Cost-Effectiveness of Thyroid Nodule Molecular Testing in Manitoba.

OBJECTIVE: To determine the cost-effectiveness of molecular testing for indeterminate (Bethesda III/IV) thyroid nodules in a real-world, single-payer healthcare system. DESIGN: This retrospective population-based cohort study analyzed fine-needle aspiration biopsy (FNAB) and lobectomy data for thyroid nodules in Manitoba, Canada, during 2023. Microcosting was performed to capture surgical, surveillance, molecular testing, and complication costs in 2023 Canadian dollars. Six molecular tests (Afirma, ThyroSeqV3, ThyroidPrint, ThyroSPEC, ThyGeNEXT/ThyraMIR, and mir-THYpe) were evaluated using site-specific malignancy prevalence (21%) and published test statistics. SETTING: The study was performed within a publicly funded healthcare system. PARTICIPANTS: Participants were 18 years and above having undergone FNAB in Manitoba.Intervention or Exposures:Three scenarios were identified Current Care, Molecular Testing, and Reference Standard (diagnostic lobectomy) pathways. The total cost per year were compared among scenarios. MAIN OUTCOME MEASURES: Cost-utility analyses compared Current Care, Molecular Testing, and Reference Standard pathways. Quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) were calculated. A $50 000/QALY willingness-to-pay (WTP) threshold was used to interpret ICERs. RESULTS: Among 1486 FNABs performed, 413 were indeterminate nodules, and 149 patients underwent diagnostic lobectomy. The cost of lobectomy was $7542.69 per patient. All molecular testing strategies improved net QALYs and demonstrated ICERs ranging from $9791.03 to $58 749.94 per QALY compared to Current Care. All tests apart from Afirma were cost-effective at the WTP threshold relative to Current Care. Compared to the Reference Standard, all molecular testing strategies were dominant. CONCLUSIONS: For the investigated Manitoba scenario, molecular testing for indeterminate thyroid nodules can be a cost-effective strategy, possibly reducing unnecessary surgeries while preserving patient outcomes. RELEVANCE: This study contributes to the body of evidence suggesting molecular testing is cost-effective and has potential to influence political decisions in health care spending.