In Haejin, MD, MBA, Elizabeth N. Pearce, MD, MSc, Arthur K. Wong, MBA, MSc, James F. Burgess, Jr., PhD, David B. McAneny, MD, FACS, Jennifer E. Rosen, MD, FACS
Boston Medical Center; Boston, MA
PURPOSE OF STUDY
First-line treatment for Gravesí disease is generally 18 months of antithyroid medication (ATM). Controversy exists concerning the best next-line treatment for patients who have failed to become euthyroid; options include lifelong ATM, radioactive iodine (RAI) or total thyroidectomy (TT). We hypothesize that TT is more cost-effective than RAI or lifelong ATM for these patients.
We performed a cost-effectiveness analysis comparing the different strategies. Treatment efficacy and complication data were derived from a literature review. Costs were examined from a healthcare system perspective using actual Medicare reimbursement to a university hospital. Outcomes were measured in quality-adjusted life years (QALY). Costs and effectiveness were examined at present values; all key variables were subject to sensitivity analysis.
SUMMARY OF RESULTS:
Total thyroidectomy (TT) resulted in a gain of 1.32 QALYs compared to RAI at an additional cost of $9,594, resulting in an incremental cost effectiveness ratio (ICER) of 7,240 $/QALY and is the most cost-effective strategy. RAI was the least costly option at $23,600 but also provided the least QALYs (25.08 QALY). Once the cost of TT exceeds $19,300, the ICERs of lifelong ATM and TT reverse, and lifelong ATM becomes the most cost-effective treatment at 15,000 $/QALY.
This is the first formal cost-effectiveness analysis in the United States regarding the optimal treatment for patients with Gravesí disease who fail to achieve euthyroidism after 18 months of ATM. Our findings demonstrate that TT is more cost-effective than RAI or lifelong ATM in these patients; this continues until the cost of TT becomes greater than $19,300.