Background: Controversy exists concerning the best treatment for asymptomatic primary hyperparathyroidism (PHPT) when the National Institutes of Health consensus conference criteria for parathyroidectomy are not met. We hypothesized that parathyroidectomy would be more cost-effective than observation or pharmacologic therapy for these patients. Methods: Cost-effectiveness analysis was performed comparing treatment strategies for asymptomatic PHPT. Treatment outcomes, their probabilities, and costs were identified on the basis of literature and cost database review. Outcomes were weighted by using established quality-of-life utility factors. Sensitivity analysis was used to examine the uncertainty of costs and utility estimates in the model. Results: The incremental cost-effectiveness ratio for parathyroidectomy was $4778 per quality-adjusted life year (QALY) gained. Operation remained cost-effective until the average cost of parathyroidectomy increased from the estimated value of $4778 to $14,650. Pharmacologic therapy was not cost-effective unless the annual cost of therapy decreased from an estimated $7406 (for cinacalcet) to $221. Parathyroidectomy ceases to be preferred over monitoring if a quality-of-life difference is not demonstrable after curative operation. Conclusions: Parathyroidectomy is more cost-effective than observation for managing asymptomatic PHPT patients who do not meet National Institutes of Health criteria for parathyroidectomy. Furthermore, pharmacologic therapies with a greater than $221 annual cost were not cost-effective in this model.
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