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Updated: May 10, 2026
Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy
Published on: May 12, 2023
Cost effectiveness of intraoperative pathology examination during diagnostic hemithyroidectomy for unilateral
Kyle Zanocco1, Michael Heller, Dina Elaraj
1Department of Surgery, Section of Endocrine Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL.
Insights
Intraoperative pathology examination during thyroid surgery for follicular neoplasms is not cost-effective. It rarely changes decisions and often leads to unnecessary procedures, increasing costs for patients.
Area of Science:
- Endocrinology
- Surgical Oncology
- Health Economics
Background:
- Intraoperative pathology examination (IPE) for follicular neoplasms during hemithyroidectomy is debated.
- IPE may prevent reoperation but rarely alters immediate surgical decisions.
- The cost-effectiveness of IPE compared to hemithyroidectomy alone is unclear.
Purpose of the Study:
- To evaluate the cost-effectiveness of diagnostic hemithyroidectomy with IPE versus without IPE for follicular thyroid neoplasms.
- To compare these strategies against upfront total thyroidectomy.
Main Methods:
- A Markov decision model was used for cost-effectiveness analysis.
- Data from literature, Medicare, and national health surveys informed costs and outcomes.
- Sensitivity analyses and Monte Carlo simulations assessed model uncertainties.
Main Results:
- Diagnostic hemithyroidectomy without IPE was the most cost-effective strategy (US$7,665, 23.95 QALYs).
- IPE was not cost-effective in 92.7% of simulations.
- IPE would require significantly higher sensitivity and specificity to become cost-effective.
Conclusions:
- Intraoperative pathology examination is not a cost-effective approach for follicular thyroid neoplasms.
- Enhanced accuracy in IPE sensitivity and specificity is necessary for its clinical justification.
- Current diagnostic hemithyroidectomy without IPE is preferred for cost-effectiveness.
Background:
The use of intraoperative pathology examination (IPE) during diagnostic hemithyroidectomy for a follicular neoplasm is controversial. Although this service rarely alters intraoperative decision making, it does provide patients with the possibility of avoiding reoperation for completion thyroidectomy if malignancy is detected. We hypothesized diagnostic hemithyroidectomy with IPE for a unilateral follicular thyroid neoplasm diagnosed on fine-needle aspiration is not cost effective compared with diagnostic hemithyroidectomy alone.
Study Design:
Cost-effectiveness analysis with a Markov decision model was performed comparing diagnostic hemithyroidectomy without IPE, diagnostic hemithyroidectomy with IPE, and total thyroidectomy. Treatment outcomes and their probabilities were identified based on literature review. Costs were estimated using data from Medicare, the US Bureau of Labor Statistics, and the Nationwide Inpatient Sample. Sensitivity analysis and a 1,000-iteration Monte Carlo simulation were used to examine the uncertainty of cost, probability, and utility estimates in the model.
Results:
Diagnostic hemithyroidectomy without IPE had an expected cost of US$7,665 and an effectiveness of 23.95 quality-adjusted life years and dominated both the IPE and total thyroidectomy strategies. Intraoperative pathology examination became cost effective during one-way sensitivity analysis if the sensitivity of IPE increased from 14.3% to 34.4%, the specificity increased from 98.6% to 99.8%, or the pretest probability of malignancy increased from 25% to 43%. Monte Carlo simulation demonstrated that the intraoperative pathology strategy was not cost effective in 92.7% of iterations.
Conclusions:
Intraoperative pathology examination is not cost effective in the diagnosis of follicular thyroid neoplasms during diagnostic hemithyroidectomy. Improvements in both the sensitivity and specificity of this service would be needed to justify its use.
