Cost-Effectiveness of 18F-Choline PET/CT Versus MIBI SPECT/CT for Preoperative Localization in Primary Hyperparathyroidism in the Colombian Healthcare System.

INTRODUCTION: Primary hyperparathyroidism (PHPT) is a common endocrine disorder, most often caused by a single parathyroid adenoma, for which parathyroidectomy is the treatment of choice. Accurate preoperative localization is essential for focused surgery. In Colombia, technetium-99 m sestamibi SPECT/CT (MIBI-SPECT/CT) is the standard, though limited by low sensitivity. 18F-choline PET/CT offers superior accuracy but at a higher cost. The only randomized trial comparing both modalities is the APACH2 study (Quak et al.).

METHODS: We developed a cost-effectiveness study using three decision-analytic models, incorporating Colombian healthcare costs, diagnostic accuracy, and surgical outcomes based on APACH2 data. One was deterministic, while two used probabilistic approaches: one directly from trial results and another adapted to local clinical practice. Decision trees assumed that imaging strategies lead to different costs and outcomes.

RESULTS: In all models, upfront PET/CT was more costly but also more effective than MIBI-SPECT/CT, with an incremental cost-effectiveness ratio below Colombia's willingness-to-pay (WTP) threshold. Sensitivity analyses identified normocalcemia probability, test sensitivity, and imaging cost as main drivers. In probabilistic and adapted models, PET/CT remained cost-effective, exceeding 99% probability when WTP surpassed COP 4 000 000 per additional cured patient.

CONCLUSIONS: 18F-choline PET/CT is a clinically useful and cost-effective strategy for preoperative localization in PHPT compared with MIBI-SPECT/CT. These findings support its selective adoption in diagnostic algorithms and inform healthcare policy decisions.