To stimulate or withdraw? A cost-utility analysis of recombinant human thyrotropin versus thyroxine withdrawal for radioiodine ablation in patients with low-risk differentiated thyroid cancer in the United States

Abstract

Context: Use of recombinant human TSH (rhTSH) prior to radioactive iodine remnant ablation for patients with differentiated thyroid cancer avoids the hypothyroid state and improves quality of life. European studies have shown that use of rhTSH vs. thyroid hormone withdrawal is a cost-effective method for preparing patients for ablation.

Objective: The objective of the study was to determine the cost-utility of rhTSH prior to ablation in the United States.

Design/setting/subjects: A Markov decision model was developed for a hypothetical group of adult patients with low-risk differentiated thyroid cancer who were prepared for ablation by either rhTSH or thyroid hormone withdrawal. Patients entered the model after initial thyroidectomy; follow-up was in accordance with current American Thyroid Association guidelines. Input data were obtained from the literature, Medicare reimbursement schedule, and U.S. Bureau of Labor Statistics. Sensitivity analyses were performed for all clinically relevant inputs.

Main outcome measures: Cost-utility, measured in U.S. dollars per quality-adjusted life-year ($/QALY), was measured.

Results: Use of rhTSH yielded an incremental cost-utility of $52,554/QALY (95% confidence interval $52,058-53,050/QALY) (incremental societal cost of $1,365/patient; incremental benefit of 0.026 QALY/patient). The majority of cost and benefit occurs during the preablation, ablation, and postablation period; differences in cost are due to cost of rhTSH and differences in productivity loss (days off work). The model was most sensitive to changes in time off work, cost of rhTSH, and differences in utilities of health states.

Conclusions: In the United States, the cost-effectiveness of rhTSH for ablation in patients with low-risk differentiated thyroid cancer is highly dependent on potential variations in cost of rhTSH, rates of remnant ablation, time off work, and quality of life.