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Re: The Management of Aldosterone-Producing Adrenal Adenomas—Does Adrenalectomy Increase Costs?
Urological Survey
Urological Oncology: Renal, Ureteral and Retroperitoneal Tumors Re: The Management of Aldosterone-Producing Adrenal Adenomas—Does Adrenalectomy Increase Costs? B. Reimel, K. Zanocco, M. J. Russo, R. Zarnegar, O. H. Clark, J. D. Allendorf, J. A. Chabot, Q. Y. Duh, J. A. Lee and C. Sturgeon Department of Surgery, Columbia University Medical Center, New York, New York Surgery 2010; 148: 1178 –1185.
Background: Most experts agree that primary hyperaldosteronism (PHA) caused by an aldosteroneproducing adenoma (APA) is best treated by adrenalectomy. From a public health standpoint, the cost of treatment must be considered. We sought to compare the current guideline-based (surgical) strategy with universal pharmacologic management to determine the optimal strategy from a cost perspective. Methods: A decision analysis was performed using a Markov state transition model comparing the strategies for PHA treatment. Pharmacologic management for all patients with PHA was compared with a strategy of screening for and resecting an aldosterone-producing adenoma. Success rates were determined for treatment outcomes based on a literature review. Medicare reimbursement rates were calculated to estimate costs from a third-party payer perspective. Results: Screening for and resecting APAs was the least costly strategy in this model. For a reference patient with 41 remaining years of life, the discounted expected cost of the surgical strategy was $27,821. The discounted expected cost of the medical strategy was $34,691. The cost of adrenalectomy would have to increase by 156% to $22,525 from $8,784 for universal pharmacologic therapy to be less costly. Screening for APA is more costly if fewer than 9.6% of PHA patients have resectable APA. Conclusion: Resection of APAs was the least costly treatment strategy in this decision analysis model. Editorial Comment: The management of functional benign renal masses has changed in recent years, owing to the identification of effective medical therapies for control of secondary hypertension. In the case of primary hyperaldosteronism the successful medical treatment of bilateral adrenal hyperplasia has led to the question of whether unilateral aldosterone producing adenomas could be managed by a similar strategy. The authors of this study demonstrate through a decision analysis that the cost of medical therapy is greater than surgical adrenalectomy for these patients. Several assumptions are required—perhaps most importantly that adrenalectomy can be performed laparoscopically with low morbidity, short hospitalization and high likelihood of correction of hypertension. The study confirms that although it is more invasive, well-done surgery is often less costly than chronic medical therapy. Samir S. Taneja, M.D.
0022-5347/11/1856-2097/0 THE JOURNAL OF UROLOGY® © 2011 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
Vol. 185, 2097-2101, June 2011 Printed in U.S.A. DOI:10.1016/j.juro.2011.02.2680
www.jurology.com
2097
Urological Oncology: Renal, Ureteral and Retroperitoneal Tumors Re: The Management of Aldosterone-Producing Adrenal Adenomas—Does Adrenalectomy Increase Costs? B. Reimel, K. Zanocco, M. J. Russo, R. Zarnegar, O. H. Clark, J. D. Allendorf, J. A. Chabot, Q. Y. Duh, J. A. Lee and C. Sturgeon Department of Surgery, Columbia University Medical Center, New York, New York Surgery 2010; 148: 1178 –1185.
Background: Most experts agree that primary hyperaldosteronism (PHA) caused by an aldosteroneproducing adenoma (APA) is best treated by adrenalectomy. From a public health standpoint, the cost of treatment must be considered. We sought to compare the current guideline-based (surgical) strategy with universal pharmacologic management to determine the optimal strategy from a cost perspective. Methods: A decision analysis was performed using a Markov state transition model comparing the strategies for PHA treatment. Pharmacologic management for all patients with PHA was compared with a strategy of screening for and resecting an aldosterone-producing adenoma. Success rates were determined for treatment outcomes based on a literature review. Medicare reimbursement rates were calculated to estimate costs from a third-party payer perspective. Results: Screening for and resecting APAs was the least costly strategy in this model. For a reference patient with 41 remaining years of life, the discounted expected cost of the surgical strategy was $27,821. The discounted expected cost of the medical strategy was $34,691. The cost of adrenalectomy would have to increase by 156% to $22,525 from $8,784 for universal pharmacologic therapy to be less costly. Screening for APA is more costly if fewer than 9.6% of PHA patients have resectable APA. Conclusion: Resection of APAs was the least costly treatment strategy in this decision analysis model. Editorial Comment: The management of functional benign renal masses has changed in recent years, owing to the identification of effective medical therapies for control of secondary hypertension. In the case of primary hyperaldosteronism the successful medical treatment of bilateral adrenal hyperplasia has led to the question of whether unilateral aldosterone producing adenomas could be managed by a similar strategy. The authors of this study demonstrate through a decision analysis that the cost of medical therapy is greater than surgical adrenalectomy for these patients. Several assumptions are required—perhaps most importantly that adrenalectomy can be performed laparoscopically with low morbidity, short hospitalization and high likelihood of correction of hypertension. The study confirms that although it is more invasive, well-done surgery is often less costly than chronic medical therapy. Samir S. Taneja, M.D.
0022-5347/11/1856-2097/0 THE JOURNAL OF UROLOGY® © 2011 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
Vol. 185, 2097-2101, June 2011 Printed in U.S.A. DOI:10.1016/j.juro.2011.02.2680
www.jurology.com
2097