Parathyroidectomy for asymptomatic primary hyperparathyroidism: A revised cost-effectiveness analysis incorporating fracture risk reduction

Background. Recent data demonstrate decreased fracture risk after operation for asymptomatic primary hyperparathyroidism. We performed a revised cost-effectiveness analysis comparing parathyroidectomy versus observation while incorporating fracture risk reduction. Methods. A Markov transition-state model was created comparing parathyroidectomy and guideline-based medical observation for a 60-year-old female patient with mild asymptomatic primary hyperparathyroidism. Costs were estimated using published Medicare reimbursement data. Treatment strategy outcomes, including risk of fracture, were identified by literature review. Quality adjustment factors were used to weight treatment outcomes. A threshold of $100,000/quality-adjusted life year was used to determine cost-effectiveness. Sensitivity analyses and Monte Carlo simulation were performed to examine the effect of uncertainty on the model. Results. Parathyroidectomy was the dominant strategy (less costly and more effective) with an incremental cost savings of $1,721 and an incremental effectiveness of 0.185 quality-adjusted life years. Parathyroidectomy remained dominant when the relative risk reduction of fracture after operation was >= 14%, the cost of fracture was >=$7,600, or the probability of recurrent laryngeal nerve injury was <12.5 %. Monte Carlo simulation showed parathyroidectomy was cost-effective in 995/1,000 hypothetical patients. Conclusion. When fracture risk reduction is considered, parathyroidectomy for mild asymptomatic primary hyperparathyroidism is the dominant strategy when compared to observation.