Skip to main content

Advertisement

SpringerLink
Log in

Preoperative Localization Strategies for Primary Hyperparathyroidism: An Economic Analysis

  • Endocrine Tumors
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Strategies for localizing parathyroid pathology preoperatively vary in cost and accuracy. Our purpose was to compute and compare comprehensive costs associated with common localization strategies.

Methods

A decision-analytic model was developed to evaluate comprehensive, short-term costs of parathyroid localization strategies for patients with primary hyperparathyroidism. Eight strategies were compared. Probabilities of accurate localization were extracted from the literature, and costs associated with each strategy were based on 2011 Medicare reimbursement schedules. Differential cost considerations included outpatient versus inpatient surgeries, operative time, and costs of imaging. Sensitivity analyses were performed to determine effects of variability in key model parameters upon model results.

Results

Ultrasound (US) followed by 4D-CT was the least expensive strategy ($5,901), followed by US alone ($6,028), and 4D-CT alone ($6,110). Strategies including sestamibi (SM) were more expensive, with associated expenditures of up to $6,329 for contemporaneous US and SM. Four-gland, bilateral neck exploration (BNE) was the most expensive strategy ($6,824). Differences in cost were dependent upon differences in the sensitivity of each strategy for detecting single-gland disease, which determined the proportion of patients able to undergo outpatient minimally invasive parathyroidectomy. In sensitivity analysis, US alone was preferred over US followed by 4D-CT only when both the sensitivity of US alone for detecting an adenoma was ≥94 %, and the sensitivity of 4D-CT following negative US was ≤39 %. 4D-CT alone was the least costly strategy when US sensitivity was ≤31 %.

Conclusions

Among commonly used strategies for preoperative localization of parathyroid pathology, US followed by selective 4D-CT is the least expensive.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. The American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons position statement on the diagnosis and management of primary hyperparathyroidism. Endocr Pract. 2005;11:49–54.

    Google Scholar 

  2. Silverberg SJ, Shane E, Jacobs TP, Siris E, Bilezikian JP. A 10-year prospective study of primary hyperparathyroidism with or without parathyroid surgery. N Engl J Med. 1999;341:1249–55.

    Article  PubMed  CAS  Google Scholar 

  3. Udelsman R, Pasieka JL, Sturgeon C, Young JE, Clark OH. Surgery for asymptomatic primary hyperparathyroidism: proceedings of the third international workshop. J Clin Endocrinol Metab. 2009;94:366–72.

    Article  PubMed  CAS  Google Scholar 

  4. Zanocco K, Angelos P, Sturgeon C. Cost-effectiveness analysis of parathyroidectomy for asymptomatic primary hyperparathyroidism. Surgery. 2006;140:874–81.

    Article  PubMed  Google Scholar 

  5. Greene AB, Butler RS, McIntyre S, et al. National trends in parathyroid surgery from 1998 to 2008: a decade of change. J Am Coll Surg. 2009;209:332–43.

    Article  PubMed  Google Scholar 

  6. Beyer TD, Solorzano CC, Starr F, Nilubol N, Prinz RA. Parathyroidectomy outcomes according to operative approach. Am J Surg. 2007;193:368–72.

    Article  PubMed  Google Scholar 

  7. Udelsman R. Six hundred fifty-six consecutive explorations for primary hyperparathyroidism. Ann Surg. 2002;235:665–70.

    Article  PubMed  Google Scholar 

  8. Irvin GL 3rd, Solorzano CC, Carneiro DM. Quick intraoperative parathyroid hormone assay: surgical adjunct to allow limited parathyroidectomy, improve success rate, and predict outcome. World J Surg. 2004;28:1287–92.

    Article  PubMed  Google Scholar 

  9. Ruda JM, Hollenbeak CS, Stack BC Jr. A systematic review of the diagnosis and treatment of primary hyperparathyroidism from 1995 to 2003. Otolaryngol Head Neck Surg. 2005;132:359–72.

    Article  PubMed  Google Scholar 

  10. Russell CF, Dolan SJ, Laird JD. Randomized clinical trial comparing scan-directed unilateral versus bilateral cervical exploration for primary hyperparathyroidism due to solitary adenoma. Br J Surg. 2006;93:418–21.

    Article  PubMed  CAS  Google Scholar 

  11. Sidhu S, Neill AK, Russell CF. Long-term outcome of unilateral parathyroid exploration for primary hyperparathyroidism due to presumed solitary adenoma. World J Surg. 2003;27:339–42.

    Article  PubMed  Google Scholar 

  12. Westerdahl J, Bergenfelz A. Unilateral versus bilateral neck exploration for primary hyperparathyroidism: five-year follow-up of a randomized controlled trial. Ann Surg. 2007;246:976–80.

    Article  PubMed  Google Scholar 

  13. Lubitz CC, Hunter GJ, Hamberg LM, et al. Accuracy of 4-dimensional computed tomography in poorly localized patients with primary hyperparathyroidism. Surgery. 2010;148:1129–37.

