Cost Effectiveness of Imaging Utilization
In the last decade, the imaging department has become the nucleus for diagnosis in most medical centers. This is certainly related to continued technologic advances and improvements in the quality of imaging. Faster processing and rapid on-site interpretations by local well-trained experts have further enhanced the feasibility of performing such examinations, both from the emergency room and in outpatient settings. As a result, primary care physicians have tended to rely ever more heavily on these interpretations, with the art of the physical exam being de-emphasized, particularly by younger physicians. Consequently, referring physicians are requesting diagnostic imaging exams more frequently. One might expect a negative financial impact, but increasing the utilization of diagnostic exams can often result in significant economic benefit.
The following is a synopsis of published literature that demonstrates how more frequent imaging or the utilization of imaging-guided procedures can produce significant cost savings compared to more standard methods of patient care. The ACR Managed Care Committee hopes you find this information useful when discussing the utilization of imaging with colleagues and payers.
Literature Search: Value of Increasing Radiology Utilization in Certain Clinical Situations
- Levin DC, Matteucci T. Do radiologists control imaging studies? Survey results from 198 academic institutions. Radiology. 1989;170:879-881.
In many of the potentially controversial imaging and interventional procedures, radiologists' domains were not challenged. Even areas such as OB US, IVC filter placement and urethrography, their roles were "significant."
- Doubilet P, Weinstein MC, McNeil BJ. Use and misuse of the term "cost effective" in medicine. NEJM. 1986;314(4):253-256.
This article had to do with the correct usage of the term "cost effective," commenting on the need to have numerical data supporting the economic benefits, which are rarely seen in both advertisements and research. The concluding paragraph, however, adds some helpful insight to our position and is as follows: ... attempting to base medical decisions on both health and monetary considerations is a difficult task that raises serious ethical issues. The data required to determine the benefits and costs of competing strategies are often unavailable or unreliable. Many medical decisions are influenced by factors that cannot be easily quantified or assigned a dollar value—for example, pain relief, the "bonding" effect of an obstetrical sonogram and the reassurance provided by a negative test.
- Rosendahl K, Markestad T, Lie RT, Sudmann E, Geitung JT. Cost-effectiveness of alternative screening strategies for developmental dysplasia of the hip. Arch Pediatr Adolesc Med. 1995;149(6):643-648.
Ultrasound screening shows economic benefit in the diagnosis of DDH, particularly because treatment of late DDH is considerably more expensive than early treatment. There were some increased costs related to higher treatment rate for infants subjected to ultrasound screening than those who were not. These costs were far outweighed by the savings for treatment of late DDH.
- Rao PM, Rhea JT, Novelline RA, Mostafavi AA, McCabe CJ. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. NEJM. 1998;338(3):141-146.
The authors evaluated 100 patients who had CT for suspected appendicitis. Fifty-three had appendicitis; 47 did not. After the cost of CT, overall savings was $447 per patient ($44,731).
- Yin D, Baum RA, Carpenter JP, Langlotz CP, Pentecost MJ. Cost effectiveness of MR angiography in cases of limb-threatening peripheral vascular disease. Radiology. 1995;194:757-764.
The authors calculated incremental "cost per quality-adjusted life year gained" using MRA with or without conventional angio. They determined the "cost effectiveness ratio" to be $25,895.
- Jordan JE, Donaldson SS, Enzmann DR. Cost effectiveness and outcome assessment of magnetic resonance imaging in diagnosing cord compression. Cancer. 1998;75(10):2579-2586.
This article is both a retrospective review and literature review. The authors found that with the use of MR in imaging patients with diagnosed cord compression, costs were reduced by 65 percent. Imaging studies utilized prior to MRI for diagnosis included myelography, CT, plain film and nuclear medicine. The average cost for diagnosis in these groups dropped from $3664/patient to $2283/patient. The lack of hospitalization costs with myelography contributed significantly to the reduced cost with MRI diagnosis.
- Garcia Pena BM, Taylor GA, Lund DP, Mandl KD. Effect of computed tomography on patient management and costs in children with suspected appendicitis. Pediatrics. 1999:104:440-446.
