Institute of Biochemistry and Molecular Medicine, University of Bern, Bern, Switzerland.
Graduate School for Cellular and Biomedical Sciences (GCB), Bern, Switzerland.
BMJ Open. 2024 Sep 5;14(9):e082901. doi: 10.1136/bmjopen-2023-082901.
Preoperative and intraoperative diagnostic tools influence the surgical management of primary hyperparathyroidism (PHPT), whereby their performance of classification varies considerably for the two common causes of PHPT: solitary adenomas and multiglandular disease. A consensus on the use of such diagnostic tools for optimal perioperative management of all PHPT patients has not been reached.
A decision tree model was constructed to estimate and compare the clinical outcomes and the cost-effectiveness of preoperative imaging modalities and intraoperative parathyroid hormone (ioPTH) monitoring criteria in a 21-year time horizon with a 3% discount rate. The robustness of the model was assessed by conducting a one-way sensitivity analysis and probabilistic uncertainty analysis.
The US healthcare system.
A hypothetical population consisting of 5000 patients with sporadic, symptomatic or asymptomatic PHPT.
Preoperative and intraoperative diagnostic modalities for parathyroidectomy.
Costs, quality-adjusted life-years (QALYs), net monetary benefits (NMBs) and clinical outcomes.
In the base-case analysis, four-dimensional (4D) CT was the least expensive strategy with US$10 276 and 15.333 QALYs. Ultrasound and Tc-Sestamibi single-photon-emission CT/CT were both dominated strategies while F-fluorocholine positron emission tomography was cost-effective with an NMB of US$416 considering a willingness to pay a threshold of US$95 958. The application of ioPTH monitoring with the Vienna criterion decreased the rate of reoperations from 10.50 to 0.58 per 1000 patients compared to not using ioPTH monitoring. Due to an increased rate of bilateral neck explorations from 257.45 to 347.45 per 1000 patients, it was not cost-effective.
4D-CT is the most cost-effective modality for the preoperative localisation of solitary parathyroid adenomas and multiglandular disease. The use of ioPTH monitoring is not cost-effective, but to minimise clinical complications, the Miami criterion should be applied for suspected solitary adenomas and the Vienna criterion for multiglandular disease.
术前和术中的诊断工具影响原发性甲状旁腺功能亢进症（PHPT）的手术管理，其对两种常见 PHPT 病因（单发腺瘤和多腺体疾病）的分类性能差异很大。对于所有 PHPT 患者的最佳围手术期管理，尚未就此类诊断工具的使用达成共识。
构建决策树模型，以在 21 年时间范围内（折现率为 3%），估算和比较术前影像学检查和术中甲状旁腺激素（ioPTH）监测标准的临床结果和成本效益。通过进行单向敏感性分析和概率不确定性分析来评估模型的稳健性。
美国医疗保健系统。
一个由 5000 名患有散发性、有症状或无症状 PHPT 的患者组成的假设人群。
甲状旁腺切除术的术前和术中诊断方法。
成本、质量调整生命年（QALYs）、净货币收益（NMB）和临床结果。
在基本案例分析中，四维（4D）CT 是最具成本效益的策略，费用为 10276 美元，QALY 为 15.333。超声和 Tc-Sestamibi 单光子发射 CT/CT 均为劣势策略，而 F-氟胆碱正电子发射断层扫描在考虑到愿意支付 95958 美元的阈值时具有成本效益，其 NMB 为 416 美元。与不使用 ioPTH 监测相比，维也纳标准下 ioPTH 监测的应用使每 1000 例患者中的再手术率从 10.50%降至 0.58%。由于双侧颈部探查率从每 1000 例患者的 257.45 例增加到 347.45 例，因此这不具有成本效益。
4D-CT 是术前定位单发甲状旁腺腺瘤和多腺体疾病的最具成本效益的方法。ioPTH 监测的使用不具有成本效益，但为了最大限度地减少临床并发症，应将迈阿密标准应用于疑似单发腺瘤，将维也纳标准应用于多腺体疾病。
