Outcomes and economic analysis of routine preoperative 4-dimensional CT for surgical intervention in de novo primary hyperparathyroidism: does clinical benefit justify the cost?
BACKGROUND
Preoperative imaging in patients with primary hyperparathyroidism provides important localization information. Although 4-dimensional neck CT (4DCT) can precisely localize hyperfunctioning parathyroid tissue, the contribution of 4DCT to overall cost, operating room time, and hospital stay is unknown.


METHODS
Records of 535 patients with primary hyperparathyroidism who underwent parathyroidectomy at our institution from 1996 to 2010 were reviewed. All patients had preoperative cervical ultrasonography and sestamibi scanning, and most (78.9%) underwent preoperative 4DCT. A decision tree was constructed to compare extent of procedure, operating room time, length of stay, failure rate, and total cost of each strategy (with and without 4DCT). Costs were determined by 2010 Medicare reimbursement.


RESULTS
For patients with and without preoperative 4DCT, respectively, mean operating room time (64.4 vs 61.4 minutes; p = 0.58) and failure rate (1.9% vs 4.4%; p = 0.12) were not significantly different. Length of stay was higher in the no-CT cohort (0.61 vs 0.23 days; p < 0.001). Patients with a preoperative 4DCT were significantly more likely to undergo a limited parathyroidectomy (90.3% vs 80.5%; p = 0.004). Mean cost of care per patient in the CT and no-CT cohorts was $6,572 and $6,306, respectively.


CONCLUSIONS
The introduction of routine 4DCT into the preoperative workup for surgical intervention in primary hyperparathyroidism does not appear to shorten operating room time or decrease failure rate significantly. However, preoperative 4DCT is associated with shorter hospital stays and improved rates of minimally invasive parathyroidectomy. This clinical benefit must be weighed against the increased cost associated with routine preoperative 4DCT.
Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
Daniel E
DE
Abbott
Scott B
SB
Cantor
Elizabeth G
EG
Grubbs
Rachel
R
Santora
Henry F
HF
Gomez
Douglas B
DB
Evans
Jeffrey E
JE
Lee
Thinh
T
Vu
Nancy D
ND
Perrier
D003362:Cost-Benefit Analysis; D003663:Decision Trees; D056973:Four-Dimensional Computed Tomography / Q000191:economics; D017721:Hospital Costs; D006801:Humans; D049950:Hyperparathyroidism, Primary / Q000000981:diagnostic imaging* / Q000191:economics / Q000601:surgery; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000191:economics; D015233:Models, Statistical; D016105:Parathyroidectomy / Q000191:economics / Q000379:methods; D011300:Preoperative Care / Q000191:economics / Q000379:methods; D013781:Texas; D013997:Time Factors; D017211:Treatment Failure; D016896:Treatment Outcome