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Accuracy, Risk and the Intrinsic Value of Diagnostic Imaging

A Review of the Cost-utility Literature
Published:February 20, 2012DOI:https://doi.org/10.1016/j.acra.2012.01.011

      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.

      Key Words

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      References

        • Hillman B.J.
        • Goldsmith J.C.
        The uncritical use of high-tech medical imaging.
        N Engl J Med. 2010; 363: 4-5
      1. The imaging boom.
        Health Aff (Millwood). 2008; 27: 1466
        • US Government Accountability Office
        Medicare: trends in fees, utilization, and expenditures for imaging services before and after implementation of the Deficit Reduction Act of 2005 (GAO-08-1102R).
        US Government Accountability Office, Washington, DC2008
        • US Government Accountability Office
        Medicare Part B imaging services: rapid spending growth and shift to physician offices indicate need for CMS to consider additional management practices (GAO-08-452).
        US Government Accountability Office, Washington, DC2008
        • Iglehart J.K.
        Health insurers and medical-imaging policy—a work in progress.
        N Engl J Med. 2009; 360: 1030-1037
        • Otero H.J.
        • Rybicki F.J.
        • Greenberg D.
        • et al.
        Twenty years of cost-effectiveness analysis in medical imaging: are we improving?.
        Radiology. 2008; 249: 917-925
        • Mendel E.
        • Singer M.E.
        • Applegate K.E.
        Cost-effectiveness analysis in radiology.
        Radiology. 2001; 219: 611-620
        • McGregor
        Cost-utility analysis: use QALYs only with great caution.
        CMAJ. 2003; 168: 433-434
        • Fryback D.G.
        • Thornbury J.R.
        The efficacy of diagnostic imaging.
        Med Decis Making. 1991; 11: 88-94
        • Hollingworth W.
        • Jarvik J.G.
        Technology assessment in radiology: putting the evidence in evidence-based radiology.
        Radiology. 2007; 244: 31-38
      2. Bossuyt PMM, McCaffery K. Additional patient outcomes and pathways in evaluations of testing. Available at: http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=350. Accessed February 10, 2012.

        • Hillman B.J.
        Outcomes research and cost-effectiveness analysis for diagnostic imaging.
        Radiology. 1994; 193: 307-310
        • Baker L.C.
        • Atlas S.W.
        • Afendulis C.C.
        Expanded use of imaging technology and the challenge of measuring value.
        Health Aff (Millwood). 2008; 27: 1467-1478
        • Otero H.J.
        • Rybicki F.J.
        • Greenberg D.
        • et al.
        Cost-effective diagnostic cardiovascular imaging: when does it provide good value for the money?.
        Int J Cardiovasc Imaging. 2010; 26: 605-612
        • Lee D.W.
        • Neumann P.J.
        • Rizzo J.A.
        Understanding the medical and nonmedical value of diagnostic testing.
        Value Health. 2010; 13: 310-314
        • Kievit J.
        • Haak H.R.
        Diagnosis and treatment of adrenal incidentaloma. A cost-effectiveness analysis.
        Endocrinol Metab Clin North Am. 2000; 29: 69-90
        • Asch D.A.
        • Patton J.P.
        • Hershey J.C.
        Knowing for the sake of knowing: the value of prognostic information.
        Med Decis Making. 1990; 10: 47-57
        • Hollingworth W.
        Radiology cost and outcomes studies: standard practice and emerging methods.
        AJR Am J Roentgenol. 2005; 185: 833-839
        • Mushlin A.I.
        • Mooney C.
        • Grow V.
        • et al.
        • Rochester-Toronto MRI Study Group
        The value of diagnostic information to patients with suspected multiple sclerosis.
        Arch Neurol. 1994; 51: 67-72
        • Lucock M.P.
        • Morley S.
        • White C.
        • et al.
        Responses of consecutive patients to reassurance after gastroscopy: results of self administered questionnaire survey.
        BMJ. 1997; 315: 572-575
      3. Neumann PJ, Cohen JT, Hammitt JK, et al. Willingness-to-pay for predictive tests with no immediate treatment implications: a survey of US residents. Health Econ. In press.

