The Economics of Intraoperative Parathyroid Hormone Monitoring for Parathyroid Surgery: A Scoping Review of Cost Analyses and Economic Evaluations

ABSTRACT

Objective

Intraoperative PTH (IOPTH) monitoring is recommended for primary hyperparathyroidism (PHPT), but questions surround its added clinical value and financial cost. We evaluated the methodological quality of economic evaluations investigating IOPTH monitoring in surgery for PHPT.

Methods

We searched several databases, including MEDLINE and EMBASE, from January 1990 to June 2026. All screening was performed in duplicate. We included studies that conducted economic evaluations of IOPTH monitoring. Risk of bias (ROB) and methodological quality were evaluated in duplicate using ECOBIAS and CHEERS for full economic evaluations, while other criteria were applied to all eligible studies. We conducted a narrative synthesis with descriptive analysis.

Results

Of the 668 articles reviewed, 22 articles met eligibility criteria. Most studies were observational (77%) and 14% were derived from decision tree models; 82% were partial economic evaluations and 18% were full economic evaluations. CHEERS adherence for full economic evaluation ranged from 46%–81%, and there was moderate/high ROB secondary to issues with reporting the time horizon, cost discounting, sensitivity analyses, and equity consideration biases. Economic perspective (14%), cost discounting (14%), economic summary measures (9%), and sensitivity analyses (23%) were infrequently reported. 50% of studies commented on IOPTH monitoring cost‐effectiveness despite not investigating incremental economic summary measures. There was a similar number of studies reporting cost reductions and cost increases from the use of IOPTH monitoring.

Conclusions

Knowledge gaps and methodological inadequacies impede our current understanding of the economics of IOPTH monitoring. The shortcomings identified should be addressed in future economic evaluations of intraoperative parathyroid technologies.

1. Introduction

Primary hyperparathyroidism (PHPT) is the most common endocrine disorder amongst post‐menopausal women and it is associated with an elevated risk of osteoporosis, nephrolithiasis, and cardiovascular disease [1]. Primary treatment is parathyroidectomy, and surgical success is dependent upon excising hyperfunctioning parathyroid tissue [2]. Over 80% of patients diagnosed with PHPT have a single parathyroid adenoma while other patients may be faced with double parathyroid adenomas or multiple gland parathyroid hyperplasia, the latter of which is associated with higher rates of persistent hyperparathyroidism and revision parathyroid surgery [3]. The past 30 years have been witness to significant innovation in perioperative technologies that can assist with surgical planning and intraoperative decision‐making when performing parathyroid surgery [4, 5, 6].

Intraoperative parathyroid hormone (IOPTH) monitoring, which was introduced in the early 1990s, exploits the short half‐life of circulating parathyroid hormone (PTH) to generate intraoperative biochemical feedback for surgeons conducting parathyroid surgery [7]. The Miami criteria, which are often used by surgeons to guide IOPTH monitoring during parathyroid surgery, defines intraoperative cure as a greater than 50% decline in PTH from the highest recorded value 10 min after parathyroid gland excision [8]. Additionally, IOPTH monitoring is standard of care in minimally invasive parathyroidectomy (MIP) for image‐localized PHPT and can also be used in surgery for other forms of PHPT and in renal hyperparathyroidism [4, 9, 10]. Despite its advantages, however, global adoption of IOPTH monitoring is limited by stakeholder concerns regarding added financial costs, prolonged operating time, and whether this adjunct is clinically necessary when used by experienced parathyroid surgeons [4, 8]. Hence, a better understanding of the economic case for IOPTH monitoring is imperative given that questions remain around its cost effectiveness across healthcare systems, and because other new intraoperative parathyroid technologies are being introduced to healthcare markets globally [4, 6]. Before we proceed to an economic evaluation of modern intraoperative technologies for guiding parathyroid surgery, we first conducted a scoping review to understand the existing knowledge gaps factor within the economic literature of IOPTH monitoring and parathyroid surgery.

