Professional Documents
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REFERENCE
1. Evidence-Based Medicine Working Group. Evidence-based medicine. JAMA 1992;268:24202425.
SELECTED ARTICLE
Treatment Options for Graves Disease:
A Cost-Effectiveness Analysis
Haejin I, Pearce EN, Wong AK, et al. J Am Coll Surg
2009;209:170179.
ABSTRACT
Objective: To determine the most cost effective option
for treating Graves disease after 18 months of antithyroid
medication (ATM).
Base case: Thirty-year-old nonpregnant woman without a large goiter, ophthalmopathy, or palpable nodules,
who has failed to remain euthyroid after completion of 18
months of ATM.
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ISSN 1072-7515/11/$36.00
doi:10.1016/j.jamcollsurg.2011.09.015
807
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on patient opinions. So, it is possible that patient assessments of the utility or disutility of different disease states
might differ considerably from those that were assigned by
the authors. In addition, costs were based on the reimbursement structure for Medicare as representative of US
payors. Actual 2007 Medicare reimbursements to a large
urban university hospital were used to calculate the cost of
treatment. Medication costs were obtained from average
US wholesale prices. Future health care costs were computed using an inflation rate of 5%. A standard discount
rate of 3% was applied to both cost and effectiveness, as
recommended by the Panel on Cost-Effectiveness in
Health and Medicine. However, although this methodology is the easiest, there are some concerns about it. The first
limitation of this method is that the price is not always
the same as the actual cost of delivering the service or
product. These variances may occur because the price was
established some time previously and does not reflect current costs; it may be due to the bargaining power of health
care institutions, third-party payers, and the profit margin
of for-profit health care systems. The second limitation is
that the results of the analysis may not be generalizable to
other systems. Because the cost of each resource is not
explicitly stated, it is not possible to substitute the cost that
may be incurred in another system in the analysis to determine if the results of the analysis are robust. Having said
that, Medicare reimbursement is not a bad way of estimating cost in the US setting because these rates are established
centrally and are not subject to bargaining and volume
discounts.
In summary, the analysis by Haejin and colleagues is a
timely article. This review brings to light the role that thyroidectomy can have in the treatment of Graves disease. It
is likely that the surgeons role will expand in the years to
come, with the increasing awareness and concerns about
the long-term impact of RAI and the increasing emphasis
J Am Coll Surg
on cost-effective therapies. Surgeons need to be more involved in the first line decision process when it comes to
treatment of Graves disease. Thyroidectomy is a valid
treatment option and it is only the surgeon who can accurately explain the surgical risk vs benefit of this modality to
the patient.