Comparative effectiveness research: what it means for radiology

Cost Comparison of Ultrasound Versus MRI to Diagnose Adolescent Female Patients Presenting with Acute Abdominal/Pelvic Pain Using Time-Driven Activity-Based Costing

RATIONALE AND OBJECTIVES

To compare the cost of ultrasound (US) versus magnetic resonance imaging (MRI) using time-driven activity-based costing in adolescent female patients with suspected appendicitis.

MATERIALS AND METHODS

Process maps were created using data from electronic medical record review and patient shadowing for adolescent female patients undergoing US or noncontrast MRI exams of the abdomen and pelvis for suspected appendicitis. Capacity cost rates for all personnel, equipment, facilities, and supplies in each exam pathway were established from institutional accounting data. The cost of each process step was determined by multiplying step-specific capacity cost rates by the mean time required to complete the step. Total pathway costs for US and MRI were computed by summing the costs of all steps through each pathway, and a direct cost comparison was made between the two modalities.

RESULTS

Process maps for US and MRI pathways were generated from 231 and 52 patient encounters, respectively. Patients undergoing US exams followed one of six pathways depending on exam order (abdomen versus pelvis performed first) and whether additional time was needed for bladder filling. Mean total US pathway time was 91 minutes longer than for MRI (US = 166 minutes; MRI = 75 minutes). Total MRI pathway cost was $209.97 compared to a mean US cost of $258.33 (range = $163.21-$293.24).

CONCLUSION

MRI can be a faster and less costly alternative to US for evaluating suspected appendicitis in adolescent female patients. While precise costs will vary by institution, MRI may be a viable and at times preferable alternative to US in this patient population.

Cost-Effectiveness Analysis: An Overview of Key Concepts, Recommendations, Controversies, and Pitfalls

The field of radiology has witnessed a burst of technological advances that improve diagnostic quality, reduce harm to patients, support clinical needs, and better serve larger more diverse patient populations. One of the critical challenges with these advances is proving that value outweighs the cost. The use of cutting-edge technology is often expensive, and the reality is that our society cannot afford all the screening and diagnostic tests that are being developed. At the societal level, we need tools to help us decide which health programs should be funded. Therefore, decision makers are increasingly looking toward scientific methods to compare health technologies in order to improve allocation of resources. One of such methods is cost-effectiveness analysis. In this article, we review key features of cost-effectiveness analysis and its specific issues as they relate to radiology.

Digital Breast Tomosynthesis and the Challenges of Implementing an Emerging Breast Cancer Screening Technology Into Clinical Practice

Emerging imaging technologies, including digital breast tomosynthesis, have the potential to transform breast cancer screening. However, the rapid adoption of these new technologies outpaces the evidence of their clinical and cost-effectiveness. The authors describe the forces driving the rapid diffusion of tomosynthesis into clinical practice, comparing it with the rapid diffusion of digital mammography shortly after its introduction. They outline the potential positive and negative effects that adoption can have on imaging workflow and describe the practice management challenges when incorporating tomosynthesis. The authors also provide recommendations for collecting evidence supporting the development of policies and best practices.

Translating New Imaging Technologies to Clinical Practice

Radiology continues to benefit from constant innovation and technological advances. However, for promising new imaging technologies to reach widespread clinical practice, several milestones must be met. These include regulatory approval, early clinical evaluation, payer reimbursement, and broader marketplace adoption. Successful implementation of new imaging tests into clinical practice requires active stakeholder engagement and a focus on demonstrating clinical value during each phase of translation.