2. Methods

We conducted a scoping review of economic evaluations and cost analyses performed for IOPTH monitoring in surgery for PHPT. This study was completed in accordance with the Preferred Reporting for Systematic Reviews and Meta‐Analyses (PRISMA) Scoping Review extension guidelines [11]. We registered this review in Open Science Framework (DOI: 10.17605/OSF.IO/F73X2).

2.1. Search Strategy

Two authors (P.S. and A.P.) searched MEDLINE, EMBASE, EMCARE, and SCOPUS from January 1, 1990 to May 21, 2026, since IOPTH was first introduced in 1991 [12]. All search strategies were performed in conjunction with a librarian specialist and were verified by a third author (J.H.). The search strategy incorporated MeSH terms, subject headings, and keywords related to IOPTH monitoring, parathyroid disease, and economic study parameters and outcomes (Appendix A1). Scottish Intercollegiate Guidelines Network economic filters were used to ensure inclusion of studies that reported cost and cost effectiveness outcomes [13]. We performed manual searches of study reference lists to identify any additional eligible studies.

2.2. Inclusion and Exclusion Criteria

We included studies of adult patients undergoing parathyroid surgery with IOPTH monitoring and we included any type of parathyroid surgery including MIP, unilateral neck exploration (UNE), and bilateral neck exploration (BNE). We included any type of preoperative imaging modality described by authors and any type of IOPTH monitoring assay. We included primary studies that performed any type of economic analysis, including full and partial economic evaluations, of IOPTH monitoring during parathyroid surgery. Given the broad scope of this review, we included simulated or model‐based and cohort‐based partial economic evaluations (i.e., cost analyses, cost‐minimization analyses, cost descriptions, and budget impact analyses) and full economic evaluations (i.e., cost–benefit analyses, cost‐effectiveness analyses, and cost‐utility analyses). We defined full economic analyses as studies that evaluated costs and clinical effectiveness between two or more treatment alternatives and reported cost effectiveness or cost utility outcomes. Review articles and meta‐analyses were excluded, but their reference lists were searched from relevant citations. We did not perform a search of the gray literature since we focused our search on peer‐reviewed primary economic evaluations.

2.3. Screening, Extraction, and Outcome Assessment

Two reviewers independently screened citations and performed full‐text reviews to determine eligible studies (A.P and J.H.). Conflicts between reviewers were resolved through discussion and review by a third reviewer if necessary (P.S.). Both reviewers extracted data separately using a standardized extraction form. We extracted study‐specific and clinical information, in addition to economic evaluation details and outcomes, including perspective, time horizon, clinical effectiveness, costs, cost discounting, and incremental summary economic measures, such as incremental cost‐effectiveness ratio (ICER) and net monetary benefit (NMB). Screening and full‐text review were completed using Covidence software (Melbourne, Australia).

2.4. Risk of Bias and Methodological Quality Appraisal

Risk of bias (ROB) assessment was performed in duplicate (A.P. and J.H.) for eligible full economic analyses using the ECOBIAS and CHEERS instruments [14, 15]. The ECOBIAS instrument is a validated tool for assessing bias in economic evaluation and consists of three domains: (1) Overall bias in economic evaluation, (2) Model‐specific bias in economic evaluation, and (3) Bias related to data. Each signaling question was evaluated for bias in the ECOBIAS using one of four terms: “high”, “moderate”, “low”, and “unclear” ROB. The CHEERS instrument is 28‐item tool used to evaluate reporting quality in economic evaluations. We did not use the ECOBIAS or CHEERS instrument on partial economic analyses, since the signaling questions were developed for full economic evaluations. Hence, we also applied the ten methodological criteria described by Kruper et al. [16] to appraise the quality of all eligible economic analyses: (1) description of comparative options, (2) statement of perspective of analysis, (3) outcome measure defined, (4) cost data provided, (5) source of cost data provided, (6) inclusion of long‐term costs, (7) discounting used, (8) inclusion of summary measure, (9) incremental computation of summary measure, and (10) sensitivity analysis [16].

