High Suspicion Sub-Centimeter Thyroid Nodules: Cost-Effectiveness of Active Surveillance versus Fine Needle Aspiration.

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To compare the cost-benefit of active surveillance (AS) against immediate fine needle aspiration (FNA) of sonographically suspicious sub-centimeter thyroid nodules.


A Markov model was constructed to compare the cost-benefit of three strategies from point of discovery till death: 1) Surveillance of All Nodules; 2) Surveillance of Nodules with Positive Cytology; and 3) Surgery of Nodules with Positive Cytology. The reference case was a 40 year-old female with a sonographically suspicious sub-centimeter thyroid nodule. Transition probabilities, costs, and health utilities were derived from the literature. Sensitivity analyses were performed to evaluate model uncertainty. Willingness-to-pay threshold was set at $100,000/quality-adjusted life year (QALY).


Surveillance of Nodules with Positive Cytology dominated in the reference scenario, and was cost-beneficial over Surveillance of All Nodules independent of the utility of AS. Surveillance of All Nodules was cost-beneficial only at life expectancy <2.6 years or surveillance duration <4 years.


While current guidelines recommend AS of sonographically suspicious sub-centimeter nodules, this study's results suggest immediate FNA (Surveillance of Nodules with Positive Cytology) is more cost-beneficial compared to AS (Surveillance of All Nodules). Patients with positive cytology on FNA may subsequently opt for AS (Surveillance of Nodules with Positive Cytology) or surgery (Surgery of Nodules with Positive Cytology) according to their level of comfort (i.e. utility) with AS.





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Woon, Tian Kai, Ke Zhou, Bien Soo Tan and David B Matchar (2022). High Suspicion Sub-Centimeter Thyroid Nodules: Cost-Effectiveness of Active Surveillance versus Fine Needle Aspiration. Journal of vascular and interventional radiology : JVIR. p. S1051-0443(22)01325-2. 10.1016/j.jvir.2022.11.005 Retrieved from https://hdl.handle.net/10161/26344.

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David Bruce Matchar

Professor of Medicine

My research relates to clinical practice improvement - from the development of clinical policies to their implementation in real world clinical settings. Most recently my major content focus has been cerebrovascular disease. Other major clinical areas in which I work include the range of disabling neurological conditions, cardiovascular disease, and cancer prevention.
Notable features of my work are: (1) reliance on analytic strategies such as meta-analysis, simulation, decision analysis and cost-effectiveness analysis; (2) a balancing of methodological rigor the needs of medical professionals; and (3) dependence on interdisciplinary groups of experts.
This approach is best illustrated by the Stroke Prevention Patient Outcome Research Team (PORT), for which I served as principal investigator. Funded by the AHCPR, the PORT involved 35 investigators at 13 institutions. The Stroke PORT has been highly productive and has led to a stroke prevention project funded as a public/private partnership by the AHCPR and DuPont Pharma, the Managing Anticoagulation Services Trial (MAST). MAST is a practice improvement trial in 6 managed care organizations, focussing on optimizing anticoagulation for individuals with atrial fibrillation.
I serve as consultant in the general area of analytic strategies for clinical policy development, as well as for specific projects related to stroke (e.g., acute stroke treatment, management of atrial fibrillation, and use of carotid endarterectomy.) I have worked with AHCPR (now AHRQ), ACP, AHA, AAN, Robert Wood Johnson Foundation, NSA, WHO, and several pharmaceutical companies.
Key Words: clinical policy, disease management, stroke, decision analysis, clinical guidelines

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