Economic evaluation in radiology: reviewing the literature and examples in oncology

RATIONALE AND OBJECTIVES

To review US health care trends related to medical imaging utilization and costs as well as to present standard methods for conducting economic evaluation for health care interventions and medical imaging specifically.

MATERIALS AND METHODS

A review of the medical literature was performed to assess health policy and health technology assessment trends, expenditures, and cost-effectiveness analysis (CEA) related to medical imaging. Standard approaches to conducting economic evaluation and cost-effectiveness analysis were reviewed and summarized. Examples of CEA evidence related to imaging in select oncology conditions were presented.

RESULTS

Several high-quality methodology publications have provided guidance for conducting economic evaluation and CEA in radiology. There is variability in the quality of CEA models and their dissemination. However, there are numerous methodologically sound cost-effectiveness analyses for radiology procedures, and the evidence base of CEA studies for medical imaging continues to increase. Advanced imaging approaches for diagnosing and staging oncology conditions have the potential to provide cost-effective care when used in appropriate patient subpopulations.

CONCLUSIONS

Additional rigorous comparative effectiveness studies for advanced imaging, including cost-effectiveness analyses, can provide useful information to policy makers and health care providers on the relative effects and costs associated with diagnostic alternatives.

Geographic origin of publications in radiological journals as a function of GDP and percentage of GDP spent on research

RATIONALE AND OBJECTIVES

The aim of this study was to examine the geographic origin of publications in the highest impacting radiology journals and to examine the link between the percentage of gross domestic product (GDP) spent on research by a country and the output of radiology publications.

MATERIALS AND METHODS

The five highest impacting general radiology journals (according to the ISI Web of Knowledge database) were selected over a 6-year period from January 2002 to December 2007. Publications were totaled according to the country of the corresponding author. Publications (total and corrected for population size) were assessed according to the GDP of a given country and the percentage of GDP spent on research in that country. Correlation was determined using Spearman's rank.

RESULTS

In total, 10,925 papers were identified. The top 10 nations produced 83.9% of the total number of papers. The United States was the most prolific country, with 41.7% of the total. The second-ranked and third-ranked countries were Germany (11.6%) and Japan (6.7%). Corrected for GDP, smaller European countries outperformed larger nations. Switzerland (0.925 publications per billion of GDP), Austria (0.694 publications per billion of GDP), and Belgium (0.648 publications per billion of GDP) produced the most papers per billion of GDP. When corrected for percentage of GDP spent on research, European countries again ranked highest, with Greece, Turkey, and Belgium having the best ratios. The percentage of GDP spent on research was positively correlated with the number of publications in high-ranking radiology journals (r = 0.603, P < .001).

CONCLUSIONS

The United States is the most productive country in absolute number of publications. The flaws of using population size to compare publication output are clear, and a comparison using GDP and the percentage of GDP spent on research may give more meaningful results. When GDP is taken into consideration, smaller European countries are more productive. The importance of investment in radiologic research is emphasized by the association between increased funding of research and the number of publications in high-impacting radiology journals.

Illustrating economic evaluation of diagnostic technologies: comparing Helicobacter pylori screening strategies in prevention of gastric cancer in Canada

OBJECTIVE

The aim of this paper is to present an economic evaluation of diagnostic technologies using Helicobacter pylori screening strategies for the prevention of gastric cancer as an illustration.

METHODS

A Markov model was constructed to compare the lifetime cost and effectiveness of 4 potential strategies: no screening, the serology test by enzyme-linked immunosorbent assay (ELISA), the stool antigen test (SAT), and the (13)C-urea breath test (UBT) for the detection of H. pylori among a hypothetical cohort of 10,000 Canadian men aged 35 years. Special parameter consideration included the sensitivity and specificity of each screening strategy, which determined the model structure and treatment regimen. The primary outcome measured was the incremental cost-effectiveness ratio between the screening strategies and the no-screening strategy. Base-case analysis and probabilistic sensitivity analysis were performed using the point estimates of the parameters and Monte Carlo simulations, respectively.

RESULTS

Compared with the no-screening strategy in the base-case analysis, the incremental cost-effectiveness ratio was $33,000 per quality-adjusted life-year (QALY) for the ELISA, $29,800 per QALY for the SAT, and $50,400 per QALY for the UBT. The probabilistic sensitivity analysis revealed that the no-screening strategy was more cost effective if the willingness to pay (WTP) was <$20,000 per QALY, while the SAT had the highest probability of being cost effective if the WTP was >$30,000 per QALY. Both the ELISA and the UBT were not cost-effective strategies over a wide range of WTP values.

CONCLUSION

Although the UBT had the highest sensitivity and specificity, either no screening or the SAT could be the most cost-effective strategy depending on the WTP threshold values from an economic perspective. This highlights the importance of economic evaluations of diagnostic technologies.

Value-driven health care: the purchasers' perspective

Value-driven health care seeks to directly link quality health care to reimbursement. The 4 cornerstones of this movement are health information technology standards, quality standards, price standards, and incentives. These standards and how purchasers plan to implement them are summarized in this article.

Rural GPs' satisfaction with radiology services to their communities: a qualitative study

INTRODUCTION

Despite the acknowledged clinical importance of radiology and an awareness of issues surrounding the rural radiology workforce and access to services and equipment, there is a paucity of information assessing the adequacy of rural radiology services in Australia. Assessing the satisfaction of rural GPs with the radiology services available to them is one way of assessing the adequacy of these services. This research aimed to contribute to this important knowledge gap by identifying the factors influencing rural GPs' satisfaction with the rural radiology services available to them.

METHODS

We used purposive sampling from Tasmanian general practice workforce data to select rural GPs with a range of demographics from all three regions of Tasmania, Australia. We performed semi-structured interviews with these GPs, in which they discussed rural radiology services in their local area. Interviews were performed by telephone and transcribed verbatim. The transcribed interviews were analysed using an iterative and interpretive technique aimed at identifying major themes and providing insight into the issues raised by the research participants.

RESULTS

Out of 15 GPs approached, two interviews were lost due to equipment problems and 10 interviews were successfully recorded. Major factors influencing GP satisfaction with rural radiology services included: access to service (particularly convenience for their patients and the level of direct and indirect costs to patients); the promptness and reliability of services; equipment; and access to training and skills levels. The GPs also described the added challenges that they and their communities face with dealing with problems requiring the use of radiology services after hours.

CONCLUSIONS

These new insights into rural radiology services can help to inform policy makers, funding bodies and private radiology providers responsible for rural radiology services of issues requiring further consideration. This contribution to the creation of an evidence base is important as a platform for further research and for the development of strategies to further assess and improve radiology services for rural communities.

Strategic planning in diagnostic imaging: meeting the challenge

PURPOSE

The 21st century has raised new and significant challenges to the practice of diagnostic imaging. Radiologists will have to navigate a difficult path as they face threats from disruptive technologies, adverse demographic changes, pressures to limit reimbursement both from the public and from the private sectors, increased domestic and crossborder competition, and many others. Success in these trying times will require greater attention to strategic planning if we are to thrive and survive in radiology.

METHODS

Strategic planning and tactical implementation methodologies were reviewed, from Sun Tzu to the present day, for applicability to the needs of modern radiology groups.

RESULTS

A framework for developing and implementing strategic plans was constructed to assist radiology leaders and groups in considering the spectrum of tasks, from gathering intelligence, to developing scenarios, to implementing and evaluating tactical plans.

CONCLUSIONS

Strategy and tactics are too important to be ignored or left to others. They need to be core activities for all radiology leaders. Frameworks can be used to help in providing structure and rigour to strategic planning efforts at the department and group level.