title: Modern parathyroid surgery: a cost-benefit analysis of localizing strategies.
abstract: OBJECTIVE
  Preoperative and intraoperative localizing techniques are more cost-effective than a nondirected bilateral neck exploration in the initial treatment of primary hyperparathyroidism (HPT).
  
  
  METHODS
  A clinical outcome model was developed to simulate the surgical management of primary HPT. Clinical scenarios modeled included a nondirected bilateral neck exploration and surgery using the following localizing strategies: preoperative technetium Tc 99m sestamibi scanning, intraoperative "quick" intact parathyroid hormone assay, or intraoperative radioguidance. Average total charges based on intent to treat were estimated from our practice and from the literature.
  
  
  METHODS
  Average total charges per patient (for the primary operation and for reexploration for persistent HPT, if needed), incidence of surgical failure (ie, persistent HPT), and risk of recurrent laryngeal nerve injury (cumulative risk of the primary procedure and a subsequent operation for persistent HPT).
  
  
  RESULTS
  The use of any localizing strategy reduced total charges, risk of persistent HPT, and cumulative risk of recurrent laryngeal nerve injury compared with a nondirected bilateral neck exploration. The greatest cost savings and the lowest risk of recurrent laryngeal nerve injury were achieved when technetium Tc 99m sestamibi scanning was combined with intraoperative radioguidance. The lowest rate of persistent HPT was found when technetium Tc 99m sestamibi scanning was combined with an intraoperative parathyroid hormone assay.
  
  
  CONCLUSIONS
  Limited parathyroid surgery using any localizing strategy is cost-effective, safe, and efficacious in the management of primary HPT. The cost benefit was primarily achieved by reduced operative charges and immediate hospital discharge rather than a lower need for reexploration for persistent HPT.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of California, Davis, Sacramento, USA.
authors.forename: Bridget N
authors.initials: BN
authors.lastname: Fahy
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Bold
authors.forename: Laurel
authors.initials: L
authors.lastname: Beckett
authors.forename: Philip D
authors.initials: PD
authors.lastname: Schneider
mesh_terms: D017046:Cost Savings; D003362:Cost-Benefit Analysis; D006801:Humans; D006961:Hyperparathyroidism / Q000175:diagnosis / Q000191:economics* / Q000601:surgery*; D007431:Intraoperative Complications / Q000191:economics; D007432:Intraoperative Period; D009333:Neck / Q000601:surgery; D010280:Parathyroid Glands / Q000000981:diagnostic imaging; D010281:Parathyroid Hormone / Q000097:blood; D016105:Parathyroidectomy / Q000191:economics*; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals / Q000191:economics; D061226:Recurrent Laryngeal Nerve Injuries; D012086:Reoperation; D012307:Risk Factors; D017256:Technetium Tc 99m Sestamibi / Q000191:economics; D017211:Treatment Failure
chemical_list: D010281:Parathyroid Hormone; D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi