The cost-effectiveness of three strategies for the surgical treatment of symptomatic primary hyperparathyroidism

Introduction: Modern surgical approaches to the treatment of primary hyperparathyroidism [unilateral neck exploration (UNE) and minimally invasive parathyroidectomy (MIP)] have become commonplace in recent years. However, the cost-effectiveness of these strategies has been questioned since the effectiveness of the gold standard, bilateral neck exploration (BNE), is well established. The objective of our study was to determine the incremental cost effectiveness of UNE and MIP compared with BNE for treatment of primary hyperparathyroidism (HPT). Methods: Patients presenting to a tertiary endocrine surgical center for treatment of HPT over a 38-month period were included in the study. The primary measure of effectiveness was the rate of postoperative complications (hypocalcemia and paresthesias) observed in our cohort. A decision analytic model was constructed to determine the incremental cost-effectiveness ratios (ICERs) of the UNE and MIP strategies compared with the BNE strategy. Deterministic and probabilistic sensitivity analyses were conducted to evaluate uncertainty around model-based estimates of costs and effectiveness. Results: A total of 94 patients (56 BNEs, 19 UNEs, and 19 MIPs) provided estimates of mean costs (BNE = $4524, UNE = $4784, MIP = $4961) and success rates (BNE = 0.91, UNE = 0.86, MIP = 0.93) for each treatment arm. The gold standard BNE strategy dominated the UNE strategy (lower cost, higher effectiveness) under most model formulations. The MIP strategy had an ICER of $28,439 per complication avoided, which is likely to be above societal willingness to pay to avoid primarily minor postoperative complications. Conclusion: Our results suggest that within our institution, and in several different model formulations, bilateral neck exploration remains the cost-effective strategy for the treatment of primary hyperparathyroidism.