title: A Cost-Utility Analysis of Recurrent Laryngeal Nerve Monitoring in the Setting of Total Thyroidectomy.
abstract: Intraoperative nerve monitoring (IONM) of the recurrent laryngeal nerve (RLN) is used as a tool to decrease the rate of nerve injury, although study findings are divergent on IONM efficacy. The cost-effectiveness of this approach to total thyroidectomy has not been well studied.
  
  
  
  To determine whether IONM is a cost-effective intervention in the setting of total thyroidectomy.
  
  
  
  This study creates a decision-tree model of total thyroidectomy to analyze, from a societal perspective, the cost-effectiveness of universal IONM (ie, use in every case) vs selective IONM (ie, high-risk cases including reoperative cases, substernal or toxic goiters, and cases with known cancer) vs no IONM (visual identification only). Parameters for the model were derived from review of the literature, and deterministic and probabilistic analyses were performed to test the model's robustness. All analyses were performed from the model; there were no human participants.
  
  
  
  Modeled total thyroidectomy with and without IONM of the RLN.
  
  
  
  Cost-effectiveness of universal IONM vs selective IONM vs visual identification only of the RLN.
  
  
  
  Visual identification of the RLN led to a cost savings of $179.40 and $683.20 per patient, and an improvement of 0.001 and 0.004 quality-adjusted life-years, over selective IONM and universal IONM, respectively. Visual identification was the most cost-effective approach, despite variations in costs and utilities in both deterministic and probabilistic sensitivity analyses. In a 1-way sensitivity analysis, decreasing the probability of RLN injury with IONM made selective IONM more cost-effective. When the rate of RLN injury for visual identification was kept constant (at 3.86%), selective IONM became the most cost-effective approach when its RLN injury rate dropped below 1.9%. As the rate of RLN injury with IONM dropped below 50.4% of the visual identification RLN injury rate, selective IONM became the most cost-effective approach.
  
  
  
  Visual identification of the RLN is more cost-effective than any use of IONM. If a clinician can, with use of IONM, decrease the rate of RLN injury by 50.4% or more compared with visual identification, selective use of IONM in high-risk cases is most cost-effective.
authors.affiliation: Department of Surgery, Division of Head and Neck Surgery & Communication Sciences, Duke University Medical Center, Durham, North Carolina.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Rocke
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Hospital, Toronto, Ontario, Canada.
authors.forename: David P
authors.initials: DP
authors.lastname: Goldstein
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Hospital, Toronto, Ontario, Canada.
authors.forename: John R
authors.initials: JR
authors.lastname: de Almeida
mesh_terms: D003362:Cost-Benefit Analysis; D003663:Decision Trees; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control*; D016343:Monitoring, Intraoperative / Q000191:economics*; D019057:Quality-Adjusted Life Years; D061226:Recurrent Laryngeal Nerve Injuries / Q000517:prevention & control*; D013965:Thyroidectomy; D014826:Vocal Cord Paralysis / Q000209:etiology / Q000517:prevention & control