title: Cost comparison of initial lobectomy versus fine-needle aspiration for diagnostic workup of thyroid nodules in children.
abstract: BACKGROUND
  Though uncommon in children, pediatric thyroid nodules carry a higher risk of malignancy than adult nodules. While fine-needle aspiration (FNA) has been well established as the initial diagnostic test in adults, it has been more slowly adopted in children. The purpose of this study was to examine the comparative cost of FNA versus initial diagnostic lobectomy (DL) in the pediatric patient with an ultrasound-confirmed thyroid nodule.
  
  
  METHODS
  A decision tree model was created using an adolescent with an asymptomatic thyroid nodule as the reference case. Probabilities were defined based on review of the pediatric and adult literature. Costs were determined from previous literature and the publicly available Medicare physician fee schedule. Tornado plot and sensitivity analyses were performed to assess sources of cost variation.
  
  
  RESULTS
  Using decision analysis, FNA was less costly than DL with an estimated cost of $2529 vs. $5680. Tornado analysis demonstrated that the probability of an initial indeterminate FNA result contributed most to cost variation. On sensitivity analysis, when probability of an indeterminate FNA result was increased to 35%, the maximum value found in the literature, FNA remained less costly. In Monte Carlo simulation set to 10,000 iterations, FNA was superior to DL in 74% of cases.
  
  
  CONCLUSIONS
  In this theoretical model based on available literature and costs, FNA is less costly than DL for initial diagnostic workup of thyroid nodules in children. Securing resources to offer FNA in the work-up of thyroid nodules may be financially beneficial to hospitals and patients.
  
  
  METHODS
  Level 1 cost effectiveness study - using reasonable costs and alternatives used in study with values obtained from many studies, study used multi-way sensitivity analysis.
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine Children's Healthcare of Atlanta, Atlanta, GA, United States.
authors.forename: Katherine J
authors.initials: KJ
authors.lastname: Baxter
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine Children's Healthcare of Atlanta, Atlanta, GA, United States.
authors.forename: Heather L
authors.initials: HL
authors.lastname: Short
authors.affiliation: Rollins School of Public Health, Emory University, Atlanta, GA, United States.
authors.forename: Mitali A
authors.initials: MA
authors.lastname: Thakore
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine Children's Healthcare of Atlanta, Atlanta, GA, United States.
authors.forename: Jeremy G
authors.initials: JG
authors.lastname: Fisher
authors.affiliation: Department of Pediatric Surgery, Women and Children's Hospital of Buffalo; Department of Surgery, University at Buffalo, State University of New York, Buffalo, NY, USA.
authors.forename: David H
authors.initials: DH
authors.lastname: Rothstein
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine Children's Healthcare of Atlanta, Atlanta, GA, United States.
authors.forename: Kurt F
authors.initials: KF
authors.lastname: Heiss
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine Children's Healthcare of Atlanta, Atlanta, GA, United States. Electronic address: mehulvraval@emory.edu.
authors.forename: Mehul V
authors.initials: MV
authors.lastname: Raval
mesh_terms: D000293:Adolescent; D044963:Biopsy, Fine-Needle / Q000191:economics*; D002648:Child; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003663:Decision Trees; D006801:Humans; D061705:Image-Guided Biopsy / Q000191:economics; D008297:Male; D016606:Thyroid Nodule / Q000191:economics* / Q000473:pathology*; D013965:Thyroidectomy / Q000191:economics*; D014463:Ultrasonography / Q000191:economics
keywords: Cost effectiveness; Decision analysis; Thyroid nodule