Radiology Research Funding: Current State and Future Opportunities

Funding for research has become increasingly difficult to obtain in an environment of decreasing clinical revenue, increasing research costs, and growing competition for federal and nonfederal funding sources. This paper identifies critical requirements to build and sustain a successful radiology research program (eg, key personnel and leadership, research training and mentorship, infrastructure, institutional and departmental funding or support), reviews the current state of available funding for radiology (including federal, nonfederal, philanthropy, crowdfunding, and industry), and describes promising opportunities for future funding (eg, health services, comparative effectiveness, and patient-centered outcomes research). The funding climate, especially at the federal level, changes periodically, so it is important to have radiology-specific organizations such as the American College of Radiology and the Academy of Radiology Research serving as our key advocates. Key to obtaining any funding, no matter what the source, is a well-formulated grant proposal, so a review of opportunities specifically available to radiologists to develop and hone their grant-writing skills is provided. Effective and sustained funding for radiology research has the potential to cultivate young researchers, bolster quality research, and enhance health care. Those interested in pursuing research need to be aware of the ever-changing funding landscape, research priority areas, and the resources available to them to succeed. To succeed, radiology researchers need to think about diversification and flexibility in their interests, developing multidisciplinary and multi-institutional projects, and engaging a broader base of stakeholders that includes patients.

Value of Imaging Part I: Perspectives for the Academic Radiologist

With payers and policymakers increasingly scrutinizing the value of medical imaging, opportunities abound for radiologists and radiology health services researchers to meaningfully and rigorously demonstrate value. Part one of this two-part series on the value of imaging explores the concept of value in health care from the perspective of multiple stakeholders and discusses the opportunities and challenges for radiologists and health service researchers to demonstrate value. The current absence of meaningful national value metrics also presents an opportunity for radiologists to take the lead on the discussions of these metrics that may serve as the basis for future value-based payments. As both practitioners and investigators, radiologists should consider the perspectives of multiple stakeholders in all they do-interdisciplinary support and cooperation are essential to the success of value-focused imaging research and initiatives that improve patient outcomes. Radiology departments that align their cultures, infrastructures, and incentives to support these initiatives will greatly increase their chances of being successful in these endeavors.

Research Challenges and Opportunities for Clinically Oriented Academic Radiology Departments

Between 2004 and 2012, US funding for the biomedical sciences decreased to historic lows. Health-related research was crippled by receiving only 1/20th of overall federal scientific funding. Despite the current funding climate, there is increased pressure on academic radiology programs to establish productive research programs. Whereas larger programs have resources that can be utilized at their institutions, small to medium-sized programs often struggle with lack of infrastructure and support. To address these concerns, the Association of University Radiologists' Radiology Research Alliance developed a task force to explore any untapped research productivity potential in these smaller radiology departments. We conducted an online survey of faculty at smaller clinically funded programs and found that while they were interested in doing research and felt it was important to the success of the field, barriers such as lack of resources and time were proving difficult to overcome. One potential solution proposed by this task force is a collaborative structured research model in which multiple participants from multiple institutions come together in well-defined roles that allow for an equitable distribution of research tasks and pooling of resources and expertise. Under this model, smaller programs will have an opportunity to share their unique perspective on how to address research topics and make a measureable impact on the field of radiology as a whole. Through a health services focus, projects are more likely to succeed in the context of limited funding and infrastructure while simultaneously providing value to the field.

Including patient-reported outcomes and patient-reported resource-use questionnaires in studies

RATIONALE

More efficient and better informed healthcare systems are expected to have improved knowledge of the impact of interventions on patient outcomes and resources used by patients and providers in specific health conditions.

OBJECTIVES

To describe trends related to putting patients at the center of healthcare decision making, regulatory trends and best practice recommendations for developing high-quality patient-reported outcomes (PROs), and strategic issues related to including PROs in studies.

MATERIALS AND METHODS

We summarize PRO concepts, definitions, and broadly-accepted scientific standards for developing, assessing, and interpreting PROs. Three conceptual models are presented as examples for assessing PROs in relation to other outcomes. We discuss different perspectives for stakeholders, including regulatory issues pertaining to formal guidance for PRO development and for use in trials. We provide examples of PROs used in studies for assessing health outcomes in oncology and resource-use outcomes in low back pain patients.