2.5. Statistical Analysis

We performed a narrative synthesis with eligible studies undergoing descriptive analysis, whereby we calculated proportions and frequencies to summarize study characteristics, where applicable. We planned to perform a systematic review and meta‐analysis of IOPTH monitoring cost effectiveness studies using the methodological approach described by Bagepally et al. [17], but were unable to perform this analysis due to the high between‐study heterogeneity and lack of reported economic summary measures such as ICER or NMB. All data was analyzed using Microsoft Excel (Redmond, WA, USA).

3. Results

3.1. Study Characteristics

Our search strategy and review of reference lists returned 668 articles, of which 22 studies met eligibility criteria (Figure 1) [18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39]. Most studies were published after 2005 (n = 14, 64%) and conducted in the USA (n = 11, 50%) (Table 1). The remaining studies were conducted in Australia, Canada, Italy, Poland, and the UK (Table S1). Five studies (23%) described model‐based economic analysis while 17 studies (77.3%) performed economic analysis from observational research [18, 20, 21, 28, 34]. Two studies described cost analyses performed alongside prospective randomized trials, but neither of these studies performed a full economic evaluation [22, 23]. Almost all studies investigated PHPT (n = 21, 96%) with most studies (n = 18, 82%) describing image‐localized PHPT performed at a single hospital center. Sample sizes ranged from 20 to 504 participants, and the most popular preoperative localization modality reported by study authors was 99 m‐sestamibi (n = 16, 73%) (Table S1).

FIGURE 1.

PRISMA flow chart.

TABLE 1.

Summary of included studies.

Study characteristic	No. of studies (%)
Year published
1995–2000	3 (14)
2001–2010	12 (55)
2011–2020	2 (9)
2021–2025	5 (23)
Type of economic analysis
Full economic analysis	4 (18)
Partial economic analysis	18 (82)
Patient population
Primary hyperparathyroidism	21 (95)
Secondary hyperparathyroidism	1 (5)
No. of study comparators
None	5 (23)
Two	10 (45)
More than two	7 (32)
Economic perspective
Payer	2 (9)
System	1 (5)
Not reported	19 (86)
Type of costs reported
Direct	22 (100)
Indirect	0 (0)
Economic summary measure (e.g., ICER or NMB)
Reported	5 (23)
Not reported	17 (77)

Abbreviations: ICER, incremental cost effectiveness ratio; NMB, net monetary benefit.

Minimally invasive parathyroidectomy was most often evaluated (n = 17, 77%). Seven studies described IOPTH monitoring conducted at central or satellite laboratories and the remaining studies described an operating room‐based instrument. Miami criteria were typically used to guide IOPTH monitoring. Six studies described PHPT patients being admitted to hospital after surgery for at least 24 h while the remaining were unclear in their perioperative care strategies [18, 22, 23, 24, 28, 30, 39]. Five studies did not perform any comparisons of parathyroid technologies and were therefore deemed cost descriptions [27, 31, 33, 37, 39]. Two studies compared central laboratory‐based IOPTH to operating room‐based IOPTH instruments [35, 38]. Frozen tissue analysis was described in 10 studies [20, 22, 23, 24, 25, 28, 31, 32, 37, 38]. Other studies compared types of parathyroid surgery, including MIP, UNE, and BNE, or the use of surgical adjuncts, such as IOPTH and parathyroid radio‐guidance.

3.2. Economic Evaluations of IOPTH Monitoring

Most eligible studies (n = 18, 82%) were partial economic evaluations, wherein costs associated with intraoperative parathyroid technologies were described but not reported alongside clinical outcomes nor compared against at least one other intraoperative technology. These partial economic evaluations were primarily cost analyses (n = 13, 72%) with five of these studies being deemed cost descriptions [27, 31, 33, 37, 39]. Four full economic evaluations were identified [18, 20, 21, 28]. Three studies reported the economic perspective and the economic time horizon was reported in Batora et al. [20, 21, 34]. Five studies reported currency‐year for costs and expenditures [20, 25, 26, 34, 35]. Direct costs focused on IOPTH instrument costs and expenses associated with laboratory processing and hospital care, but reporting detail varied between studies. Physician billing and hospital personnel salaries were reported in eight studies [18, 20, 21, 28, 32, 35, 37, 38]. All reported costs were primarily estimated with Baliski et al. [20] performing quasi case‐costing while no studies reported indirect costs incurred when surgically managing PHPT. Four full economic analyses were variable in their reporting practices and their use of economic summary measures, such as ICER and NMB, and willingness‐to‐pay thresholds [18, 20, 21, 28]. Fifty percent of studies commented on the cost‐effectiveness of IOPTH and parathyroid localizing technologies despite not being full economic evaluations or reporting economic summary measures (Table S1) [18, 22, 23, 25, 26, 28, 30, 31, 35, 37, 39].

