Surgery versus medical follow-up in patients with asymptomatic primary hyperparathyroidism: a decision analysis.
OBJECTIVE
To examine the cost-effectiveness of strategies for management of primary asymptomatic hyperparathyroidism: surgical strategies and medical follow-up versus surgery.


METHODS
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 Euro) 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 Euro/QALY versus BNES and VAPS of 17,250 Euro/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.
Sejean
Karine
K
Université Paris Descartes, Faculté de Médecine, Services de Santé publique, AP-HP, groupe hospitalier Cochin - Saint Vincent de Paul, 27 rue du faubourg Saint Jacques, 75014 Paris, France.
Calmus
Sophie
S
Durand-Zaleski
Isabelle
I
Bonnichon
Philippe
P
Thomopoulos
Pierre
P
Cormier
Catherine
C
Legmann
Paul
P
Richard
Bruno
B
Bertagna
Xavier Y
XY
Vidal-Trecan
Gwenaelle M
GM
D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D049950:Hyperparathyroidism, Primary / Q000601:surgery* / Q000628:therapy*; D008875:Middle Aged; D016105:Parathyroidectomy; D011788:Quality of Life