to be a cost-effective strategy for patients who receive antiplatelet or anticoagulation therapy. This approach should be studied in a controlled trial.

Improvement in patient-reported physical and mental health after parathyroidectomy for primary hyperparathyroidism.

BACKGROUND The 2007 National Cancer Institute (NCI) conference on Thyroid Fine-Needle Aspiration (FNA) introduced the category atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS). Repeat FNA in 3 to 6 months was recommended for low-risk patients. Compliance with these recommendations has been suboptimal. We hypothesized that repeat FNA would be more effective than diagnostic lobectomy, with decreased costs and improved rates of cancer detection. METHODS Cost-effectiveness analysis was performed in which we compared diagnostic lobectomy with repeat FNA. A Markov model was developed. Outcomes and probabilities were identified from literature review. Third-party payer costs were estimated in 2010 US dollars. Outcomes were weighted by use of the quality-of-life utility factors, yielding quality-adjusted life years (QALYs). Monte Carlo simulation and sensitivity analysis were used to examine the uncertainty of probability, cost, and utility estimates. RESULTS The diagnostic lobectomy strategy cost

Cost-Effectiveness of Long-Term Every Three-Year Versus Annual Postoperative Surveillance for Low-Risk Papillary Thyroid Cancer

8,057 and produced 23.99 QALYs. Repeat FNA cost

Parathyroidectomy for asymptomatic primary hyperparathyroidism: A revised cost-effectiveness analysis incorporating fracture risk reduction

2,462 and produced 24.05 QALYs. Repeat FNA was dominant until the cost of FNA increased to