Buying Protection from Hypoparathyroidism: Is High-Tech Parathyroid Identification During Thyroidectomy Worth the Cost?

Hypoparathyroidism remains a major complication of total thyroidectomy, with long-term morbidity and substantial healthcare costs. Multiple intraoperative technologies have been introduced to improve parathyroid identification, but their comparative economic value and optimal use across settings are uncertain.

A decision-analytic study was conducted using a decision tree linked to a state-transition micro-costing model to simulate 1,000 adults undergoing total thyroidectomy, 70% without and 30% with central neck dissection. Analyses were performed from the hospital provider perspective under standardised calcium-parathyroid hormone pathways. Nine strategies were compared: visual inspection, magnifying loupes, methylene blue, ultrasound mapping, intraoperative intact parathyroid hormone measurement, camera-based near-infrared autofluorescence (camera-based NIRAF), camera-based NIRAF with or without indocyanine green (ICG), probe-based NIRAF (PTeye), and carbon nanoparticles. Primary outcomes were rates of transient and permanent hypoparathyroidism, total costs per patient, and incremental cost-effectiveness ratios, evaluated at 12 months and over 10 years with 3% annual discounting. Deterministic and probabilistic sensitivity analyses (10,000 simulations) explored parameter and structural uncertainty. The model was intended as a decision-support framework for institutions considering adoption, identifying the case-volume, baseline-risk and cost conditions under which added intraoperative costs could be offset.

With visual identification alone, simulated 12‑month rates of transient and permanent hypoparathyroidism were 27.5% and 3.8% in high-volume centres and 34.2% and 5.6% in low-volume centres. Applying literature-derived relative risks, camera-based NIRAF was associated with lower modelled rates of transient hypoparathyroidism (16.8%-20.5%), an effect supported by randomised and meta-analytic evidence, and with smaller modelled reductions in permanent hypoparathyroidism (1.6%-2.4%), for which clinical evidence remains uncertain. In patients undergoing central neck dissection, camera-based NIRAF plus ICG was associated with lower modelled transient (21.7% vs. 42.3%) and permanent hypoparathyroidism (2.8% vs. 7.9%). At 12 months, modelled mean costs with camera-based NIRAF were €160-€270 lower per patient, and €590 lower in high-risk cases with central compartment lymph node dissection. Over 10 years, under the base-case assumption of a modest reduction in permanent hypoparathyroidism, camera-based NIRAF was frequently cost-saving and had the highest probability of being cost-effective. In a prespecified scenario assuming no reduction in permanent hypoparathyroidism, camera-based NIRAF was only marginally cost-saving at 12 months and was no longer clearly dominant over 10 years, indicating that its long-term economic advantage depends substantially on the assumed permanent-hypoparathyroidism benefit.

In this model-based economic evaluation, camera-based NIRAF-guided parathyroid identification showed favourable modelled cost profiles, particularly in high-volume and high-risk thyroid surgery. Modelled reductions in transient hypocalcaemia were supported by comparatively robust evidence, whereas reductions in permanent hypoparathyroidism, and the associated long-term savings, were more uncertain and should be regarded as model-based projections rather than established clinical expectations. The projected economic benefits are consequences of assumed clinical effects and do not constitute additional evidence of clinical efficacy. Because all costs were derived from a single healthcare system, the absolute costs, incremental cost-effectiveness ratios, and cost-saving thresholds require local recalibration before informing procurement or policy decisions in other settings. Rather than supporting a specific adoption strategy, these findings identify the conditions under which camera-based NIRAF could provide economic value (higher baseline risk, sufficient case volume, and a genuine effect on permanent hypoparathyroidism), and should be confirmed in prospective comparative studies.