Cost Minimisation Analysis: Kilovoltage Imaging with Automated Repositioning Versus Electronic Portal Imaging in Image-guided Radiotherapy for Prostate Cancer

Optimising patient care in medical radiation services through health economics: an introduction

The role of health economics in optimising patient care in medical radiation clinical settings is of increasing importance in ensuring efficient and effective service delivery. This commentary introduces health economics to medical radiation professionals by outlining the main analysis types utilised, highlighted by examples in the literature. The purpose is to provide an over-arching framework and starting point for incorporating health economics into medical radiation research study protocols.

Critical review and quality-assessment of cost analyses in radiotherapy: How reliable are the data?

PURPOSE/OBJECTIVE

Health economic evaluations (HEE) are increasingly having an impact on policymakers, although the results greatly depend on the quality of the methodology used and on transparent reporting. The two main objectives of this study were to evaluate the quality of cost analyses of external beam radiotherapy (EBRT) and to assess the comprehensiveness and relevance of cost criteria defined in three validated quality-assessment instruments.

MATERIALS AND METHODS

The selection of articles was based on a previous systematic literature review of EBRT-costing studies retrieved from January 2004 to January 2015 (Period 1) in MEDLINE, Embase, and NHS-EED databases and completed in a second time period from January 2015 to November 2018 (Period 2). Three validated instruments to assess the methodology quality with the CHEC and the QHES, and the methodology with the CHEERS checklists were used. The quality was evaluated by both quantitative and qualitative analyses. The scoring robustness was examined with the Kendall coefficient of concordance and inter-class correlation coefficients.

RESULTS

In total, twenty-three articles were selected. The main geographic areas of cost analyses were Canada (n = 5), France (n = 4), and the USA (n = 4). The most commonly studied pathologies and technologies were prostate (n = 7) and head and neck cancer (n = 5) and IMRT (n = 8) and IGRT (n = 2), respectively. The mean instrument scores demonstrated a fair degree of methodological quality, with 69.7% for the CHEC, 73.6% for the QHES, as well as for the reporting quality, with 59.4% for CHEERS for Period 1 (74.4%, 71.5%, and 66.1%, respectively, for Period 2). An additional qualitative analysis per criterion revealed that certain items, essential for understanding the costing methodology and the results (e.g., the time horizon, discount rate, sensitivity analysis) were often only partially completed. Statistical analysis confirmed that the reviewers' scoring was consistent. The instruments identified the same top three articles, albeit with a degree of variation in the ranking.

CONCLUSION

Qualitative and quantitative assessment of cost analyses in EBRT exhibits a fair level of study quality in terms of the methodology and reporting transparency. The impact of cost calculations on the final HEE result appears to be underestimated, and increased transparency of the data sources and the methodologies is needed.

Cost evaluations of radiotherapy: What do we know? An ESTRO-HERO analysis

Although economic evidence is becoming mandatory to support health care decision-making, challenges remain in generating high quality cost data, especially for complex and rapidly evolving treatment modalities, such as radiotherapy. The overall aim of this systematic literature review was to critically analyse the type and quality of radiotherapy cost information available in cost calculation studies, from the health care provider's perspective, published since 1981. A selection process, based on strict and explicit criteria, yielded 52 articles. In spite of meeting our criteria these studies displayed large heterogeneity in scope, costing method, inputs and outputs. The limited use of conventional costing methodologies along with insufficient information on resource inputs hampered comparability across studies. A consistent picture of radiotherapy costs, based on methodologically sound costing studies, has yet to emerge. These results call for developing a well-defined and generally accepted cost methodology for performing economic evaluation studies in radiotherapy.

Seminal vesicle intrafraction motion analysed with cinematic magnetic resonance imaging

PURPOSE

This study analyses seminal vesicle displacement relative to the prostate and in relation to treatment time.

METHOD

A group of eleven patients undergoing prostate cancer radiotherapy were imaged with a continuous 3 T cine-MRI in the standard treatment setup position. Four images were recorded every 4 seconds for 15 minutes in the sagittal plane and every 6.5 seconds for 12 minutes in the coronal plane. The prostate gland and seminal vesicles were contoured on each MRI image. The coordinates of the centroid of the prostate and seminal vesicles on each image was analysed for displacement against time. Displacements between the 2.5 percentile and 97.5 percentile (i.e. the 2.5% trimmed range) for prostate and seminal vesicle centroid displacements were measured for 3, 5, 10 and 15 minutes time intervals in the anterior-posterior (AP), left-right (LR) and superior-inferior (SI) directions. Real time prostate and seminal vesicle displacement was compared for individual patients.

RESULTS

The 2.5% trimmed range for 3, 5, 10 and 15 minutes for the seminal vesicle centroids in the SI direction measured 4.7 mm; 5.8 mm; 6.5 mm and 7.2 mm respectively. In the AP direction, it was 4.0 mm, 4.5 mm, 6.5 mm, and 7.0 mm. In the LR direction for 3, 5 and 10 minutes; for the left seminal vesicle, it was 2.7 mm, 2.8 mm, 3.4 mm and for the right seminal vesicle, it was 3.4 mm, 3.3 mm, and 3.4 mm. The correlation between the real-time prostate and seminal vesicle displacement varied substantially between patients indicating that the relationship between prostate displacement and seminal vesicles displacement is patient specific with the majority of the patients not having a strong relationship.

CONCLUSION

Our study shows that seminal vesicle motion increases with treatment time, and that the prostate and seminal vesicle centroids do not move in unison in real time, and that an additional margin is required for independent seminal vesicle motion if treatment localisation is to the prostate.

Assessing the Efficiency and Consistency of Daily Image-guided Radiation Therapy in a Modern Radiotherapy Centre

BACKGROUND

Patients at Radiation Oncology Queensland Toowoomba are treated using the assistance of daily image-guided radiation therapy (IGRT). Each patient's daily setup is exposed to a number of variables. This study investigates the effect that these variables have on the total time taken to analyse field placement and the total time taken for treatment, as well accessing setup error across a variety of treatment types.

METHODS

This is a retrospective study of 80 patients across a variety of treatment sites where daily IGRT was undertaken using kilovoltage and megavoltage orthogonal images. Variables investigated include the treatment type, the imaging modality used, and the setup error of each session. Statistical analysis was then performed on the data.

RESULTS

Patients being treated in the thoracic region had the greatest random setup error. The mean matching times were also longer for chest patients (197 seconds), whereas there were minimal differences in times regarding modality. Treatment times were longest for head and neck variables (399-405 seconds).

CONCLUSIONS

Pretreatment daily IGRT is beneficial to all patients and can be performed efficiently. Pelvic variables were the strongest performer, with fiducial markers providing the most consistent and rapid match times. Chest variables were the worst performer specifically regarding random setup error and match times indicating future work required on chest stabilization.