The management of aldosterone-producing adrenal adenomas--does adrenalectomy increase costs?
BACKGROUND
Most experts agree that primary hyperaldosteronism (PHA) caused by an aldosterone-producing adenoma (APA) is best treated by adrenalectomy. From a public health standpoint, the cost of treatment must be considered. We sought to compare the current guideline-based (surgical) strategy with universal pharmacologic management to determine the optimal strategy from a cost perspective.


METHODS
A decision analysis was performed using a Markov state transition model comparing the strategies for PHA treatment. Pharmacologic management for all patients with PHA was compared with a strategy of screening for and resecting an aldosterone-producing adenoma. Success rates were determined for treatment outcomes based on a literature review. Medicare reimbursement rates were calculated to estimate costs from a third-party payer perspective.


RESULTS
Screening for and resecting APAs was the least costly strategy in this model. For a reference patient with 41 remaining years of life, the discounted expected cost of the surgical strategy was $27,821. The discounted expected cost of the medical strategy was $34,691. The cost of adrenalectomy would have to increase by 156% to $22,525 from $8,784 for universal pharmacologic therapy to be less costly. Screening for APA is more costly if fewer than 9.6% of PHA patients have resectable APA.


CONCLUSIONS
Resection of APAs was the least costly treatment strategy in this decision analysis model.
Department of Surgery, Columbia University Medical Center, New York, NY, USA.
Bethann
B
Reimel
Kyle
K
Zanocco
Mark J
MJ
Russo
Rasa
R
Zarnegar
Orlo H
OH
Clark
John D
JD
Allendorf
John A
JA
Chabot
Quan-Yang
QY
Duh
James A
JA
Lee
Cord
C
Sturgeon
D000236:Adenoma / Q000191:economics / Q000601:surgery*; D000310:Adrenal Gland Neoplasms / Q000191:economics / Q000378:metabolism / Q000601:surgery*; D000315:Adrenalectomy / Q000191:economics / Q000379:methods; D000368:Aged; D000450:Aldosterone / Q000096:biosynthesis*; D000465:Algorithms; D003365:Costs and Cost Analysis; D003658:Decision Making, Computer-Assisted; D006801:Humans; D008403:Mass Screening / Q000191:economics; D006278:Medicare; D011336:Probability; D012680:Sensitivity and Specificity; D014481:United States
D000450:Aldosterone