Of the 17 studies that commented on IOPTH monitoring, seven studies reported that IOPTH was associated with better cost effectiveness or cost savings when compared to neck exploration without IOPTH while 10 studies identified that IOPTH monitoring did not confer an economic benefit in surgery. Amongst the seven studies with findings suggestive of an economic benefit of IOPTH monitoring, all were published at least 20 years ago with one study being a full economic evaluation with high ROB and 46% CHEERS reporting compliance [22, 24, 25, 26, 28, 31, 37]. These studies were primarily single‐centre and were often conducted in the US and Europe with the largest sample size being 217 patients [26]. Amongst the 10 studies that did not identify an economic benefit of IOPTH monitoring, three studies were full economic evaluations with moderate or high ROB and up to 81% CHEERS reporting adherence [18, 19, 20, 21, 29, 32, 34, 36, 39]. A closer look at these studies found that four studies did find a clinical benefit of using IOPTH monitoring, but the study authors were unable to justify the cost increase or they found an unhelpful ICER relative to their willingness‐to‐pay threshold [18, 20, 21, 34]. The remaining studies either did not find a clinical benefit with IOPTH monitoring or found that it was associated with a cost increase. Lastly, two studies identified cost savings with point‐of‐care IOPTH monitoring while one study identified cost savings with central laboratory IOPTH monitoring [33, 35, 38].

3.3. Methodological Quality and Risk of Bias Appraisal

Twenty eligible studies reported five or fewer of the 10 methodological quality items deemed necessary for economic evaluations in Kruper et al. [16] (Table 2). The worst reported items were economic perspective (n = 3, 14%), economic discounting (n = 3, 14%), economic summary measures like ICER and NMB (n = 2, 9%), and sensitivity analyses (n = 5, 23%). Time horizon for economic outcomes was also infrequently addressed by study authors (n = 2, 9%) [20, 21]. The most reported items were cost data, (n = 22, 100%), source of cost data (n = 18, 82%), and description of comparative options (n = 17, 77%). None of the eligible studies addressed the healthcare system costs that may impact patients with recurrent parathyroid disease who require revision surgery.

TABLE 2.

Reporting compliance with methodological criteria.

Study characteristic	No. of articles (%)
Description of comparative options	17 (77)
Statement of perspective of analysis	3 (14)
Outcome measure defined	16 (73)
Cost data provided	22 (100)
Source of data cost provided	18 (82)
Inclusion of long‐term costs	0 (0)
Discounting utilized	3 (14)
Inclusion of summary measure	3 (14)
Incremental computation of summary measure	2 (9)
Sensitivity analysis performed	5 (23)
Total no. of articles	22 (100)

ECOBIAS evaluation of the full economic analyses identified that Batora et al. [21] had a low or moderate ROB for most signaling questions but did have a high ROB related to equity consideration bias and the lack of reporting model calibration and validity due largely to concerns about the robustness of their model assumptions (Table S2). Baliski et al. [20] had a high ROB secondary to a lack of cost discounting, well‐defined clinical effectiveness outcomes, and economic time horizons. The remaining two studies, published before 2005, had less transparent methods with a high ROB secondary to a lack of cost discounting, insufficiently reported economic modeling methods, inadequate cost sourcing, and a lack of economic summary measures [18, 28]. With regards to the CHEERS instrument, we found that Batora et al. [21] adhered to most checklist items (21/26 items, 81%) while the remaining full economic analyses had lower adherence to CHEERS with adherence ranging from 46% (12/26 items) to 58% (15/21 items) (Table S3) [18, 20, 28]. CHEERS reporting deficiencies primarily pertained to a lack of study protocol release, inadequate costing and currency details, concerns with regards to economic model rationale and assumptions, no patient engagement, a lack of economic perspective, and no sensitivity or probabilistic analyses.