RESULTS

Psychometric scientists working closely with multi-disciplinary teams and regulatory authorities have greatly improved the science of collecting, assessing, and understanding patient-reported outcomes in clinical trials. A simplified framework is presented for strategic considerations for including PROs in studies, such as the appropriate timing for PRO endpoints. Asking patients about their health status and/or use of resources improves our understanding of how interventions and care processes may impact their lives and their budgets. We provide examples from a back pain trial of patient-reported resource-use questionnaires for medicines taken and other services or products used by patients.

CONCLUSIONS

Healthcare stakeholders are placing increased emphasis on resource use and the impact of interventions on patients, including effects associated with diagnostic tests. Patient-reported outcomes are being used in clinical practice and in clinical research, supported by formal best-practice guidelines. Radiology has a role as an engaged stakeholder in the design, conduct, and interpretation of patient-based evidence, and in its relevance to health policy implementation.

Patient-centered outcomes research in radiology: trends in funding and methodology

The creation of the Patient-Centered Outcomes Research Trust Fund and the Patient-Centered Outcomes Research Institute (PCORI) through the Patient Protection and Affordable Care Act of 2010 presents new opportunities for funding patient-centered comparative effectiveness research (CER) in radiology. We provide an overview of the evolution of federal funding and priorities for CER with a focus on radiology-related priority topics over the last two decades, and discuss the funding processes and methodological standards outlined by PCORI. We introduce key paradigm shifts in research methodology that will be required on the part of radiology health services researchers to obtain competitive federal grant funding in patient-centered outcomes research. These paradigm shifts include direct engagement of patients and other stakeholders at every stage of the research process, from initial conception to dissemination of results. We will also discuss the increasing use of mixed methods and novel trial designs. One of these trial designs, the pragmatic trial, has the potential to be readily applied to evaluating the effectiveness of diagnostic imaging procedures and imaging-based interventions among diverse patient populations in real-world settings.

Comparative effectiveness research in pediatric radiology

Comparative effectiveness research is designed to help patients, physicians and policymakers choose the best medical option among alternative diagnostic and interventional strategies. In this commentary, we provide a brief overview of comparative effectiveness research, discuss some of the challenges to applying it in pediatric radiology, and give several reasons behind the continued push for more comparative effectiveness research by governmental and other funding agencies.

Digital breast tomosynthesis and the challenges of implementing an emerging breast cancer screening technology into clinical practice

Emerging imaging technologies, including digital breast tomosynthesis, have the potential to transform breast cancer screening. However, the rapid adoption of these new technologies outpaces the evidence of their clinical and cost-effectiveness. The authors describe the forces driving the rapid diffusion of tomosynthesis into clinical practice, comparing it with the rapid diffusion of digital mammography shortly after its introduction. They outline the potential positive and negative effects that adoption can have on imaging workflow and describe the practice management challenges when incorporating tomosynthesis. The authors also provide recommendations for collecting evidence supporting the development of policies and best practices.

How to set up a departmental comparative effectiveness research unit: one department's experience

OBJECTIVE

Comparative effectiveness research (CER) is the comparison of clinical interventions in real-world settings. The purpose of this article is to discuss the experiences of a CER unit created within the radiology department of one medical institution to provide an example of how to pursue CER within the field of radiology.

CONCLUSION

Medical institutions would benefit from investing in CER by creating research groups specifically devoted to this evolving field.

The total value equation: a suggested framework for understanding value creation in diagnostic radiology

As a result of macroeconomic forces necessitating fundamental changes in health care delivery systems, value has become a popular term in the medical industry. Much has been written recently about the idea of value as it relates to health care services in general and the practice of radiology in particular. Of course, cost, value, and cost-effectiveness are not new topics of conversation in radiology. Not only is value one of the most frequently used and complex words in management, entire classes in business school are taught around the concept of understanding and maximizing value. But what is value, and when speaking of value creation strategies, what is it exactly that is meant? For the leader of a radiology department, either private or academic, value creation is a core function. This article provides a deeper examination of what value is, what drives value creation, and how practices and departments can evaluate their own value creation efficiencies. An equation, referred to as the Total Value Equation, is presented as a framework to assess value creation activities and strategies.