    Article  PubMed  Google Scholar 

  14. Cheung K, Wang TS, Farrokhyar F, Roman SA, Sosa JA. A meta-analysis of preoperative localization techniques for patients with primary hyperparathyroidism. Ann Surg Oncol. 2012;19(2):577–83.

    Article  PubMed  Google Scholar 

  15. Mortenson MM, Evans DB, Lee JE, et al. Parathyroid exploration in the reoperative neck: improved preoperative localization with 4D-computed tomography. J Am Coll Surg. 2008;206:888–95; discussion 895.

    Article  PubMed  Google Scholar 

  16. Rodgers SE, Hunter GJ, Hamberg LM, et al. Improved preoperative planning for directed parathyroidectomy with 4-dimensional computed tomography. Surgery. 2006;140:932–40; discussion 940.

    Article  PubMed  Google Scholar 

  17. Starker LF, Mahajan A, Bjorklund P, Sze G, Udelsman R, Carling T. 4D parathyroid CT as the initial localization study for patients with de novo primary hyperparathyroidism. Ann Surg Oncol. 2011;18:1723–8.

    Article  PubMed  Google Scholar 

  18. Chen H, Sokoll LJ, Udelsman R. Outpatient minimally invasive parathyroidectomy: a combination of sestamibi-SPECT localization, cervical block anesthesia, and intraoperative parathyroid hormone assay. Surgery. 1999;126:1016–21; discussion 1021-2.

    Article  PubMed  CAS  Google Scholar 

  19. Fahy BN, Bold RJ, Beckett L, Schneider PD. Modern parathyroid surgery: a cost-benefit analysis of localizing strategies. Arch Surg. 2002;137:917-22; discussion 922–3.

    Article  PubMed  Google Scholar 

  20. Goldstein RE, Blevins L, Delbeke D, Martin WH. Effect of minimally invasive radioguided parathyroidectomy on efficacy, length of stay, and costs in the management of primary hyperparathyroidism. Ann Surg. 2000;231:732–42.

    Article  PubMed  CAS  Google Scholar 

  21. Mihai R, Weisters M, Stechman MJ, Gleeson F, Sadler G. Cost-effectiveness of scan-directed parathyroidectomy. Langenbecks Arch Surg. 2008;393:739–43.

    Article  PubMed  Google Scholar 

  22. Zanocco K, Heller M, Sturgeon C. Cost-effectiveness of parathyroidectomy for primary hyperparathyroidism. Endocr Pract. 2011;17(Suppl 1):69–74.

    Article  PubMed  Google Scholar 

  23. Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB. Recommendations of the panel on cost-effectiveness in health and medicine. JAMA. 1996;276:1253–8.

    Article  PubMed  CAS  Google Scholar 

  24. Arici C, Cheah WK, Ituarte PH, et al. Can localization studies be used to direct focused parathyroid operations? Surgery. 2001;129:720–9.

    Article  PubMed  CAS  Google Scholar 

  25. Bergenfelz AO, Jansson SK, Wallin GK, Martensson HG, Rasmussen L, Eriksson HL, Reihner EI. Impact of modern techniques on short-term outcome after surgery for primary hyperparathyroidism: a multicenter study comprising 2,708 patients. Langenbecks Arch Surg. 2009;394:851–60.

    Article  PubMed  Google Scholar 

  26. Casara D, Rubello D, Pelizzo MR, Shapiro B. Clinical role of 99mTcO4/MIBI scan, ultrasound and intra-operative gamma probe in the performance of unilateral and minimally invasive surgery in primary hyperparathyroidism. Eur J Nucl Med. 2001;28:1351–9.

    Article  PubMed  CAS  Google Scholar 

  27. Civelek AC, Ozalp E, Donovan P, Udelsman R. Prospective evaluation of delayed technetium-99m sestamibi SPECT scintigraphy for preoperative localization of primary hyperparathyroidism. Surgery. 2002;131:149–57.

    Article  PubMed  Google Scholar 

  28. Gotthardt M, Lohmann B, Behr TM, et al. Clinical value of parathyroid scintigraphy with technetium-99m methoxyisobutylisonitrile: discrepancies in clinical data and a systematic metaanalysis of the literature. World J Surg. 2004;28:100–7.

    Article  PubMed  Google Scholar 

  29. Harari A, Zarnegar R, Lee J, Kazam E, Inabnet WB 3rd, Fahey TJ 3rd. Computed tomography can guide focused exploration in select patients with primary hyperparathyroidism and negative sestamibi scanning. Surgery. 2008;144:970–6; discussion 976-9.

    Article  PubMed  Google Scholar 

  30. Tresoldi S, Pompili G, Maiolino R, et al. Primary hyperparathyroidism: can ultrasonography be the only preoperative diagnostic procedure? Radiol Med. 2009;114:1159–72.

    Article  PubMed  CAS  Google Scholar 

  31. Van Husen R, Kim LT. Accuracy of surgeon-performed ultrasound in parathyroid localization. World J Surg. 2004;28:1122–6.

