Cost-Effective Analysis of Dual-Energy Computed Tomography for the Diagnosis of Occult Hip Fractures Among Older Adults.

OBJECTIVE: Early and accurate diagnosis of hip fractures minimizes morbidity and mortality. Although current guidelines favor magnetic resonance imaging (MRI) for the diagnosis of occult hip fractures, a new technology called dual-energy computed tomography (DECT) seems an effective alternative. This article investigates a potentially cost-effective strategy for the diagnosis of occult hip fractures in older adults in Singapore. METHODS: A decision tree model was developed to compare costs from a payer's perspective and outcomes in terms of quality-adjusted life-years (QALYs) of different imaging strategies for diagnosing occult hip fracture, comparing MRI with DECT supplementing single-energy computed tomography (SECT) and SECT alone. Model inputs were obtained from local sources where available. Sensitivity analyses are performed to test the robustness of the results. RESULTS: The MRI strategy was dominated by the DECT strategy, whereas DECT supplementing SECT provided 0.30 more QALYs at an incremental cost of SGD106.41 with an incremental cost-effectiveness ratio of SGD352.52 per QALY relative to SECT alone. DECT seemed a cost-effective strategy at a willingness-to-pay threshold of SGD50 000 per QALY. CONCLUSION: DECT supplementing SECT is a cost-effective imaging strategy to diagnose occult hip fractures among older adults in Singapore and should be included in clinical pathways to expedite timely treatment and considered for reimbursement schemes.

Impact of Dual-Energy CT in the Emergency Department: Increased Radiologist Confidence, Reduced Need for Follow-Up Imaging, and Projected Cost Benefit.

OBJECTIVE. The purpose of this study was to analyze the contribution of dual-energy CT (DECT) to radiologist interpretation in the emergency department (ED) to determine whether recommendations for follow-up imaging decrease. MATERIALS AND METHODS. Reports of all DECT studies performed in an ED in 2016 were reviewed. A board-certified radiologist noted the number of times a report indicated that use of DECT techniques contributed to radiologist interpretation. For studies containing DECT findings in the report, the mixed datasets, representing conventional CT images, were read again separately. The difference between the numbers of follow-up studies recommended after conventional CT and DECT was converted into U.S. dollars by use of the Medicare fee schedule to estimate a projected cost benefit due to any reduction in follow-up imaging. RESULTS. The study included 3159 cases. DECT findings potentially altered management in 298 (9.4%) cases, increased diagnostic confidence in 455 (14.4%) cases, provided relevant information in 174 (5.6%) cases, helped characterize an incidental finding in 44 (1.4%) cases, and were mentioned to be noncontributory in three (0.09%) cases. DECT was not mentioned in the report in 2272 cases (71.9%). DECT findings avoided 162-191 recommended follow-up MRI examinations, 21-28 CT examinations, and 2-25 US examinations compared with conventional CT alone. The DECT findings also prompted one additional recommended interventional angiography procedure, one ventilation-perfusion scan, and one imaging-guided biopsy. The projected net cost reduction was $52,991.53-61,598.44. CONCLUSION. DECT added value to routine ED imaging by increasing diagnostic confidence, leading to a reduction in the number of recommended follow-up studies and a projected cost benefit.

Clinical and Payer-Based Analysis of Value of Dual-Energy Computed Tomography for Workup of Incidental Abdominal Findings.

OBJECTIVE: To perform a clinical and payer-based analysis of the value of dual-energy computed tomography (DECT) for workup of incidental abdominal findings. METHODS: This was a single-center, retrospectively designed, Health Insurance Portability and Accountability Act-compliant study approved by our institutional review board. Sixty-nine examinations in 69 patients (45 men, 24 women; mean age, 57.7 years) who underwent single-phase postcontrast abdominal DECT studies between January 1, 2011, and December 31, 2017, were included. Two radiologists, blinded to study objective and design, reviewed all cases and identified incidental abdominal findings needing further imaging. All incidental findings were reviewed by 2 other investigators, who determined whether an imaging-based diagnosis could be made using DECT virtual noncontrast images and iodine maps. Additional studies and associated payer-reimbursement amounts avoided by use of DECT were estimated. All imaging costs were estimated based on the US Centers for Medicare & Medicaid Services reimbursement amounts. RESULTS: Thirty-four incidental findings (renal mass, n = 20; adrenal nodule, n = 8; pancreatic cystic lesions, n = 3; others, n = 3) were identified in 19 (27.5%) of 69 patients. Dual-energy computed tomography characterized 27 incidental findings in 15 patients and accounted for cost savings of 15 additional imaging examinations (abdominal magnetic resonance imaging, n = 11; abdominal computed tomography, n = 4). Based on Centers for Medicare & Medicaid Services reimbursement amounts, we estimated that, by abolishing the need for additional imaging use, DECT saved US $84.95 per patient. CONCLUSIONS: Dual-energy computed tomography can provide an imaging-based diagnosis of incidental abdominal findings, otherwise incompletely characterized on routine abdominal computed tomography, in approximately 21% of patients. In select patients, the monetary savings from abolishing additional imaging may reduce payer costs associated with use of DECT.

