Cost-effectiveness of preoperative parathyroid imaging in primary hyperparathyroidism: A synthesis of eight health-economic analyses.

PURPOSE: Preoperative localisation of hyperfunctioning parathyroid tissue underpins minimally invasive parathyroidectomy (MIP) in primary hyperparathyroidism (pHPT). Cervical ultrasound (cUS), [⁹⁹ᵐTc]Tc-sestamibi ([⁹⁹ᵐTc]Tc-MIBI) single-photon emission computed tomography/computed tomography (SPECT/CT), and choline positron emission tomography/computed tomography (PET/CT) differ in diagnostic accuracy and cost. Whether choline PET/CT should be reserved for second-line use or implemented first-line remains debated. We synthesised cost-effectiveness evidence from recent health-economic analyses across different healthcare systems.

METHODS

In this narrative review, MEDLINE (via PubMed) was searched for original health-economic analyses evaluating preoperative parathyroid imaging in pHPT published 2022-2026, supplemented by reference-list screening. Eight studies were included. The modelling framework, analytical perspective, imaging comparators, base-case costs, incremental cost-effectiveness ratios (ICERs), incremental cost-utility ratios (ICURs) and willingness-to-pay (WTP) thresholds were extracted.

RESULTS

The included studies comprised two retrospective cohorts, three decision trees, one Markov model, one cohort-level state-transition model, and one randomised controlled trial (APACH2). Across most healthcare settings, first-line choline PET/CT was more cost-effective than [⁹⁹ᵐTc]Tc-MIBI-based pathways. Reported ICERs included €471 per additional surgical cure (APACH2), US$470 per quality-adjusted life-year (QALY) (USA), €12,650 per QALY (France), and Colombian pesos (COP) 101,727-277,037 per additional cure. At one Dutch centre, [¹¹C]choline PET/CT was a dominant strategy (ICUR -€18,846/QALY), while a Spanish cohort demonstrated approximately 19% lower per-patient costs with PET-only imaging. PET tariff and local [⁹⁹ᵐTc]Tc-MIBI performance were the principal determinants of cost-effectiveness.

CONCLUSIONS

First-line choline PET/CT is cost-effective compared with [⁹⁹ᵐTc]Tc-MIBI-based imaging pathways across most WTP thresholds. Implementation should be guided by local PET reimbursement and [⁹⁹ᵐTc]Tc-MIBI performance.