Health-related quality of life and cost-effectiveness analysis in radiology

Identification of Abusive Head Trauma in High-Risk Infants: A Cost-Effectiveness Analysis

OBJECTIVES

To evaluate the cost-effectiveness of abusive head trauma detection strategies in emergency department settings with and without rapid magnetic resonance imaging (rMRI) availability.

STUDY DESIGN

A Markov decision model estimated outcomes in well-appearing infants with high-risk chief complaints. In an emergency department without rMRI, we considered 3 strategies: clinical judgment, universal head computed tomography (CT) scan, or the Pittsburgh Infant Brain Injury Score (PIBIS) with a CT scan. In an emergency department with rMRI for brain availability, we considered additional strategies: universal rMRI, universal rMRI with a CT scan, PIBIS with rMRI, and PIBIS with rMRI followed by a CT scan. Correct diagnosis eliminated future risk; missed abusive head trauma led to reinjury risk with associated poor outcomes. Cohorts were followed for 1 year from a healthcare perspective. One-way and probabilistic sensitivity analyses were performed. The main outcomes evaluated in this study were abusive head trauma correctly identified and incremental cost per quality-adjusted life-year.

RESULTS

Without rMRI availability, PIBIS followed by a CT scan was the most cost-effective strategy. Results were sensitive to variation of CT scan-induced cancer parameters and abusive head trauma prevalence. When rMRI was available, universal rMRI followed by a confirmatory CT scan cost $25 791 to gain 1 additional quality-adjusted life-year compared with PIBIS followed by rMRI with a confirmatory CT scan. In both models, clinical judgement was less effective than alternative strategies.

CONCLUSIONS

By applying CT scans to a more targeted population, PIBIS decreases radiation exposure and is more effective for the identification of abusive head trauma compared with clinical judgment. When rMRI is available, universal rMRI with a CT scan is more effective than PIBIS and is economically favorable.

Do Integrated Systems of Stroke Care Improve Symptom to Surgery Times in Patients with Symptomatic Carotid Stenosis? A Single Centre Decision Tree Analysis

OBJECTIVE

The objective of this study was to examine the impact of an integrated system of stroke care on symptom to surgery times, cost-effectiveness, and quality of life measures in patients with symptomatic carotid stenosis.

METHODS

Patients who underwent carotid endarterectomy (CEA) in a regional vascular centre between April 1, 2011, and March 31, 2016, were identified from the National Vascular Registry (NVR). Risk of stroke on medical therapy for each patient was calculated using the Oxford stroke risk calculator. Symptom to surgery times were compared among patients referred from a stroke service providing an integrated stroke care and the stroke service in an adjacent NHS trust which provides standard urgent referral pathway. A decision analytic Markov process model was constructed to determine the cost-effectiveness of CEA versus medical treatment in patients who followed the standard and integrated pathways. This model examined the lifetime costs and health benefits of CEA through each pathway.

RESULTS

A total of 376 patients underwent CEA, of whom 243 were managed through the integrated stroke pathway and 133 through the standard urgent referral pathway. Median symptom to surgery time was 11 (0-66) days for the former and 15 (3-90) days for the latter (p < .001). There was no significant difference in peri-operative stroke death rate between integrated (2.1%) and standard (1.5%) pathways (chi-square = 0.14, p = .73). CEA through the integrated pathway improved quality adjusted life expectancy by an additional 0.13 (0.64 QALYs [integrated pathway] to 0.51 QALYs [standard pathway]) and was associated with an incremental lifetime cost benefit of £2203.4.

CONCLUSIONS

An integrated stroke system of care is cost-effective and associated with significant improvements in quality adjusted life years.

Cost-effective diagnostic cardiovascular imaging: when does it provide good value for the money?