Percutaneous Cryoablation of Metastatic Lesions from Colorectal Cancer: Efficacy and Feasibility with Survival and Cost-Effectiveness Observations

Purpose

To assess feasibility, complications, local tumor recurrences, overall survival (OS) and estimates of cost-effectiveness for multi-site cryoablation (MCA) of oligo-metastatic colorectal cancer (mCRC) in a prospective study.

Materials and Methods

111 CT and/or US-guided percutaneous MCA procedures were performed on 151 tumors in 59 oligo mCRC patients. Mean patient age was 63 years (range 21–92 years), consisting of 29 males and 30 females. Tumor location was grouped according to common metastatic sites. Median OS was determined using the Kaplan-Meier. Estimates of MCA costs per LYG were compared to historical values for systemic therapies.

Results

A mean 1.9 MCAs per patient were performed with a median clinical follow-up of 12 months. Major complication and local recurrence rates were 8% (9/111) and 12% (18/151), respectively. Median overall-survival (OS) was 23.6 months with an estimated 3-year survival rate of ~30%. Cryoablation remained cost effective with or without the presence of systemic therapies, with an adjunctive cost-effectiveness ratio (ACER) of $39,661–$85,580 per LYG.

Conclusions

Multi-site cryoablation had very low complication and local recurrence rates, and was able to provide local control even for diverse soft tissue locations. Even as an adjunct to systemic therapies, MCA appeared cost-effective, with apparent increased survival.

Accuracy, risk and the intrinsic value of diagnostic imaging: a review of the cost-utility literature

RATIONALE AND OBJECTIVES

The aim of this study was to systematically review the reporting of the value of imaging unrelated to treatment consequences and test characteristics in all imaging-related published cost-utility analyses (CUAs) in the medical literature.

MATERIALS AND METHODS

All CUAs published between 1976 and 2008 evaluating diagnostic imaging technologies contained in the CEA Registry, a publicly available comprehensive database of health related CUAs, were screened. Publication characteristics, imaging modality, and the inclusion of test characteristics including accuracy, costs, risks, and the potential value unrelated to treatment consequences (eg, reassurance or anxiety) were assessed.

RESULTS

Ninety-six published CUAs evaluating 155 different imaging technologies were included in the final sample; 27 studies were published in imaging-specialized journals. Fifty-two studies (54%) evaluated the performance of a single imaging modality, while 44 studies (46%) compared two or more different imaging modalities. The most common areas of interest were cardiovascular (45%) and neuroradiology (17%). Forty-two technologies (27%) concerned ultrasound, while 34 (22%) concerned magnetic resonance. Seventy-nine (51%) technologies used ionizing radiation. Test accuracy was reported or calculated for 90% (n = 133 and n = 5, respectively) and assumed perfect (reference test or gold-standard test without alternative testing strategy to capture false-negatives and false-positives) for 8% (n = 12) of technologies. Only 22 studies (23%) assessing 40 imaging technologies (26%) considered inconclusive or indeterminate results. The risk of testing was reported for 32 imaging technologies (21%). Fifteen studies (16%) considered the value of diagnostic imaging unrelated to treatment. Four studies incorporated it as quality-of-life adjustments, while 10 studies mentioned it only in their discussions or as a limitation.

CONCLUSIONS

The intrinsic value of imaging (the value of imaging unrelated to treatment) has not been appropriately defined or incorporated in the existing cost-utility literature, which could be due to a lack of evidence on the issue. Thus, more research is needed on metrics for a more comprehensive evaluation of diagnostic imaging. Similarly, the incorporation of variations in imaging tests accuracy, inconclusive results and associated risks has lacked uniformity in the cost-utility literature. Acknowledgment of these characteristics in future cost-utility publications will enhance their value and provide results that more closely resemble routine clinical practice.

Percutaneous cryoablation of metastatic renal cell carcinoma for local tumor control: feasibility, outcomes, and estimated cost-effectiveness for palliation

PURPOSE

To assess complications, local tumor recurrences, overall survival (OS), and estimates of cost-effectiveness for multisite cryoablation (MCA) of oligometastatic renal cell carcinoma (RCC).

