title: Cost-Effectiveness of Diagnostic Lobectomy Versus Observation for Thyroid Nodules >4 cm.
abstract: BACKGROUND
  The management of thyroid nodules >4 cm with benign cytology after fine-needle aspiration biopsy (FNAB) is controversial. FNAB is associated with a high false-negative rate in this setting, and may result in a delayed diagnosis and management of thyroid cancer. However, the majority of these nodules are benign. Therefore, the objective of this study was to determine the cost-utility of observation versus surgical management for thyroid nodules >4 cm with benign cytology after FNAB.
  
  
  METHODS
  A microsimulation model comparing routine thyroid lobectomy with observation for low-risk patients with >4 cm thyroid nodules with benign FNAB cytology was constructed. Costs, quality-adjusted life-years (QALYs), and life-years gained were calculated over a lifetime time horizon from a U.S. Medicare perspective.
  
  
  RESULTS
  The proportion of patients undergoing thyroid lobectomy for benign final pathology was 40% in the observation strategy versus 66% in the surgical strategy (p < 0.001). Overall, the surgical strategy was associated with higher lifetime costs compared with the observation strategy (incremental difference: + US$12,992 [confidence interval (CI) 13,042-13,524]), but also more QALYs (+0.12 QALYs [CI 0.02-0.24]) and longer life expectancy (+1.67 years [CI 1.00-2.41]). Incremental lifetime costs were lower for patients <55 years compared with those ≥55 years (+11,181 vs. +14,811, p < 0.001). The probability of cost-effectiveness of the surgical strategy was 49% at a $100k/QALY threshold or 65% at a $100k/life-year gained threshold.
  
  
  CONCLUSIONS
  Routine thyroid lobectomy is associated with improved outcomes at an acceptable cost compared with observation for thyroid nodules >4 cm with benign cytology after FNAB. Surgical resection may be a cost-effective strategy to rule out malignancy in these nodules.
authors.affiliation: 1 Division of General Surgery, Department of Surgery, McGill University Health Centre , Montreal, Canada .
authors.forename: Lawrence
authors.initials: L
authors.lastname: Lee
authors.affiliation: 1 Division of General Surgery, Department of Surgery, McGill University Health Centre , Montreal, Canada .
authors.forename: Elliot J
authors.initials: EJ
authors.lastname: Mitmaker
authors.affiliation: 2 Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Medical Center , New York, New York.
authors.forename: John A
authors.initials: JA
authors.lastname: Chabot
authors.affiliation: 2 Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Medical Center , New York, New York.
authors.forename: James A
authors.initials: JA
authors.lastname: Lee
authors.affiliation: 2 Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Medical Center , New York, New York.
authors.forename: Jennifer H
authors.initials: JH
authors.lastname: Kuo
mesh_terms: D044963:Biopsy, Fine-Needle / Q000379:methods; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D003951:Diagnostic Errors; D005188:False Negative Reactions; D005260:Female; D006801:Humans; D008017:Life Expectancy; D008297:Male; D006278:Medicare; D008875:Middle Aged; D011336:Probability; D019057:Quality-Adjusted Life Years; D015203:Reproducibility of Results; D012306:Risk; D012680:Sensitivity and Specificity; D013961:Thyroid Gland / Q000601:surgery; D013964:Thyroid Neoplasms / Q000175:diagnosis* / Q000191:economics / Q000601:surgery*; D016606:Thyroid Nodule / Q000175:diagnosis* / Q000191:economics / Q000601:surgery*; D013965:Thyroidectomy / Q000191:economics* / Q000379:methods*; D014481:United States