        • Eckman M.H.
        • Greenfield S.
        • Mackey W.C.
        • et al.
        Foot infections in diabetic patients. Decision and cost-effectiveness analyses.
        JAMA. 1995; 273: 712-720
        • Mushlin A.I.
        • Mooney C.
        • Holloway R.G.
        • et al.
        The cost-effectiveness of magnetic resonance imaging for patients with equivocal neurological symptoms.
        Int J Technol Assess Health Care. 1997; 13: 21-34
        • McMahon P.M.
        • Araki S.S.
        • Neumann P.J.
        • et al.
        Cost-effectiveness of functional imaging tests in the diagnosis of Alzheimer disease.
        Radiology. 2000; 217: 58-68
        • Keen J.D.
        • Dunne P.M.
        • Keen R.R.
        • et al.
        Proximity arteriography: cost-effectiveness in asymptomatic penetrating extremity trauma.
        J Vasc Interv Radiol. 2001; 12: 813-821
        • Gould M.K.
        • Sanders G.D.
        • Barnett P.G.
        • et al.
        Cost-effectiveness of alternative management strategies for patients with solitary pulmonary nodules.
        Ann Intern Med. 2003; 138: 724-735
        • Hollingworth W.
        • Gray D.T.
        • Martin B.I.
        • et al.
        Rapid magnetic resonance imaging for diagnosing cancer-related low back pain.
        J Gen Intern Med. 2003; 18: 303-312
        • Stout N.K.
        • Rosenberg M.A.
        • Trentham-Dietz A.
        • et al.
        Retrospective cost-effectiveness analysis of screening mammography.
        J Natl Cancer Inst. 2006; 98: 774-782
        • Guadagnolo B.A.
        • Punglia R.S.
        • Kuntz K.M.
        • et al.
        Cost-effectiveness analysis of computerized tomography in the routine follow-up of patients after primary treatment for Hodgkin’s disease.
        J Clin Oncol. 2006; 24: 4116-4122
        • Wong I.O.
        • Kuntz K.M.
        • Cowling B.J.
        • et al.
        Cost effectiveness of mammography screening for Chinese women.
        Cancer. 2007; 110: 885-895
        • Norman R.P.
        • Evans D.G.
        • Easton D.F.
        • et al.
        The cost-utility of magnetic resonance imaging for breast cancer in BRCA1 mutation carriers aged 30-49.
        Eur J Health Econ. 2007; 8: 137-144
        • Hernández R.
        • Vale L.
        The value of myocardial perfusion scintigraphy in the diagnosis and management of angina and myocardial infarction: a probabilistic economic analysis.
        Med Decis Making. 2007; 27: 772-788
        • Wermer M.J.
        • Koffijberg H.
        • van der Schaaf I.C.
        • ASTRA Study Group
        Effectiveness and costs of screening for aneurysms every 5 years after subarachnoid hemorrhage.
        Neurology. 2008; 70: 2053-2062
        • Takao H.
        • Nojo T.
        • Ohtomo K.
        Screening for familial intracranial aneurysms: decision and cost-effectiveness analysis.
        Acad Radiol. 2008; 15: 462-471
        • Ladapo J.A.
        • Hoffmann U.
        • Bamberg F.
        • et al.
        Cost-effectiveness of coronary MDCT in the triage of patients with acute chest pain.
        AJR Am J Roentgenol. 2008; 191: 455-463
        • Neumann P.J.
        • Rosen A.B.
        • Weinstein M.C.
        Medicare and cost-effectiveness analysis.
        N Engl J Med. 2005; 353: 1516-1522
        • Gazelle G.S.
        • McMahon P.M.
        • Siebert U.
        • et al.
        Cost-effectiveness analysis in the assessment of diagnostic imaging technologies.
        Radiology. 2005; 235: 361-370
        • Tarride J.E.
        • Blackhouse G.
        • Bischof M.
        • et al.
        Approaches for economic evaluations of health care technologies.
        J Am Coll Radiol. 2009; 6: 307-316
        • Sunshine J.H.
        • Applegate K.E.
        Technology assessment for radiologists.
        Radiology. 2004; 230: 309-314
        • Gunderman R.B.
        • Boland G.W.
        Value in radiology.
        Radiology. 2009; 253: 597-599
        • Pandharipande P.V.
        • Gazelle G.S.
        Comparative effectiveness research: what it means for radiology.
        Radiology. 2009; 253: 600-605
        • Uppot R.N.
        • Sahani D.V.
        • Hahn P.F.
        • et al.
        Effect of obesity on image quality: fifteen-year longitudinal study for evaluation of dictated radiology reports.
        Radiology. 2006; 240: 435-439
        • Smith-Bindman R.
        Is computed tomography safe?.
        N Engl J Med. 2010; 363: 1-4
      4. American College of Radiology. Image Wisely Campaign of the American College of Radiology. Available at: http://www.imagewisely.org/Imaging-Professionals/Imaging-Physicians.aspx. Accessed February 10, 2012.

      5. Society for Pediatric Radiology. Image Gently of the Society for Pediatric Radiology. Available at: http://www.pedrad.org/associations/5364/ig/. Accessed February 10, 2012.

        • Neumann P.J.
        • Tunis S.R.
        Medicare and medical technology—the growing demand for relevant outcomes.
        N Engl J Med. 2010; 362: 377-379
        • Thorwarth Jr., W.T.
        Radiology in the era of accountability: perfect storm or new dawn?.
        J Am Coll Radiol. 2004; 1: 893-896
        • Hendee W.R.
        • Becker G.J.
        • Borgstede J.P.
        • et al.
        Addressing overutilization in medical imaging.
        Radiology. 2010; 257: 240-245