CT was obtained with three strategies: 1) obtain on all patients and discharge if nl, 2) obtain on all pts and admit all, 3) selectively obtain CT if wbc>10,000.
All strategies decreased the number of hospital days, negative laparotomies and the per patient cost. Savings for strategy 1 was $2018/patient, for strategy 2 $554/patient, and for strategy 3 $691/patient.
- Cullinane DC, Parkus DE, Reddy VS, Nunn CR, Rutherford EJ. Futility of chest roentgenograms following routine central venous line changes. Am J Surg. 1998;176(3):283-285.
Article suggests that chext X-ray after central line placement is of no utility. Annual reduction of costs in the surgical ICU at Vanderbilt was $46,800.
- Rhea JT, Rao PM, Novelline RA, McCabe CJ. A focused appendiceal CT technique to reduce the cost of caring for patients with clinically suspected appendicitis. AJR. 1997;169:113-118.
Use of focused CT reduced both variable and total cost by $23,030 and $ 45,556 respectively per 100 patients. Costs were reduced through decreased number of negative laparotomies and decreased number of hospital days (cost of one negative appendectomy equals the cost of 18 appendiceal CT scans).
- Liberman L, Feng TL, Dershaw DD, Morris EA, Abramson AF. US-guided core breast biopsy: use and cost effectiveness. Radiology. 1998;208:717-723.
This study compared costs based on Medicare reimbursements between ultrasound-guided and wire localization with subsequent excisional biopsy for nonpalpable breast lesions. The authors found that the cost of ultrasound-guided biopsy was $385 versus $1332 for surgical biopsy with wire localization. When accounting for some cases in which inadequate sampling occurred, the overall savings per case was $744. Interestingly, they also calculated a potential national cost savings of $59,520,000.
- Liberman L, Fahs MC, Dershaw DD et al. Impact of stereotaxic core breast biopsy on cost of diagnosis. Radiology. 1995;195:633-637.
The cost savings for stereotactic biopsy of nonpalpable breast lesions is compared with that of wire localization and subsequent surgical excisional biopsy. The average medical reimbursement for stereotaxic biopsy was $733 compared to $1626 for surgical biopsy. Dr. Liberman does note significantly that in situations when the histopathology shows small foci of DCIS or atypical hyperplasia, an additional step before surgical biopsy is added. Since both DCIS and atypical hyperplasia tend more commonly to present as calcifications, the likelihood of needing excisional surgical biopsy following stereotactic biopsy is more common with calcifications. As a result, the adjusted cost savings are different when comparing values for calcifications and those for masses. She found an adjusted cost savings for calcifications of $714 versus $1007 for masses. From a socioeconomic standpoint, one can also account for additional savings on a national basis with less time off from work and savings that approach $200 million annually.
- Rosen MP, Sands DZ, Longmaid HE 3rd, Reynolds KF, Wagner M, Raptopoulos V. Impact of abdominal CT on the management of patients presenting to the emergency department with acute abdominal pain. AJR. 2000;174:1391-1396.
This is a review of fifty-seven patients who presented to the emergency room with acute abdominal pain of a nontraumatic origin. CT added significantly to the confidence level of the emergency room physician's diagnosis evaluated subjectively. The use of CT averted the admission of ten of 42 of these patients, approximately 24 percent. Furthermore, patient management was altered in 60 percent of patients.
- Hricak H, Yu KK, Powell CB, Subak LL, Stem J. Comparison of diagnostic studies in the pretreatment evaluation of stage 1b carcinoma of the cervix. Academic Radiology. 1996; 3(Suppl 1):S44-46.
This study evaluated patients with carcinoma of cervix with primary lesion greater than 2cm size. The size of the mass limits the clinician's ability to accurately stage extent of disease beyond the uterus. They showed a high correlation of both abnormal and normal MRI scans with respect to demonstration of parametrial invasion at surgery. When MR was utilized in the diagnostic work-up, there was a significant decrease in use of other diagnostic exams, both invasive and noninvasive. Using the national average Medicare global fee schedule, the total cost of these test were $887 in the MR group, in comparison to $1336 in those without MR. No significant differences in staging accuracy occurred between the two groups. The authors recommend that diagnostic exams such as excretory urography, barium enema, cystoscopy, and sigmoidoscopy be eliminated from routine use and that MR be utilized in all patients with primary lesions greater than 2 cm.
- von Schulthess GK, Steinert HC, Dummer R, et al. Cost effectiveness of whole body PET imaging in non-small cell lung cancer and malignant melanoma. Academic Radiology. 1998; 5(Suppl 2):S300-302.
The authors have reviewed cost analysis of diagnostic and therapy with the value of FDG-PET scanning in directing therapies in two specific disease categories, specifically those with non-small cell lung cancer (NSCLC) and patients with melanoma. By demonstrating otherwise unsuspected distant metastases in 10% of patients with NSCLC, thoracic surgery was averted, thus significantly reducing unnecessary costs. In the patient groups with melanoma, the value of PET scanning was particularly emphasized in differentiating patients who would benefit from newer more costly therapies such as adjuvant immunochemotherapy. Patients without metastases were candidates, whereas those with FDG proven metastases would not be given this extremely expensive, but apparently effective treatment.
- Marcy PY, Chevallie r P, Grannon C, et al. Cost-benefit analysis of percutaneous interventional radiological procedures in cancer patients. Supportive Care in Cancer. 1999;7(5):365-367.
The authors evaluated the benefit of performing certain image guided interventional procedures in a group of oncology patients. Procedures performed included percutaneous placement of ureteral stents for obstructive uropathy, IVC filter placement, and percutaneous gastrostomy tube placement. The procedures resolved the symptoms and thus improved quality of life in at least 80% of patients. The costs of the procedures were relatively small based on the cost of hospitalization (0.85-11.3%). Overall length of hospitalization was decreased. Although the authors didn't mention it, had they also compared cost of hospitalization in patients who had not undergone such palliative procedures, perhaps their data might have shown global decreases in cost secondary to markedly shorter hospital stays.
- Baba Y, Takahashi M, Korogi Y. Decision analysis of cost-effectiveness of magnetic resonance angiography for mass screening for intracranial aneurysms. Academic Radiology. 1998; 5 (Suppl 2) S297-299.
In an analysis of a large group of patients at two different facilities, the author evaluated the sensitivity and specificity of MRA for detection of intracranial aneurysms, and indicate specificity was on the order of 80% and sensitivity was approximately 87%. When factored in with the incidence of intracranial aneurysms, estimated to be approximately 2% in the general population, and the rupture rate of 2% per year, it would require that 50 patients with aneurysms undergo treatment to save one patient with an aneurysm before it ruptures. The author emphasizes that these results are for the general population and that screening may in fact be practical for patients at high risk for aneurysms such as those with family members having had previous subarachnoid hemorrhage, as well as patients with polycystic kidney disease, fibromuscular dysplasia, and severe atherosclerotic disease of other vessels.
- Ruckdeschel JC. Rapid cost-effective diagnosis of spinal cord compression due to cancer. Cancer Control. 1995; 2(4) 320-323.
In a cost analysis of the radiological workup of cancer patients with back pain at risk for epidural compression, comparison is made between more conventional radiology assessments and the use of MRI. The conventional imaging evaluation would include plain films, bone scan and myelography (often followed by CT). The authors show a significant cost savings when imaging is routed directly to MRI, and particularly limited to the region of the location of the back pain.
- Rosen MP, Siewert B, Sands DZ, Bromberg R, Edlow J, Raptopoulos V. Value of abdominal CT in the emergency department for patients with abdominal pain. Eur Radiol. 2003;13:418-424.
Patients with abdominal pain who presented to a teaching facility were evaluated with CT when appropriate. This article demonstrated that 17% of hospitals admissions and 62% of surgeries were avoided based on the CT findings. There was also a significant benefit derived by the treating physician markedly improving their confidence level with their diagnoses.
- Bryan S, Weatherburn G, Bungay H, et al. The cost effectiveness of magnetic resonance imaging for investigation of the knee joint. Health Technology Assessment. 2001; 5(27): 1-95.
This rather extensive evaluation of the role of MRI in patients with chronic knee pain shows that MRI does not increase costs of health care as surgery was avoided in a significant proportion of patients.
Note: This bibliography does not outline all of the supporting literature on this subject.