Cost-effectiveness of consensus guideline based management of pancreatic cysts: The sensitivity and specificity required for guidelines to be cost-effective

Jeremy Sharib, Laura Esserman, Eugene J. Koay, Anirban Maitra, Yu Shen, Kimberly S. Kirkwood, Elissa M. Ozanne

Research output: Contribution to journalArticlepeer-review

16 Scopus citations


Background: Detection of cystic lesions of the pancreas has outpaced our ability to stratify low-grade cystic lesions from those at greater risk for pancreatic cancer, raising a concern for overtreatment. Methods: We developed a Markov decision model to determine the cost-effectiveness of guideline-based management for asymptomatic pancreatic cysts. Incremental costs per quality-adjusted life year gained and survival were calculated for current management guidelines. A sensitivity analysis estimated the effect on cost-effectiveness and mortality if overtreatment of low-grade cysts is avoided, and the sensitivity and specificity thresholds required of methods of cyst stratification to improve costs expended. Results: “Surveillance” using current management guidelines had an incremental cost-effectiveness ratio of $171,143/quality adjusted life year compared with no surveillance or operative treatment (“do nothing”). An incremental cost-effectiveness ratio for surveillance decreases to $80,707/quality adjusted life year if the operative overtreatment of low-grade cysts was avoided. Assuming a societal willingness-to-pay of $100,000/quality adjusted life year, the diagnostic specificity for high-risk cysts must be >67% for surveillance to be preferred over surgery and “do nothing.” Changes in sensitivity alone cannot make surveillance cost-effective. Most importantly, survival in surveillance is worse than “do nothing” for 3 years after cyst diagnosis, although long-term survival is improved. The disadvantage is eliminated when overtreatment of low-grade cysts is avoided. Conclusion: Current management of pancreatic cystic lesions is not cost-effective and may increase mortality owing to overtreatment of low-grade cysts. The specificity for risk stratification for high-risk cysts must be greater than 67% to make surveillance cost-effective.

Original languageEnglish (US)
Pages (from-to)601-609
Number of pages9
JournalSurgery (United States)
Issue number4
StatePublished - Oct 2020


  • Adult
  • Aged
  • Aged, 80 and over
  • Asymptomatic Diseases
  • Cost-Benefit Analysis
  • Decision Support Techniques
  • Diagnostic Imaging/economics
  • Humans
  • Incidental Findings
  • Markov Chains
  • Middle Aged
  • Pancreatic Cyst/diagnostic imaging
  • Practice Guidelines as Topic
  • Quality-Adjusted Life Years
  • Risk Assessment/economics
  • Sensitivity and Specificity
  • Survival Analysis
  • Unnecessary Procedures

ASJC Scopus subject areas

  • Surgery


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