Baxter Katherine J, Short Heather L, Thakore Mitali A, Fisher Jeremy G, Rothstein David H, Heiss Kurt F, Raval Mehul V
Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine Children's Healthcare of Atlanta, Atlanta, GA, United States.
Rollins School of Public Health, Emory University, Atlanta, GA, United States.
J Pediatr Surg. 2017 Sep;52(9):1471-1474. doi: 10.1016/j.jpedsurg.2016.12.021. Epub 2016 Dec 30.
Though uncommon in children, pediatric thyroid nodules carry a higher risk of malignancy than adult nodules. While fine-needle aspiration (FNA) has been well established as the initial diagnostic test in adults, it has been more slowly adopted in children. The purpose of this study was to examine the comparative cost of FNA versus initial diagnostic lobectomy (DL) in the pediatric patient with an ultrasound-confirmed thyroid nodule.
A decision tree model was created using an adolescent with an asymptomatic thyroid nodule as the reference case. Probabilities were defined based on review of the pediatric and adult literature. Costs were determined from previous literature and the publicly available Medicare physician fee schedule. Tornado plot and sensitivity analyses were performed to assess sources of cost variation.
Using decision analysis, FNA was less costly than DL with an estimated cost of $2529 vs. $5680. Tornado analysis demonstrated that the probability of an initial indeterminate FNA result contributed most to cost variation. On sensitivity analysis, when probability of an indeterminate FNA result was increased to 35%, the maximum value found in the literature, FNA remained less costly. In Monte Carlo simulation set to 10,000 iterations, FNA was superior to DL in 74% of cases.
In this theoretical model based on available literature and costs, FNA is less costly than DL for initial diagnostic workup of thyroid nodules in children. Securing resources to offer FNA in the work-up of thyroid nodules may be financially beneficial to hospitals and patients.
Level 1 cost effectiveness study - using reasonable costs and alternatives used in study with values obtained from many studies, study used multi-way sensitivity analysis.
尽管儿童甲状腺结节并不常见，但与成人结节相比，其恶性风险更高。虽然细针穿刺抽吸活检（FNA）在成人中已被确立为初始诊断检查方法，但在儿童中的应用则较为缓慢。本研究的目的是比较在超声确诊甲状腺结节的儿科患者中，FNA与初始诊断性甲状腺叶切除术（DL）的成本。
以一名无症状甲状腺结节的青少年为参考病例，创建决策树模型。根据儿科和成人文献综述确定概率。成本根据以往文献和公开的医疗保险医师收费表确定。进行龙卷风图分析和敏感性分析以评估成本变化的来源。
通过决策分析，FNA的成本低于DL，估计成本分别为2529美元和5680美元。龙卷风分析表明，初始FNA结果不确定的概率对成本变化的影响最大。在敏感性分析中，当FNA结果不确定的概率增加到文献中发现的最大值35%时，FNA的成本仍然较低。在设置为10000次迭代的蒙特卡洛模拟中，FNA在74%的病例中优于DL。
在这个基于现有文献和成本的理论模型中，对于儿童甲状腺结节的初始诊断检查，FNA的成本低于DL。在甲状腺结节检查中确保有资源提供FNA可能对医院和患者在经济上有益。
1级成本效益研究——使用合理的成本和研究中使用的替代方法，其值来自许多研究，该研究使用了多向敏感性分析。
