title: Surgery versus medical follow-up in patients with asymptomatic primary hyperparathyroidism: a decision analysis.
abstract: 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.
authors.affiliation: 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.
authors.forename: Karine
authors.initials: K
authors.lastname: Sejean
authors.forename: Sophie
authors.initials: S
authors.lastname: Calmus
authors.forename: Isabelle
authors.initials: I
authors.lastname: Durand-Zaleski
authors.forename: Philippe
authors.initials: P
authors.lastname: Bonnichon
authors.forename: Pierre
authors.initials: P
authors.lastname: Thomopoulos
authors.forename: Catherine
authors.initials: C
authors.lastname: Cormier
authors.forename: Paul
authors.initials: P
authors.lastname: Legmann
authors.forename: Bruno
authors.initials: B
authors.lastname: Richard
authors.forename: Xavier Y
authors.initials: XY
authors.lastname: Bertagna
authors.forename: Gwenaelle M
authors.initials: GM
authors.lastname: Vidal-Trecan
mesh_terms: 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