A Cost-Utility Analysis of Recurrent Laryngeal Nerve Monitoring in the Setting of Total Thyroidectomy
A Cost-Utility Analysis of Recurrent Laryngeal Nerve Monitoring in the Setting of Total Thyroidectomy
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DOI：
10.1001/jamaoto.2016.2860
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发表时间：
2016-12-01
影响因子：
7.8
通讯作者：
de Almeida, John R.
中科院分区：
文献类型：
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作者：
Rocke, Daniel J.;Goldstein, David P.;de Almeida, John R.
重要性 喉返神经 (RLN) 的术中神经监测 (IONM) 被用作降低神经损伤率的工具，尽管研究结果对 IONM 的功效存在分歧。这种甲状腺全切除术的成本效益尚未得到充分研究。 目的 确定 IONM 在甲状腺全切除术中是否是一种具有成本效益的干预措施。 设计和设置 本研究创建了甲状腺全切除术的决策树模型，从社会角度分析通用 IONM（即在每个病例中使用）与选择性 IONM（即高危病例，包括再手术病例、胸骨后或中毒病例）的成本效益甲状腺肿和已知癌症的病例）与无 IONM（仅视觉识别）。该模型的参数来自文献综述，并进行确定性和概率分析来测试模型的稳健性。所有分析均根据模型进行；干预措施 模拟全甲状腺切除术，使用和不使用 RLN IONM。 主要结果和措施 通用 IONM 与选择性 IONM 与仅 RLN 视觉识别的成本效益。 结果 RLN 视觉识别为每位患者节省了 179.40 美元和 683.20 美元的成本，并改善了 0.001 和 0.004质量调整生命年，分别优于选择性 IONM 和通用 IONM。尽管确定性和概率敏感性分析的成本和效用存在差异，但视觉识别是最具成本效益的方法。在单向敏感性分析中，通过 IONM 降低 RLN 损伤的可能性使得选择性 IONM 更具成本效益。当用于视觉识别的RLN损伤率保持恒定（3.86%）时，当其RLN损伤率降至1.9%以下时，选择性IONM成为最具成本效益的方法。由于 IONM 导致的 RLN 损伤率下降到视觉识别 RLN 损伤率的 50.4% 以下，选择性 IONM 成为最具成本效益的方法。结论和相关性 RLN 的视觉识别比任何 IONM 的使用都更具成本效益。如果临床医生使用 IONM 与目视识别相比可以将 RLN 损伤率降低 50.4% 或更多，那么在高危病例中选择性使用 IONM 是最具成本效益的。
IMPORTANCE Intraoperative nerve monitoring (IONM) of the recurrent laryngeal nerve (RLN) is used as a tool to decrease the rate of nerve injury, although study findings are divergent on IONM efficacy. The cost-effectiveness of this approach to total thyroidectomy has not been well studied.OBJECTIVE To determine whether IONM is a cost-effective intervention in the setting of total thyroidectomy.DESIGN AND SETTING This study creates a decision-tree model of total thyroidectomy to analyze, from a societal perspective, the cost-effectiveness of universal IONM (ie, use in every case) vs selective IONM (ie, high-risk cases including reoperative cases, substernal or toxic goiters, and cases with known cancer) vs no IONM (visual identification only). Parameters for the model were derived from review of the literature, and deterministic and probabilistic analyses were performed to test the model's robustness. All analyses were performed from the model; there were no human participants.INTERVENTIONS Modeled total thyroidectomy with and without IONM of the RLN.MAIN OUTCOMES AND MEASURES Cost-effectiveness of universal IONM vs selective IONM vs visual identification only of the RLN.RESULTS Visual identification of the RLN led to a cost savings of $179.40 and $683.20 per patient, and an improvement of 0.001 and 0.004 quality-adjusted life-years, over selective IONM and universal IONM, respectively. Visual identification was the most cost-effective approach, despite variations in costs and utilities in both deterministic and probabilistic sensitivity analyses. In a 1-way sensitivity analysis, decreasing the probability of RLN injury with IONM made selective IONM more cost-effective. When the rate of RLN injury for visual identification was kept constant (at 3.86%), selective IONM became the most cost-effective approach when its RLN injury rate dropped below 1.9%. As the rate of RLN injury with IONM dropped below 50.4% of the visual identification RLN injury rate, selective IONM became the most cost-effective approach.CONCLUSIONS AND RELEVANCE Visual identification of the RLN is more cost-effective than any use of IONM. If a clinician can, with use of IONM, decrease the rate of RLN injury by 50.4% or more compared with visual identification, selective use of IONM in high-risk cases is most cost-effective.