Would scan, but which scan? A cost-utility analysis to optimize preoperative imaging for primary hyperparathyroidism

Area of Science:

• Endocrinology
• Nuclear Medicine
• Radiology

Background:

• Minimally invasive parathyroidectomy for primary hyperparathyroidism relies on precise preoperative localization of abnormal parathyroid glands.
• Accurate localization is crucial for surgical success and minimizing complications.
• Various imaging modalities are available, each with potential cost and efficacy differences.

Purpose of the Study:

• To evaluate the cost-utility of different preoperative localization strategies for primary hyperparathyroidism.
• To compare the economic value of ultrasound, sestamibi-SPECT, and 4D-CT, individually and in combination.
• To determine the optimal imaging protocol for guiding minimally invasive parathyroidectomy.

Main Methods:

• A decision tree model was developed to simulate patient pathways for initial parathyroidectomy.
• Five distinct preoperative localization protocols were analyzed: ultrasound, sestamibi-SPECT, 4D-CT, sestamibi-SPECT plus ultrasound, and sestamibi-SPECT plus ultrasound with 4D-CT for discordant results.
• Cost data were sourced from literature and Medicare, with quality-adjusted life years (QALY) used to assess utility. Sensitivity analyses were conducted.

Main Results:

• Ultrasound was the least expensive modality ($6666).
• The combination of sestamibi-SPECT and ultrasound, with 4D-CT if discordant (sestamibi-SPECT and ultrasound ± 4D-CT), emerged as the most cost-effective strategy due to improved localization and reduced bilateral neck explorations.
• While QALYs were similar across modalities, several combinations offered a 'win-win' scenario, costing less and providing greater utility compared to sestamibi-SPECT alone.

Conclusions:

• The combined approach of sestamibi-SPECT and ultrasound, supplemented by 4D-CT when necessary, represents the most cost-effective method for preoperative parathyroid localization.
• 4D-CT and ultrasound alone were also found to be more cost-effective than sestamibi-SPECT alone.
• The cost-utility of these imaging techniques is influenced by their diagnostic accuracy and institutional variations.