Cost-Effectiveness Analysis of Microscopic and Endoscopic Transsphenoidal Surgery Versus Medical Therapy in the Management of Microprolactinoma in the United States
Cost-Effectiveness Analysis of Microscopic and Endoscopic Transsphenoidal Surgery Versus Medical Therapy in the Management of Microprolactinoma in the United States
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DOI：
10.1016/j.wneu.2015.10.090
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发表时间：
2016-03-01
影响因子：
2
通讯作者：
Liu, James K.
中科院分区：
文献类型：
--
作者：
Jethwa, Pinakin R.;Patel, Tapan D.;Liu, James K.
背景技术背景：虽然泌乳素瘤是有效的治疗与多巴胺激动剂，有些人提出了根治性手术切除的选择情况下，微小泌乳素瘤，以避免终身的药物治疗。我们进行了成本效益分析比较经蝶手术（显微手术或内窥镜）和药物治疗（溴隐亭或卡麦角林）与decision analysis modeling.METHODS：一个2臂决策树与TreeAge Pro Suite 2012创建比较前期经蝶手术与药物治疗。经济角度是医疗保健第三方付款人的角度。在文献回顾的基础上，我们将医疗和手术成本以及并发症考虑在内，为每种潜在结局分配了合理的成本和效用分布。进行基础病例分析，敏感性分析和蒙特卡罗模拟，以确定每个策略的成本效益在5年和10年的时间horizontal.Results：在基础病例的情况下，显微镜经蝶手术是最具成本效益的选择，在5年的时间诊断，但是，由10年的时间范围内，内窥镜经蝶手术成为最具成本效益的选择。在这两个时间范围内，发现药物治疗（溴隐亭和卡麦角林两者）比经蝶手术（即，在该模式中，医疗部门由外科部门主导）。双向敏感性分析表明，如果内镜手术的治愈率大于90%，并发症发生率小于1%，则内镜切除术将是最具成本效益的策略。在两个时间范围内对内窥镜手术与显微镜手术进行蒙特卡罗模拟。该分析产生了5年时每质量调整生命年80，235美元和10年时每质量调整生命年40，737美元的增量成本效果比，这意味着随着时间间隔的增加，内窥镜经蝶手术是更具成本效益的治疗策略。根据我们模型的结果，经蝶手术切除微小泌乳素瘤，无论是显微手术还是内窥镜，在预期寿命超过10年的年轻患者中，似乎比终身药物治疗更具成本效益。我们提醒，微泌乳素瘤的手术切除只能在选择的情况下，由经验丰富的垂体外科医生在高容量的中心，高生化治愈率和低并发症发生率。
BACKGROUND: Although prolactinomas are treated effectively with dopamine agonists, some have proposed curative surgical resection for select cases of microprolactinomas to avoid life-long medical therapy. We performed a cost-effectiveness analysis comparing transsphenoidal surgery (either microsurgical or endoscopic) and medical therapy (either bromocriptine or cabergoline) with decision analysis modeling.METHODS: A 2-armed decision tree was created with TreeAge Pro Suite 2012 to compare upfront transsphenoidal surgery versus medical therapy. The economic perspective was that of the health care third-party payer. On the basis of a literature review, we assigned plausible distributions for costs and utilities to each potential outcome, taking into account medical and surgical costs and complications. Base-case analysis, sensitivity analysis, and Monte Carlo simulations were performed to determine the cost-effectiveness of each strategy at 5-year and 10-year time horizons.RESULTS: In the base-case scenario, microscopic transsphenoidal surgery was the most cost-effective option at 5 years from the time of diagnosis; however, by the 10-year time horizon, endoscopic transsphenoidal surgery became the most cost-effective option. At both time horizons, medical therapy (both bromocriptine and cabergoline) were found to be more costly and less effective than transsphenoidal surgery (i.e., the medical arm was dominated by the surgical arm in this model). Two-way sensitivity analysis demonstrated that endoscopic resection would be the most cost-effective strategy if the cure rate from endoscopic surgery was greater than 90% and the complication rate was less than 1%. Monte Carlo simulation was performed for endoscopic surgery versus microscopic surgery at both time horizons. This analysis produced an incremental cost-effectiveness ratio of $80,235 per quality-adjusted life years at 5 years and $40,737 per quality-adjusted life years at 10 years, implying that with increasing time intervals, endoscopic transsphenoidal surgery is the more cost-effective treatment strategy.CONCLUSIONS: On the basis of the results of our model, transsphenoidal surgical resection of microprolactinomas, either microsurgical or endoscopic, appears to be more cost-effective than life-long medical therapy in young patients with life expectancy greater than 10 years. We caution that surgical resection for microprolactinomas be performed only in select cases by experienced pituitary surgeons at high-volume centers with high biochemical cure rates and low complication rates.