MATERIALS AND METHODS

A total of 60 computed tomography- and/or ultrasound-guided percutaneous MCA procedures were performed on 72 tumors in 27 patients (three women and 24 men). Average patient age was 63 years. Tumor location was grouped according to common metastatic sites. Established surgical selection criteria graded patient status. Median OS was determined by Kaplan-Meier method and defined life-years gained (LYGs). Estimates of MCA costs per LYG were compared with established values for systemic therapies.

RESULTS

Total number of tumors and cryoablation procedures for each anatomic site are as follows: nephrectomy bed, 11 and 11; adrenal gland, nine and eight; paraaortic, seven and six; lung, 14 and 13; bone, 13 and 13; superficial, 12 and nine; intraperitoneal, five and three; and liver, one and one. A mean of 2.2 procedures per patient were performed, with a median clinical follow-up of 16 months. Major complication and local recurrence rates were 2% (one of 60) and 3% (two of 72), respectively. No patients were graded as having good surgical risk, but median OS was 2.69 years, with an estimated 5-year survival rate of 27%. Cryoablation remained cost-effective with or without the presence of systemic therapies according to historical cost comparisons, with an adjunctive cost-effectiveness ratio of $28,312-$59,554 per LYG.

CONCLUSIONS

MCA was associated with very low morbidity and local tumor recurrence rates for all anatomic sites, with apparent increased OS. Even as an adjunct to systemic therapies, MCA appeared cost-effective for palliation of oligometastatic RCC.

The emergence of diagnostic imaging technologies in breast cancer: discovery, regulatory approval, reimbursement, and adoption in clinical guidelines

In this article, we trace the chronology of developments in breast imaging technologies that are used for diagnosis and staging of breast cancer, including mammography, ultrasonography, magnetic resonance imaging, computed tomography, and positron emission tomography. We explore factors that affected clinical acceptance and utilization of these technologies from discovery to clinical use, including milestones in peer-reviewed publication, US Food and Drug Administration approval, reimbursement by payers, and adoption into clinical guidelines. The factors driving utilization of new imaging technologies are mainly driven by regulatory approval and reimbursement by payers rather than evidence that they provide benefits to patients. Comparative effectiveness research can serve as a useful tool to investigate whether these imaging modalities provide information that improves patient outcomes in real-world settings.

Delivering affordable cancer care in high-income countries

The burden of cancer is growing, and the disease is becoming a major economic expenditure for all developed countries. In 2008, the worldwide cost of cancer due to premature death and disability (not including direct medical costs) was estimated to be US$895 billion. This is not simply due to an increase in absolute numbers, but also the rate of increase of expenditure on cancer. What are the drivers and solutions to the so-called cancer-cost curve in developed countries? How are we going to afford to deliver high quality and equitable care? Here, expert opinion from health-care professionals, policy makers, and cancer survivors has been gathered to address the barriers and solutions to delivering affordable cancer care. Although many of the drivers and themes are specific to a particular field-eg, the huge development costs for cancer medicines-there is strong concordance running through each contribution. Several drivers of cost, such as over-use, rapid expansion, and shortening life cycles of cancer technologies (such as medicines and imaging modalities), and the lack of suitable clinical research and integrated health economic studies, have converged with more defensive medical practice, a less informed regulatory system, a lack of evidence-based sociopolitical debate, and a declining degree of fairness for all patients with cancer. Urgent solutions range from re-engineering of the macroeconomic basis of cancer costs (eg, value-based approaches to bend the cost curve and allow cost-saving technologies), greater education of policy makers, and an informed and transparent regulatory system. A radical shift in cancer policy is also required. Political toleration of unfairness in access to affordable cancer treatment is unacceptable. The cancer profession and industry should take responsibility and not accept a substandard evidence base and an ethos of very small benefit at whatever cost; rather, we need delivery of fair prices and real value from new technologies.

Enabling comparative effectiveness research with informatics: show me the data!

