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Sunday, 15 October 2006


Chris R. Baliski, MD, FRCSC, Kelowna General Hospital, Kelowna, BC, Canada, Bohdan Nosyk, MA, St. Paul's Hospital, Vancouver, BC, Canada, Adrienne Melck, MD, University of British Columbia, Vancouver, BC, Canada, Samuel P. Bugis, MD, FRCSC, St. Paul's Hospital, Vancouver, BC, Canada, Frances Rosenberg, MD, PhD, FRCPC, St. Paul's Hospital, Vancouver, BC, Canada, and Aslam H. Anis, PhD, University of British Columbia, Vancouver, BC, Canada.

Purpose: Modern surgical approaches to the treatment of HPT (Unilateral Neck Exploration (UNE), Minimally Invasive Parathyroidectomy (MIP)) have become commonplace in recent years, however the cost-effectiveness of these strategies has been questioned, given the well-documented effectiveness of the gold standard Bilateral Neck Exploration (BNE). The objective of our study was to determine the relative incremental cost-effectiveness of the BNE, UNE and MIP surgical techniques in treating patients with HPT.

Methods: Resource utilization and outcome data was collected prospectively on patients presenting to St. Paul's hospital for surgical treatment for HPT, 2002-2005. The primary measure of effectiveness was the rate of complications (hypocalcemia, paresthesias) post-surgery. Net benefits were compared between the three treatment options using a range of cost-effectiveness threshold (lambda) values. Non-parametric bootstrapping was applied to evaluate uncertainty around estimates of costs and effectiveness, from which cost-effectiveness acceptability curves (CEACs) were derived for each treatment strategy within a range of lambda values.

Results: Patient-level data on a total of 94 patients (BNE=50, UNE=19, MIP=25) provided estimates of mean costs between treatment arms (BNE=$4843; SE=($944), UNE=$4881 ($519), MIP=$5954 ($842)) as well as estimates of rates of complications (BNE=0.10, UNE=0.16, MIP=0.04). Subjects from the 3 treatment groups did not differ significantly with regard to age, sex, mean pre- and post-operative calcium levels, or hospital length of stay. The gold standard BNE strategy displayed 1st-order stochastic dominance over the UNE strategy, and 2nd-order stochastic dominance over the MIP strategy at lambda=$15,000. The CEAC showed that up to lambda=$5,000 per complication avoided, the BNE strategy was the most cost-effective with no uncertainty. It was only at lambda=$30,000 per complication avoided that a (marginally) higher proportion of iterations of net benefits of the MIP strategy were higher.

Conclusion: Our results suggest that in the experience of HPT surgery at St. Paul's Hospital, newer, costlier strategies of treatment of HPT may be less cost-effective than the gold standard Bilateral Neck Exploration.

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See more of The 28th Annual Meeting of the Society for Medical Decision Making (October 15-18, 2006)