Endocrine Abstracts

Background: Guidelines in healthcare shall be evidence-based, satisfy patients’ needs and improve patients’ outcomes. We aimed to estimate incremental costs after the introduction of a national guideline for Graves’ disease in Sweden adding the Graves’ Recurrent Events After Therapy (GREAT) score with genetic determinants to predict recurrence, a thyroid nurse, calcium-D-vitamin treatment preoperatively, and thyroid stimulating immunoglobulins.

Methods: To do a cost-utility analysis using quality of life (QoL) data from two Swedish studies, one in 1996 and one in 2012, to calculate QALYs.

Findings: Antithyroid drugs (ATD) was less costly, achieved 0.88 QALYs during 8 years, and dominated over radioactive iodine (RAI) treatment. The relevant ICER was ATD vs thyroid surgery. Surgery was more costly than ATD, but was also more effective, and the ICER was equal to 39 631 Euro (43 561 USD, 412 960 SEK) per QALY gained. In recurrent Graves’ disease, the QALY weight for surgery after ATD was 0.76 compared to 0.79 when surgery was the initial treatment. If individuals requiring surgery could be identified at start of first treatment, QALYs would be higher (6.32) and the cost lower (13 947 Euro (15 351 USD, 145 330 SEK)). The net cost after the new guideline was +17.6%, which was an effect by more time with the patient for the thyroid nurse and genetic analyses 816 Euro (8500 SEK). If the GREAT score was also applied, the total net cost was +14.8% if 24% of the tested patients changed treatment to surgery.

Interpretation: Thyroid surgery was more cost-effective than RAI when ablative treatments is advocated. Prediction scores for recurrence directing patients to earlier thyroid surgery is cost-effective and facilitates introduction of a thyroid nurse. The price for genetic analyses is based on historical costs, but could it be lower the gain would be even larger. Also, the effect lasts probably much longer than the eight years we could observe in our study. If we assume a life-long effect, i.e. further 30 years, the cost per QALY drops significantly to around 2 498 Euro (2 747 USD, 26 000 SEK). This means that our calculations certainly overestimate the cost per won QALY. The threshold value for cost-effectiveness in Sweden is 48 000 Euro (53 000 USD, 500 000 SEK) per QALY gained and is approximately at the same level as other countries in Northwest Europe. Health economic evaluations shall accompany future guidelines.