4. Discussion

Although IOPTH monitoring is widely used during parathyroid surgery, challenges around its elevated financial costs, prolonged operating room time, and added diagnostic utility persist with similar questions being raised for other newer intraoperative parathyroid technologies [4, 9]. Robust economic evaluations are, therefore, needed to address these challenges especially with parathyroid disease rising in prevalence globally and newer, more expensive parathyroid technologies entering the healthcare market globally [40]. Prior to undertaking an economic evaluation of intraoperative parathyroid technologies, our group conducted this scoping review to describe the knowledge gaps and methodological limitations within the economic literature of IOPTH monitoring, which remains the most popular intraoperative technology used by parathyroid surgeons [4].

We found that fewer than 20% of included studies were full economic evaluations while half of the remaining studies commented on the cost effectiveness of IOPTH monitoring despite not evaluating its clinical effectiveness or utility. We also found that studies often did not report incremental summary economic measures when evaluating IOPTH monitoring, thereby limiting the applicability of their findings on using intraoperative parathyroid technologies. Additionally, cost sources were often reported heterogeneously and with insufficient methodological detail, and studies were primarily conducted at single institutions in the USA, thereby limiting their generalizability to other institutions and countries. Lastly, most studies were conducted in the 2000s and so, these authors were unable to compare IOPTH monitoring to newer parathyroid technologies, nor were they consistently able to account for the cost savings of outpatient parathyroid surgery, which has been largely adopted over the past decade [41]. We are using the knowledge gained from this scoping review to directly inform a model‐based economic evaluation of intraoperative parathyroid technologies.

Economic evaluations in healthcare, especially surgery, often face methodological challenges, including missing data, improper economic model assumptions, and a lack of sensitivity or probabilistic analyses [16, 42, 43]. We similarly identified using validated checklists that economic evaluations of IOPTH monitoring often failed to report study components such as economic perspective, time horizon, incremental economic summary measures, and sensitivity or probabilistic analyses. When these challenges are not addressed, healthcare economic evaluations can be prone to short‐sighted economic insights with limited applications for clinical and administrative stakeholders [44, 45]. We further identified that full economic evaluations of IOPTH monitoring often had notable levels of between‐study heterogeneity in both ROB and methodological reporting quality, especially amongst older studies, which were published prior to the more recent calls for improved methods and standardization in healthcare economic evaluations [18, 28, 44, 46]. The two highest quality economic evaluations identified in this scoping review were (1) Baliski et al. [20] which was a model‐based economic evaluation of MIP with IOPTH monitoring, but these authors were unable to account for modern parathyroid localization technologies, modern IOPTH monitoring practices, or routine outpatient parathyroid surgery management since their study was published two decades ago; and (2) Batora et al. [21] which was also a model‐based economic evaluation, but these authors primarily focused on comparing the economics of several preoperative parathyroid localization technologies rather than intraoperative technologies. These authors did suggest, however, that IOPTH monitoring may reduce rates of revision parathyroid surgery in PHPT, but that it is likely not cost‐effective in PHPT since it increased rates of BNE, but other studies have conflictingly suggested that IOPTH monitoring does help reduce unnecessary neck exploration [7, 8, 20, 21, 47, 48, 49]. Their model, however, assumed that surgeons are always successful when visually differentiating a parathyroid adenoma from normal parathyroid tissue, but this assumption may break down in real‐world practice given that less experienced surgeons can make errors when visually identifying pathological parathyroid tissue without intraoperative adjuncts [20, 21, 47, 48, 49].

