Surgery versus medical follow-up in patients with asymptomatic primary hyperparathyroidism: a decision analysis

Objectives: To examine the cost-effectiveness of strategies for management of primary asymptomatic hyperparathyroidism: surgical strategies and medical follow-up versus surgery. Design: We used a Markov state-transition decision-analytic model for an hypothetical cohort of 55-year-old women to compare with a lifetime horizon costs and effectiveness of bilateral neck exploration (BNE), unilateral neck exploration (LINE), video-assisted parathyroidectomy (VAP) and lifelong medical follow-up shifting for either BNE or LINE in case of disease progression. Methods: Data on localization tests, complications and treatment efficacies were derived from a systematic review of the literature. Outcomes were expressed as quality-adjusted life years (OALY). Costs ( 2002) discounted at 3% yearly were estimated from the health care system perspective. Results: In the base-case analysis, VAP strategy (VAPS) was the most effective and BNE strategy (BNES) was the least costly. LINE strategy (LINES) had an incremental cost-effectiveness ratio of E2688/OALY versus BNES and VAPS of E17 250/OALY in comparison with LINES. Surgical management was more effective than medical follow-up with acceptable incremental cost-effectiveness ratios. VAPS became less effective than LINES over 71 years. Differences between LINES and VAPS were sensitive to success and complication rates, quality-of-life weights and procedural costs. Medical follow-up strategies became the most effective if quality-of-life weight for this condition was higher than 0.99. Conclusions: Surgery is more effective than medical follow-up at a reasonable cost and can be preferred except in patients choosing medical follow-up. Minimally invasive surgery is cost-effective compared to the traditional surgical approach.