The Utility of Dual-Energy Computed Tomographic Angiography for the Evaluation of Brain Aneurysms After Surgical Clipping: A Prospective Study.

OBJECTIVE: The purpose of this prospective study was to compare a novel dual-energy computed tomographic angiography (DECTA) method for postoperative assessment of clipped brain aneurysms to detect aneurysm remnants and parent artery patency, with catheter-based digital subtraction angiography (DSA). METHODS: Patients who underwent microsurgical cerebral aneurysm repair were prospectively evaluated after surgery by both DECTA and conventional DSA. CTA was performed using a novel dual-energy method with single source and fast kilovoltage switching (Gemstone Spectral Imaging [GSI]). DSA was performed using biplanar cerebral angiography. An experienced neuroradiologist and a neurosurgeon, both blinded to the original radiologic results, reviewed the images. RESULTS: On DSA, 8 of 15 aneurysms (53%) had a remnant after clipping. All of these remnants were <2 mm except for 1. The only residual aneurysm >2 mm was clearly detected by GSI CTA. Of those 7 DSA-confirmed <2-mm remnants, 5 were detected by GSI CTA. Metal artifacts compromised the image quality in 2 patients. The sensitivity and specificity of GSI CTA for remnant aneurysm <2-mm detection in single clip-treated patients were 100%. In all patients, these were 71.4 % and 100%, respectively. GSI CTA was 100% sensitive and 77% specific to detect parent vessel compromise, with associated positive and negative predictive values of 60% and 100%, respectively. CONCLUSIONS: DECTA is a promising noninvasive alternative to conventional catheter-based angiography for identification of aneurysm remnants and assessment of adjacent arteries after surgical clipping of brain aneurysms treated by 2 or fewer clips. It allows for a more rapid image acquisition than DSA, is more cost effective, and is widely available at clinical centers.

Cost-effectiveness of substituting dual-energy CT for SPECT in the assessment of myocardial perfusion for the workup of coronary artery disease.

PURPOSE: We compared cost-effectiveness and potential lifetime benefits of using dual-energy computed tomography (DECT) for myocardial perfusion assessment instead of single photon emission computed tomography (SPECT) for the workup of coronary artery disease (CAD). MATERIALS AND METHODS: A decision and simulation model was developed to estimate cost and health effects of using DECT myocardial perfusion imaging instead of SPECT for identifying patients in need of invasive imaging and possible revascularization. The model was based on the performance indices of stress/rest DECT compared with stress/rest SPECT for detecting myocardial perfusion deficits in 50 patients (mean age 61±10 years) with CAD. Stress/rest perfusion and delayed enhancement cardiac MRI served as reference standard. For DECT a reimbursement of US$1700 was assumed but costs of cardiac MRI were not included in the model. All other actual healthcare costs in these patients were derived from MUSC's hospital billing system. RESULTS: Compared with cardiac MRI, DECT (versus SPECT) had 90% (85%) sensitivity and 71% (58%) specificity for identifying patients with obstructive CAD. Compared with the no imaging and no treatment strategy, routine SPECT gained 13.49 quality-adjusted life-years (QALYs) with an incremental cost-effectiveness ratio (ICER) of US$3557 (in 2010) per QALY. In comparison, DECT ICER was lower (US$3.191 per QALY, p=0.0002) and an additional 0.64 QALYs was obtained (total of 14.13 QALYs) if compared with the SPECT strategy as well as the no imaging and no treatment strategy. CONCLUSION: Using DECT as the first-line imaging test for myocardial perfusion for the workup of patients with CAD has the potential to provide gains in QALYs, while lowering costs if compared to routine myocardial perfusion SPECT.