RATIONALE

Both outcomes researchers and informaticians are concerned with information and data. As such, some of the central challenges to conducting successful comparative effectiveness research can be addressed with informatics solutions.

METHODS

Specific informatics solutions which address how data in comparative effectiveness research are enriched, stored, shared, and analyzed are reviewed.

RESULTS

Imaging data can be made more quantitative, uniform, and structured for researchers through the use of lexicons and structured reporting. Secure and scalable storage of research data is enabled through data warehouses and cloud services. There are a number of national efforts to help researchers share research data and analysis tools.

CONCLUSION

There is a diverse arsenal of informatics tools designed to meet the needs of comparative effective researchers.

Comparative effectiveness research in radiology: patients, physicians and policy makers

Health care costs continue to rise, with significant geographic differences in spending on health care and outcomes within the United States. The goal of comparative effectiveness research is to reduce health care spending without adversely effecting overall health according to the Congressional Budget Office. There are unique challenges and barriers to applying comparative effectiveness research to radiology, including rapidly changing technology, complex multistep care processes, and the burden of proving the impact of a diagnostic exam on patient outcome. Radiology shares other challenges of acceptance of comparative effectiveness research results (diffusion of new knowledge and successful implementation of changes in clinical practice) with all of health care, but with the added complication that radiologists do not order radiology exams.

Innovation in diagnostic imaging services: assessing the potential for value-based reimbursement

Innovation in the field of diagnostic imaging is based primarily on the availability of new and improved equipment that opens the door for new clinical applications. Payments for these imaging procedures are subject to complex Medicare price control schemes, affecting incentives for appropriate use and innovation. Achieving a "dynamically efficient" health care system-one that elicits a socially optimal amount of innovation-requires that innovators be rewarded in relation to the value they add and can demonstrate with evidence. The authors examine how and whether value-based reimbursement for diagnostic imaging services might better reward innovation explicitly for expected improvements in health and economic outcomes.

Radioembolization results in longer time-to-progression and reduced toxicity compared with chemoembolization in patients with hepatocellular carcinoma

BACKGROUND & AIMS

Chemoembolization is one of several standards of care treatment for hepatocellular carcinoma (HCC). Radioembolization with Yttrium-90 microspheres is a novel, transarterial approach to radiation therapy. We performed a comparative effectiveness analysis of these therapies in patients with HCC.

METHODS

We collected data from 463 patients who were treated with transarterial locoregional therapies (chemoembolization or radioembolization) over a 9-year period. We excluded patients who were not appropriate for comparison and analyzed data from 245 (122 who received chemoembolization and 123 who received radioembolization). Patients were followed for signs of toxicity; all underwent imaging analysis at baseline and follow-up time points. Overall survival was the primary outcome measure. Secondary outcomes included safety, response rate, and time-to-progression. Uni- and multivariate analyses were performed.

RESULTS

Abdominal pain and increased transaminase activity were more frequent following chemoembolization (P < .05). There was a trend that patients treated with radioembolization had a higher response rate than with chemoembolization (49% vs 36%, respectively, P = .104). Although time-to-progression was longer following radioembolization than chemoembolization (13.3 months vs 8.4 months, respectively, P = .046), median survival times were not statistically different (20.5 months vs 17.4 months, respectively, P = .232). Among patients with intermediate-stage disease, survival was similar between groups that received chemoembolization (17.5 months) and radioembolization (17.2 months, P = .42).

CONCLUSIONS

Patients with HCC treated by chemoembolization or radioembolization with Yttrium-90 microspheres had similar survival times. Radioembolization resulted in longer time-to-progression and less toxicity than chemoembolization. Post hoc analyses of sample size indicated that a randomized study with > 1000 patients would be required to establish equivalence of survival times between patients treated with these two therapies.

Managing radiation use in medical imaging: a multifaceted challenge

This special report aims to inform the medical community about the many challenges involved in managing radiation exposure in a way that maximizes the benefit-risk ratio. The report discusses the state of current knowledge and key questions in regard to sources of medical imaging radiation exposure, radiation risk estimation, dose reduction strategies, and regulatory options.

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.