Between‐study heterogeneity was a pervasive challenge in conducting this review and it precluded us from undertaking a meta‐analysis of economic summary measures, thereby hindering the clinical applicability of our conclusions. This heterogeneity was largely a consequence of clinical, institutional, economic, and methodological discrepancies between studies. Clinical and institutional factors that can influence both the utility and economic profile of IOPTH monitoring were inconsistently reported between included studies, such factors, which have been posited before, often pertained to the rates of multiglandular parathyroid disease and double parathyroid adenoma, annual surgical case volumes, preoperative parathyroid localizing technologies, surgeon experience, operative and IOPTH monitoring strategies, and postoperative management [4, 8, 21]. Additionally, half of the included studies were conducted in the USA, which is a market‐driven healthcare system that may facilitate faster adoption of new intraoperative technologies, but may conversely be associated with elevated healthcare system expenditures [50]. The remaining studies were conducted in Australia, Canada, or Europe, which have nationalized single‐payer or hybrid healthcare systems that may be slower to adopt new intraoperative technologies, but may also prioritize evidence of cost‐effectiveness when adopting new technologies [51]. Healthcare system differences were not captured by included studies, thus limiting their generalizability and highlighting that future cross‐system economic evaluations should adjust for differences in costs, resources, discount rates, and willingness‐to‐pay thresholds that exist between countries [52]. Lastly, most included studies were conducted in the 2000s and therefore did not capture the economics of modern preoperative and intraoperative parathyroid technologies, nor the transition to MIP and outpatient management for parathyroid surgery, the latter of which appears to be safe and cost‐effective in both private and public healthcare systems [21, 41, 53, 54]. Additional sources of heterogeneity stemmed from the inconsistent reporting of economic methods and results, which remains a pervasive issue amongst modern health technology assessments and should be improved in the future [55].

Unfortunately, we were unable to provide clear economic guidance for using intraoperative parathyroid technologies due largely to the between‐study heterogeneity, but we were able to advance our economic understanding of surgical parathyroid management while generating hypotheses that should be evaluated in future economic evaluations. First, MIP with IOPTH monitoring, relative to routine neck exploration, may be conditionally cost effective in primary surgery for PHPT based upon clinician and institutional factors such as the diagnostic accuracy of preoperative localization technologies and rates of multiple parathyroid gland disease, surgeon experience and operating time, institutional case volumes, IOPTH assay type and turnover time, IOPTH monitoring criteria used, and local rates of surgical failure [20, 21, 28, 34]. Future confirmatory model‐based economic evaluations with sensitivity and probabilistic analysis are needed to evaluate how these parameters can affect the applicability and cost‐effectiveness of IOPTH monitoring. Next, MIP with IOPTH monitoring may permit additional cost savings by reducing the use of intraoperative frozen tissue analysis, reducing rates of bilateral neck exploration and their associated complications, and permitting outpatient management after parathyroid surgery but these points require further investigation [18, 21, 26, 31, 41]. Lastly, most included studies were published over a decade ago and by and large cannot be applied to modern surgical practices in PHPT. Going forward, we should prioritize economic evaluations that incorporate all modern intraoperative parathyroid technologies, account for differences between healthcare systems globally, and address present‐day clinical challenges in surgically managing PHPT.

To our knowledge, this review is the first to appraise the quality of modern economic evaluations into IOPTH monitoring for parathyroid surgery. We did not prioritize pre‐print articles or unpublished internal cost analyses since we aimed to only evaluate peer‐reviewed scientific sources. We also did not proceed with meta‐analysis due to high between‐study heterogeneity, thereby limiting the reach of our conclusions. Modern‐day knowledge gaps impede our understanding of the economics of IOPTH monitoring for parathyroid surgery. These knowledge gaps largely stem from low quality and heterogeneous economic evaluations that we must improve so that we can provide healthcare stakeholders with the information needed to navigate the evolving landscape of intraoperative parathyroid technologies.

Funding

The authors have nothing to report.

Disclosure

No generative AI was used in conducting this research or generating this manuscript. No generative AI tools were used in the preparation of this manuscript.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix A1. Search strategy.

Table S1: Included studies (N = 22).

Table S2: Reporting compliance with ECOBIAS.

Table S3: Reporting compliance with CHEERS.

Data Availability Statement

The data that supports the findings of this study are available in the Supporting Information of this article.