title: Would scan, but which scan? A cost-utility analysis to optimize preoperative imaging for primary hyperparathyroidism.
abstract: BACKGROUND
  Minimally invasive parathyroidectomy for primary hyperparathyroidism depends on accurate preoperative localization. This study examines the cost-utility of sestamibi in combination with single photon emission computed tomography (sestamibi-SPECT); ultrasound; and 4-dimensional computed tomography (4D-CT).
  
  
  METHODS
  A decision tree was constructed for patients undergoing initial parathyroidectomy. Patients were randomized to 1 of 5 preoperative localization protocols: (1) ultrasound; (2) sestamibi-SPECT; (3) 4D-CT; (4) sestamibi-SPECT and ultrasound; and (5) sestamibi-SPECT and ultrasound and 4D-CT, if discordant (sestamibi-SPECT and ultrasound ± 4D-CT). From a societal perspective, all relevant costs were included. Input data were obtained from literature and Medicare. The incremental cost-utility ratio was determined in dollars per quality-adjusted life years ($/QALY). Sensitivity analyses were performed.
  
  
  RESULTS
  In the base-case, ultrasound was least expensive, with a cost of $6666, compared to $6773 (4-D CT); $7214 (sestamibi-SPECT and ultrasound ± 4D-CT); $7330 (sestamibi-SPECT); and $7371(sestamibi-SPECT and ultrasound). Sestamibi-SPECT and ultrasound ± 4D-CT were most cost-effective because improved localization resulted in fewer bilateral explorations. QALY were comparable across modalities. Compared to sestamibi-SPECT, ultrasound, 4D- CT, and sestamibi-SPECT and ultrasound ± 4D-CT resulted a win-win situation-costing less and accruing more utility. Sensitivity analyses demonstrated that the model was sensitive to surgery cost and diagnostic accuracy of imaging.
  
  
  CONCLUSIONS
  In our model, sestamibi-SPECT and ultrasound ± 4D-CT were the most cost-effective methods, followed by 4D-CT and ultrasound. Sestamibi-SPECT alone was least cost-effective. Cost-utilities were dependent on the sensitivities of ultrasound and 4D-CT and may vary by institution.
authors.affiliation: Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA. tswang@mcw.edu
authors.forename: Tracy S
authors.initials: TS
authors.lastname: Wang
authors.forename: Kevin
authors.initials: K
authors.lastname: Cheung
authors.forename: Forough
authors.initials: F
authors.lastname: Farrokhyar
authors.forename: Sanziana A
authors.initials: SA
authors.lastname: Roman
authors.forename: Julie A
authors.initials: JA
authors.lastname: Sosa
mesh_terms: D000465:Algorithms; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D056973:Four-Dimensional Computed Tomography / Q000191:economics*; D017048:Health Care Costs; D006801:Humans; D049950:Hyperparathyroidism, Primary / Q000175:diagnosis* / Q000191:economics / Q000601:surgery; D018803:Models, Economic; D016105:Parathyroidectomy; D011300:Preoperative Care / Q000191:economics*; D019057:Quality-Adjusted Life Years; D019275:Radiopharmaceuticals / Q000191:economics; D017256:Technetium Tc 99m Sestamibi / Q000191:economics; D015899:Tomography, Emission-Computed, Single-Photon / Q000191:economics*; D014463:Ultrasonography / Q000191:economics*; D014481:United States
chemical_list: D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi