CANADIAN ASSOCIATION OF GENERAL SURGEONS AND ACS,EVIDENCE-BASED REVIEWS IN SURGERY

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Thettcioabeviknknimpossible for an individual clinician to read all the medi-cal literature. For clinicians to practice evidence-basedmedicine, theymust have the skills to read and interpret themerelThcriknan

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toanmeareonpacanviews in Surgery through the American College of Sur-geons Web site (www.facs.org). All journal articles and re-views are available electronically through the Web site.CuwhofwhceiquACen

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Base case: Thirty-year-old nonpregnant woman with-

2Pubjective: To determine the most cost effective optiontreating Graves disease after 18 months of antithyroiddication (ATM).

sign: A decision tree model was used to examine thest effectiveness of 3 treatment options (lifelong antithy-

out a large goiter, ophthalmopathy, or palpable nodules,who has failed to remain euthyroid after completion of 18months of ATM.

Interventions: Each treatment option incorporated allassociated events, their probabilities, and costs including

806011 by the American College of Surgeons ISSN 1072-7515/11/$36.00lished by Elsevier Inc. doi:10.1016/j.jamcollsurg.2011.09.015dical literature so that they can determine the validity,iability, credibility, and utility of individual articles.ese skills are known as critical appraisal skills. Generally,tical appraisal requires that the clinician have someowledge of biostatistics, clinical epidemiology, decisionalysis, and economics as well as clinical knowledge.The Canadian Association of General Surgeons (CAGS)d the American College of Surgeons (ACS) jointly spon-a program titled Evidence-Based Reviews in Surgery

BRS), supported by an educational grant from Ethiconand Ethicon Endo Surgery Inc. The primary objective

this initiative is to help practicing surgeons improve theirtical appraisal skills. During the academic year, 8 clinicalicles are chosen for review and discussion. They are se-ted not only for their clinical relevance to general sur-ns, but also because they cover a spectrum of issuesportant to surgeons; for example, causation or risk fac-s for disease, natural history or prognosis of disease, how

LECTED ARTICLEeatment Options for Graves Disease:Cost-Effectiveness Analysisejin I, Pearce EN, Wong AK, et al. J Am Coll Surg09;209:170179.rrently we have a library of 50 articles and reviews,ich can be accessed at any time. Each October, a new setarticles will be available eachmonth until May. Surgeonso participate in the current (modules) packages can re-ve CME credits by completing a series ofmultiple choiceestions. Additional information about EBRS is on theSWeb site or by email to the administrator,MargMcK-zie at mmckenzie@mtsinai.on.ca.In addition to making the reviews available through theS andCAGSWeb sites, 4 of the reviews are published inndensed versions in the Canadian Journal of Surgery, 4the Journal of the American College of Surgeons, and 4 inseases of Colon and Rectum each year.

FERENCE

Evidence-BasedMedicineWorking Group. Evidence-based med-icine. JAMA 1992;268:24202425.

d medication, radioactive iodine [RAI], and totalroidectomy).

tting: Treatment efficacy and complication data wererived from a literature review. Costs were examined fromealth care system perspective using actual Medicare re-bursement rates to an urban university hospital.reatment Options for Gravosanto K Chaudhury, MD, FACS, Peter Angelos, MDe Evidence-Based Reviews in Surgery Group

e term evidence-based medicine was first coined by Sack-and colleagues1 as the conscientious, explicit and judi-us use of current best evidence in making decisionsout the care of individual patients.The key to practicingdence-based medicine is applying the best currentowledge to decisions in individual patients. Medicalowledge is continually and rapidly expanding, and it is DiseaseS, Janice L Pasieka, MD, FACS; for Members of

quantify disease (measurement issues), diagnostic testsd the diagnosis of disease, and the effectiveness of treat-nt. Bothmethodologic and clinical reviews of the articleperformed by experts in the relevant areas and postedthe EBRSWeb site. A listserve discussion is held whererticipants can discuss the monthly article. Fellows anddidates of the College can access Evidence Based Re-

medications, laboratory tests, clinic visits, treatment costs,cosisate

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807Vol. 213, No. 6, December 2011 Evidence-Based Reviews in Surgerysts associated with adverse events, such as agranulocyto-and recurrent laryngeal nerve damage; and costs associ-d with change in treatment for failed intervention.

ain outcomes: Outcomes were measured in quality-justed life-years (QALY).

sults: Total thyroidectomy was the most cost-ective strategy, resulting in a gain of 1.32 QALYs com-red with RAI (at an additional cost of $9,594) and anremental cost-effectiveness ratio of $7,240/QALY. RAIs the least costly option at $23,600, but provided thest QALY (25.08). Once the cost of total thyroidectomyeeds $19,300, the incremental cost-effectiveness ra-of lifelong ATM and total thyroidectomy reverse,

d lifelong ATM becomes the more cost-effective strat-y at $15,000/QALY.

nclusions: The findings demonstrate that total thy-dectomy is more cost effective than RAI or lifelongM in these patients; this continues until the cost of totalroidectomy becomes greater than $19,300.

mmentary: Graves disease is an autoimmune disor-r that affects approximately 0.5% of theNorth Americanpulation. Graves disease is the most common cause ofmary hyperthyroidism.Treatment of hyperthyroidism isential because overt manifestations of the condition cand to long-term effects on the heart, bones, and psycho-ical well being of the patient. Immediate control ofptoms is obtained with the use of beta-blockers; the

tithyroidial drugs take effect and block further synthesesthyroxin production. The goals of therapy are to con-l symptoms and restore the patient to a euthyroidte. There are 3 modes of therapy for the treatment ofaves disease: antithyroidal medication, RAI, and to-thyroidectomy.Typically, patients with Graves disease are treated withM for a period of time in hopes that the disease willolve spontaneously. Remission, depending on the size ofgland, can occur in 30% to 50% of patients after a 12-18-month course of the drugs. After 12 to 18 months,st patients are faced with 3 possible treatment choices:ntinue the ATM for an indefinite period of time; receiveI; or have a total thyroidectomy. The authors have cor-tly assumed that the best surgical option is a total thy-dectomy, and yet some surgeons continue to offer thetion of a subtotal thyroidectomy to their patients. Inntrast to a subtotal thyroidectomy, patients undergoing aal thyroidectomy will predictably require thyroid hor-ne replacement but will have a significantly lower risk ofurrence.al thyroidectomy option is the one that has the mostdily identifiable risks. As a result, many surgeons look atal thyroidectomy as something that should be stronglynsidered by patients only if there is a reason why ATMorI is not a safe option. For example, if the patient isgnant or has suspicious nodules, RAI is not a safe op-n, or if a patient has had a bad reaction to the ATM,ntinuing medication is not a good option. Surgeons inUS are not commonly sent patients for total thyroid-omy for Graves disease unless there is some other reasony RAI or continuing ATMs for long periods of time ist safe.Total thyroidectomy, when done by experienced sur-ns, is safe and provides an immediate and permanentution to the hyperthyroid state. Surgery should continuebe used in all patients who fail to become euthyroid wither treatments, patients with very large goiters, in whomI would likely fail or is contraindicated, and those withnificant Graves ophthalmopathy. This analysis providesther evidence that thyroidectomy should also be consid-d the first line treatment option in patients with refrac-y Graves disease because the long-term benefits andst-effectiveness of this treatment are superior to lifelongdication and RAI. Although thyroidectomy is morestly up front, the benefit is realized in the long-term. It isportant, however, to recognize that this benefit is real-d only when the thyroidectomy is done by an experi-ced surgeon who has a low risk profile and understandscomplexity of operating on a patient with Graves dis-e. This study provides a rational basis for a physician toommend a total thyroidectomy to patients even if theyve no contraindication to ATM or RAI. Namely, totalroidectomy is the most cost-effective strategy as long ascost of total thyroidectomy does not exceed $19,300.e authors also report the results of sensitivity analyses fory variables that would influence medical decisions orve substantial medical consequences. The cost of thy-dectomy had the greatest influence on the results. Asg as the cost of total thyroidectomy remained less than9,300, total thyroidectomy remained the most cost-ective strategy. Other variables, including cost of medi-ion, cost of RAI, patient age, probability of cancer withdication or RAI, success rate of RAI, rate of hypothy-dism with RAI, and complication rates of total thyroid-omy, did not influence the results. The sensitivity anal-s are included as an online supplement (Appendix: 2).This study has several limitations. It was based on retro-ctive nonexperimental data supplemented by expertinion to generate probabilities and quality-of-life adjust-nt factors. In addition, utilities were not derived based

on patient opinions. So, it is possible that patient assess-ments of the utility or disutility of different disease statesmight differ considerably from those that were assigned bythe authors. In addition, costs were based on the reim-bursement structure for Medicare as representative of USpayors. Actual 2007 Medicare reimbursements to a largeurban university hospital were used to calculate the cost oftreatment. Medication costs were obtained from averageUS wholesale prices. Future health care costs were com-puted using an inflation rate of 5%. A standard discountrate of 3% was applied to both cost and effectiveness, asrecommended by the Panel on Cost-Effectiveness inHealth and Medicine. However, although this methodol-ogy is the easiest, there are some concerns about it.The firstlimitation of this method is that the price is not alwaysthe same as the actual cost of delivering the service orproduct. These variances may occur because the price wasestrencarofthaothexpmamithaingcendis

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on cost-effective therapies. Surgeons need to be more in-volved in the first line decision process when it comes totreatment of Graves disease. Thyroidectomy is a validtreatment option and it is only the surgeon who can accu-rately explain the surgical risk vs benefit of this modality tothe patient.

The Evidence-Based Reviews in Surgery GroupComprises:Members of the EBRS Steering Committee

Nancy N Baxter, MD, FACS, Toronto, ON Canada

Karen J Brasel, MD, FACS, Milwaukee, WI

Carl J Brown, MD, Vancouver, BC Canada

Prosanto K Chaudhury, MD, Montreal, QC Canada

C Suzanne Cutter, MD, Los Angeles, CA

808 Evidence-Based Reviews in Surgery J Am Coll Surgablished some time previously and does not reflect cur-t costs; it may be due to the bargaining power of healthe institutions, third-party payers, and the profit marginfor-profit health care systems. The second limitation ist the results of the analysis may not be generalizable toer systems. Because the cost of each resource is notlicitly stated, it is not possible to substitute the cost thaty be incurred in another system in the analysis to deter-ne if the results of the analysis are robust. Having saidt, Medicare reimbursement is not a bad way of estimat-cost in the US setting because these rates are establishedtrally and are not subject to bargaining and volumecounts.In summary, the analysis by Haejin and colleagues is aely article. This review brings to light the role that thy-dectomy can have in the treatment of Graves disease. Itikely that the surgeons role will expand in the years tome, with the increasing awareness and concerns aboutlong-term impact of RAI and the increasing emphasisCelia M Divino, MD, FACS, New York, NY

Elijah Dixon, MD, FACS, Calgary AB, Canada

Luc Dubois, MD, London, ON Canada

GWilliamNFitzgerald,MD, St. Anthony,NLCanada

SMoradHameed,MD, FACS,Vancouver, BCCanada

Harry J Henteleff, MD, FACS, Halifax, NS Canada

AndrewWKirkpatrick,MD, FACS,Calgary, ABCanada

Steven Latosinsky, MD, London, ON Canada

Tara M Mastracci, MD, Cleveland, OH

Robin SMcLeod, MD, FACS, Toronto, ON Canada

Arden M Morris, MD, FACS, Ann Arbor, MI

Leigh A Neumayer, MD, FACS, Salt Lake City, UT

Larissa K Temple, MD, FACS, New York, NY

Marg McKenzie, RN, Toronto, ON Canada

Treatment Options for Graves` DiseaseReferenceSelected ArticleTreatment Options for Graves` Disease: A Cost-Effectiveness Analysis

AbstractObjectiveDesignSettingBase caseInterventionsMain outcomesResultsConclusionsCommentary

The Evidence-Based Reviews in Surgery Group Comprises