    Article  PubMed  Google Scholar 

  32. Udelsman R, Lin Z, Donovan P. The superiority of minimally invasive parathyroidectomy based on 1650 consecutive patients with primary hyperparathyroidism. Ann Surg. 2011;253:585–91.

    Article  PubMed  Google Scholar 

  33. Medicare reimbursement schedule. In: Centers for medicare and medicaid services.

  34. Bilezikian JP, Khan AA, Potts JT Jr. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the third international workshop. J Clin Endocrinol Metab. 2009;94:335–9.

    Article  PubMed  CAS  Google Scholar 

  35. Bergenfelz A, Lindblom P, Tibblin S, Westerdahl J. Unilateral versus bilateral neck exploration for primary hyperparathyroidism: a prospective randomized controlled trial. Ann Surg. 2002;236:543–51.

    Article  PubMed  Google Scholar 

  36. Siperstein A, Berber E, Barbosa GF, Tsinberg M, Greene AB, Mitchell J, Milas M. Predicting the success of limited exploration for primary hyperparathyroidism using ultrasound, sestamibi, and intraoperative parathyroid hormone: analysis of 1158 cases. Ann Surg. 2008;248:420–8.

    PubMed  Google Scholar 

  37. Udelsman R. Surgery in primary hyperparathyroidism: the patient without previous neck surgery. J Bone Miner Res. 2002;17(Suppl 2):N126–32.

    PubMed  Google Scholar 

  38. BEIR biological effects of ionizing radiation, Report BEIR VII. In: Council NR (ed) BEIR VII. Washington DC: National Academies Press; 2007.

  39. Kutler DI, Moquete R, Kazam E, Kuhel WI. Parathyroid localization with modified 4D-computed tomography and ultrasonography for patients with primary hyperparathyroidism. Laryngoscope. 2011;121:1219–24.

    Article  PubMed  Google Scholar 

  40. Mahajan A, Starker LF, Ghita M, Udelsman R, Brink JA, Carling T. Parathyroid four-dimensional computed tomography: evaluation of radiation dose exposure during preoperative localization of parathyroid tumors in primary hyperparathyroidism. World J Surg. 2012;36(6):1335–9.

    Article  PubMed  Google Scholar 

  41. Mettler FAJ, Huda W, Yoshizumi TT, Mahesh M. Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology. 2006;248:254–64.

    Article  Google Scholar 

  42. Sejean K, Calmus S, Durand-Zaleski I, et al. Surgery versus medical follow-up in patients with asymptomatic primary hyperparathyroidism: a decision analysis. Eur J Endocrinol. 2005;153:915–27.

    Article  PubMed  CAS  Google Scholar 

  43. Baliski C, Nosyk B, Melck A, Bugis S, Rosenberg F. The cost-effectiveness of three strategies for the surgical treatment of symptomatic primary hyperparathyroidism. Ann Surg Oncol. 2008;15:2653–60.

    Article  PubMed  Google Scholar 

  44. Ruda J, Stack BC Jr, Hollenbeak CS. The cost-effectiveness of sestamibi scanning compared to bilateral neck exploration for the treatment of primary hyperparathyroidism. Otolaryngol Clin North Am. 2004;37:855–70, x–xi.

    Article  PubMed  Google Scholar 

  45. Ruda JM, Stack BC Jr, Hollenbeak CS. The cost-effectiveness of additional preoperative ultrasonography or sestamibi-SPECT in patients with primary hyperparathyroidism and negative findings on sestamibi scans. Arch Otolaryngol Head Neck Surg. 2006;132:46–53.

    Article  PubMed  Google Scholar 

  46. Wang TS, Cheung K, Farrokhyar F, Roman SA, Sosa JA. Would scan, but which scan? A cost-utility analysis to optimize preoperative imaging for primary hyperparathyroidism. Surgery. 2011;150:1286–94.

    Article  PubMed  Google Scholar 

Download references

Acknowledgment

The authors thank Ekin Turan for help verifying radiation exposure estimates. This research is supported in part by the Program in Cancer Outcomes Research Training Grant (NCI R25CA092203) (Lubitz), and by Award Number K07CA133097 from the National Cancer Institute (Pandharipande). The research content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health.

Disclosures

Dr. Pandharipande receives funding from the Medical Imaging and Technology Alliance, for unrelated research.

Author information

Authors and Affiliations

  1. Endocrine Surgery Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Carrie C. Lubitz MD, MPH, Antonia E. Stephen MD & Richard A. Hodin MD

  2. Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Pari Pandharipande MD, MPH

Authors
  1. Carrie C. Lubitz MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Antonia E. Stephen MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Richard A. Hodin MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Pari Pandharipande MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Carrie C. Lubitz MD, MPH.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Lubitz, C.C., Stephen, A.E., Hodin, R.A. et al. Preoperative Localization Strategies for Primary Hyperparathyroidism: An Economic Analysis. Ann Surg Oncol 19, 4202–4209 (2012). https://doi.org/10.1245/s10434-012-2512-2

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-012-2512-2

Keywords

Search

Navigation