High-Dose Dexamethasone Suppression Testing Versus Inferior Petrosal Sinus Sampling in the Differential Diagnosis of Adrenocorticotropin-Dependent Cushing’s Syndrome: A Decision Analysis

Abstract

Differentiation of adrenocorticotropin (ACTH)-dependent Cushing's syndrome between Cushing's disease and the occult ectopic ACTH syndrome is difficult. Simultaneous bilateral inferior petrosal sinus sampling (IPSS) for ACTH levels in response to corticotropin-releasing hormone has high diagnostic accuracy, but its cost-effectiveness has not been analyzed. In this study, decision analysis was used to compare two diagnostic strategies: IPSS versus high-dose dexamethasone suppression (HDD) followed by IPSS in those with a negative HDD test. Sensitivity analyses were performed for all variables. The authors found that at 100% accuracy, IPSS has an incremental cost-effectiveness ratio of $1,000,000 per life saved. Incremental cost, incremental effectiveness, and incremental cost-effectiveness are sensitive to the pretest probability of Cushing's disease, test characteristics, and test costs. As the pretest probability of Cushing's disease decreases, cost per life saved also decreases to less than 85%, the HDD strategy saves more lives and costs less. When the HDD test has a 83% sensitivity rate and a 100% specificity rate, the two strategy remains less expensive. The IPSS strategy saves lives whenever HDD specificity is less than 100%.(ABSTRACT TRUNCATED AT 250 WORDS)