To summarize the results of all original cost-utility analyses (CUAs) in diagnostic cardiovascular imaging (CVI) and characterize those technologies by estimates of their cost-effectiveness. We systematically searched the literature for original CVI CUAs published between 2000 and 2008. Studies were classified according to several variables including anatomy of interest (e.g. cerebrovascular, aorta, peripheral) and imaging modality under study (e.g. angiography, ultrasound). The results of each study, expressed as cost of the intervention to number of quality-adjusted life years saved ratio (cost/QALY) were additionally classified as favorable or not using $20,000, $50,000, and $100,000 per QALY thresholds. The distribution of results was assessed with Chi Square or Fisher exact test, as indicated. Sixty-nine percent of all cardiovascular imaging CUAs were published between 2000 and 2008. Thirty-two studies reporting 82 cost/QALY ratios were included in the final sample. The most common vascular areas studied were cerebrovascular (n = 9) and cardiac (n = 8). Sixty-six percent (21/32) of studies focused on sonography, followed by conventional angiography and CT (25%, n = 8, each). Twenty-nine (35.4%), 42 (51.2%), and 53 (64.6%) ratios were favorable at WTP $20,000/QALY, $50,000/QALY, and $100,000/QALY, respectively. Thirty (36.6%) ratios compared one imaging test versus medical or surgical interventions; 26 (31.7%) ratios compared imaging to a different imaging test and another 26 (31.7%) to no intervention. Imaging interventions were more likely (P < 0.01) to be favorable when compared to observation, medical treatment or non-intervention than when compared to a different imaging test at WTP $100,000/QALY. The diagnostic cardiovascular imaging literature has growth substantially. The studies available have, in general, favorable cost-effectiveness profiles with major determinants relating to being compared against observation, medical or no intervention instead of other imaging tests.

Advancing radiology through informed leadership: summary of the proceedings of the Seventh Biannual Symposium of the International Society for Strategic Studies in Radiology (IS(3)R), 23-25 August 2007

The International Society for Strategic Studies in Radiology (IS³R) brings together thought leaders from academia and industry from around the world to share ideas, points of view and new knowledge. This article summarizes the main concepts presented at the 2007 IS³R symposium, providing a window onto trends shaping the future of radiology. Topics addressed include new opportunities and challenges in the field of interventional radiology; emerging techniques for evaluating and improving quality and safety in radiology; and factors impeding progress in molecular imaging and nanotechnology and possible ways to overcome them. Regulatory hurdles to technical innovation and drug development are also discussed more broadly, along with proposals for addressing regulators’ concerns and streamlining the regulatory process.

Twenty years of cost-effectiveness analysis in medical imaging: are we improving?

PURPOSE

To determine the growth rate, methodologic clarity, and quality changes in cost-effectiveness analyses (CEAs) and to assess whether the U.S. Panel on Cost-effectiveness in Health and Medicine recommendations affected CEA studies in which imaging technologies were evaluated.

MATERIALS AND METHODS

Six databases were systematically searched for CEA reports published between 1985 and 2005. All imaging-related studies were selected and grouped according to year, country, and journal of publication, as well as imaging modality and disease being studied. Two readers with formal training in decision analysis and CEA used a seven-point (1, low; 7, high) Likert scale based on reasonableness of assumptions, quality of presentation, and adherence to guidelines to independently evaluate study quality. Quality scores according to year, country, and journal of publication were compared with the unpaired Student t test.

RESULTS

The first radiology-related CEA was published in 1985; 111 radiology-related CEAs were published between 1985 and 2005. The average number of studies increased from 1.6 per year between 1985 and 1995 to 9.4 per year between 1996 and 2005. Eighty-six studies were performed to evaluate diagnostic imaging technologies, and 25 were performed to evaluate interventional imaging technologies. Ultrasonography (35.0%), angiography (31.5%), magnetic resonance imaging (22.5%), and computed tomography (19.8%) were evaluated most frequently. Forty-nine studies received government funds; 42 did not disclose the source of funding. The mean quality score was 4.23 +/- 1.12 (standard deviation), without significant improvement over time. Scores in studies performed in the United States were significantly higher than scores in studies that were not performed in the United States (4.45 +/- 1.02 vs 3.61 +/- 1.17, respectively; P < .01). Scores were also higher in journals with three or more CEA articles published during the study period than in journals with two or fewer CEA articles published during this period (4.54 +/- 1.09 vs 3.91 +/- 1.06, respectively; P < .01).

CONCLUSION

CEAs are an important tool with which to analyze the value of diagnostic imaging. However, improvement in the quality of analyses is needed.

SUPPLEMENTAL MATERIAL

http://radiology.rsnajnls.org/cgi/content/full/249/3/917/DC1.

[Referral guidelines in diagnostic imaging]

This article describes the causes and motivations for the introduction of referral guidelines for diagnostic radiology. Guidelines are not intended to serve as directives, but as a concept for good practice and as a basis for discussion and communication between prescribers and practitioners of radiological examinations. Although not all questions about the most effective way of implementation have been solved, it has been shown that referral guidelines serve as a means of avoiding unnecessary x-ray examinations and therefore represent an important tool within a comprehensive concept of radiation protection.