376 chapter 6 This reduced the cost difference between both strategies to a mean difference of -€1,000 (p=0.06) in thyroid nodule-related medical costs. Costs for surgical complications and other healthcare consumption (i.e., care unrelated to the thyroid nodule), patient costs, and productivity losses were similar across both groups. The total first-year societal costs were €15,500 in the [18F]FDG-PET/CTdriven group as compared to €20,100 in the diagnostic surgery group, with a mean difference of -€4,500 (p=0.06). Lifelong utilities and costs Estimated using our Markov model, the lifelong utilities were similar for both strategies, with 19.273 mean QALYs for the [18F]FDG-PET/CT-driven group and 18.871 for the diagnostic surgery group (p=0.42). None of the lifelong societal costs were statistically significantly different between the two groups (Table 6). The mean discounted lifelong societal costs were €103,500 per patient in the [18F] FDG-PET/CT-driven group as compared to €113,400 in the diagnostic surgery group, with a mean difference of -€9,900 (p=0.14). Lifelong extrapolation thus increased the size of the difference in QALYs and costs without reaching statistical significance. Cost-effectiveness analysis From a societal perspective, lifelong costs appeared in favour of [18F]FDG-PET/CT-driven management while HRQoL was sustained. Consequently, according to our analysis, [18F]FDG-PET/CT-driven management is very likely cost-effective as compared to diagnostic surgery for Bethesda III/IV thyroid nodules, regardless of the willingness to pay per QALY. The probability of cost-effectiveness is >80% for any willingness to pay and minimally varies over the range of willingness to pay. The probability is 87% at €20,000 per QALY, 84% at €50,000, and 82% at €80,000 per QALY (Figure 3). Univariate sensitivity analysis Results of the univariate sensitivity analysis are shown in Figure 4. At a willingness-to-pay of €50,000 per QALY, [18F]FDG-PET/CT-driven management remained cost-effective as compared to diagnostic surgery for the predetermined ranges of all of the parameters tested. Of the parameters selected for univariate sensitivity analysis, the disutility after HT for a benign nodule, the probability of a missed malignancy after initial surveillance for an [18F]FDG-negative nodule (representing the false-negative rate or NPV of [18F]FDG-PET/CT), the disutility of active surveillance of an [18F]FDG-negative nodule, and the price of the [18F]FDG-PET/CT had the largest influence on cost-effectiveness to the detriment of [18F]FDG-PET/CT-driven management.
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