Economic Considerations for Radiation Protection in Medical Settings-Is It Time for a New Paradigm?

ABSTRACT: The full ALARA principle includes "as low as reasonably achievable" taking social and economic factors into consideration. The International Commission on Radiological Protection advises a conventional cost benefit approach (e.g., cost per monetized averted stochastic effects or years of life saved) to consider economic factors. Given small incremental radiation dose reductions to patients, workers, or the public that may be realized in medical settings and the correspondingly small changes to theoretical stochastic effects, a conventional cost benefit approach is less than ideal. This is illustrated in the case studies presented in this paper. Alternate approaches, such as cost per unit of radiation dose averted (e.g., $/µSv averted), cancer induction/fatality probabilistic thresholds, or thresholds relative to natural background radiation may be alternate options. However, the decision regarding what is a "safe" level of radiation and what are reasonable costs to make it "safer" are driven by societal values and may vary from jurisdiction to jurisdiction.

Helping Health Care Providers and Clinical Scientists Understand Apparently Irrational Policy Decisions.

Health care providers (HCP) and clinical scientists (CS) are generally most comfortable using evidence-based rational decision-making models. They become very frustrated when policymakers make decisions that, on the surface, seem irrational and unreasonable. However, such decisions usually make sense when analysed properly. The goal of this paper to provide a basic theoretical understanding of major policy models, to illustrate which models are most prevalent in publicly funded health care systems, and to propose a policy analysis framework to better understand the elements that drive policy decision-making. The proposed policy framework will also assist HCP and CS achieve greater success with their own proposals.

The effect of furosemide dose timing on bladder activity in oncology imaging with 18F-fluorodeoxyglucose PET/CT.

OBJECTIVE: To compare the effects of two furosemide administration protocols on bladder activity during 18F-fluorodeoxyglucose (18F-FDG) PET/computed tomography (CT) imaging. METHODS: A total of 109 consecutive patients with known or suspected malignancy, meeting our inclusion criteria, were chosen over a discrete time period. Group 1 (n=39) received furosemide 20 mg intravenous 15 min before PET/CT imaging (i.e. approximately 45 min after 18F-FDG administration). Group 2 (n=45) received furosemide 20 mg intravenous 15 min after 18F-FDG. Group 3 (n=25) did not receive furosemide and served as controls. Bladder standard uptake values (SUVs) and volume, and liver SUV data were collected. RESULTS: Relative to the control group, both furosemide groups showed significantly lower mean and maximum SUV bladder activities (P<0.001), lower mean bladder-to-liver SUV ratios (P<0.001), larger mean bladder volumes (P<0.001) and higher proportions of bladder PET/CT image mis-registration. Patients tolerated earlier administration of furosemide (group 2) better relative to urinary urgency during imaging. CONCLUSION: The use of a relatively simple diuretic protocol can significantly lower bladder FDG activity and potentially improve image quality by reducing bladder activity artifacts and avoid invasive bladder catheterization. Administering furosemide earlier after FDG injection (i.e. 15 min) versus later (i.e. 15 min before imaging) appears to be better tolerated by patients.

The cost of lung cancer in Alberta.

BACKGROUND: Lung cancer is the leading cause of cancer morbidity and mortality. In addition, lung cancer has a significant economic impact on society. OBJECTIVE: To present an economic analysis of the actual care costs of lung cancer which will allow comparison with, and verification of, cost estimates that were developed through modelling and opinion. METHODS: A chart review was conducted of incident cases (circa 1998) of primary bronchogenic lung cancer. Cases were censored at two years from the date of diagnosis. Relevant clinical and health utilization data were collected. Health utilization data included hospital and institutional outpatient (ie, ambulatory clinic) costs. Cost estimates were derived for over 200 specific health services. The present analysis was performed from the economic perspective of the health care institution. RESULTS: A total of 13,389 health service events were captured with an estimated total cost of $8.4 million. Laboratory tests, diagnostic imaging and ambulatory visits constituted 86% of the service events while patient admissions and therapy constituted 76% of the costs. The vast majority of overall costs occurred just before, or within, three months of diagnosis. The median nonsmall cell lung cancer and small cell lung cancer case costs were $10,928 (range $9,234 to $11,047) and $15,350 (range $13,033 to $21,436), respectively. CONCLUSION: The results agree with the literature that the majority of lung cancer case costs are realized around the date of diagnosis (ie, early phase). The present study illustrates Canadian health care system lung cancer case costs based on actual care received versus hypothetical care algorithms.

Variation in heart rate influences the assessment of transient ischemic dilation in myocardial perfusion scintigraphy.

BACKGROUND: Transient arrhythmias can affect transient ischemic dilation (TID) ratios. This study was initiated to evaluate the frequency and effect of normal heart rate change on TID measures in routine clinical practice. METHODS: Consecutive patients undergoing stress/rest sestamibi gated myocardial perfusion scintigraphy were studied (N = 407). Heart rate at the time of stress and rest imaging were recorded. TID ratios were analyzed in relation to absolute change in heart rate (stress minus rest) for subjects with normal perfusion and systolic function (Group 1, N = 169) and those with abnormalities in perfusion and/or function (Group 2, N = 238). RESULTS: In Group 1, mean TID ratio was inversely correlated with the change in heart rate (r = -0.47, P < 0.0001). For every increase of 10 BPM in heart rate change, the TID ratio decreased by approximately 0.06 (95% confidence interval 0.04-0.07). In Group 2, multiple linear regression demonstrated that the change in heart rate (beta = -0.25, P < 0.0001) and the summed difference score (beta = 0.36, P < 0.0001) were independent predictors of the TID ratio. CONCLUSION: Normal variation in heart rate between the stress and rest components of myocardial perfusion scans is common and can influence TID ratios in patients with normal and abnormal cardiac scans.

The descriptive epidemiology of primary lung cancer in an Alberta cohort with a multivariate analysis of survival to two years.

BACKGROUND: Lung cancer contributes significantly to cancer morbidity and mortality. Although case fatality rates have not changed significantly over the past few decades, there have been advances in the diagnosis, staging and management of lung cancer. OBJECTIVE: To describe the epidemiology of primary lung cancer in an Alberta cohort with an analysis of factors contributing to survival to two years. PATIENTS AND METHODS: Six hundred eleven Albertans diagnosed with primary lung cancer in 1998 were identified through the Alberta Cancer Registry. Through a chart review, demographic and clinical data were collected for a period of up to two years from the date of diagnosis. RESULTS: The mean age at diagnosis was 66.5 years. The majority of cases (92%) were smokers. Adenocarcinoma, followed by squamous cell carcinoma, were the most frequent nonsmall cell lung cancer histologies. Adenocarcinoma was more frequent in women, and squamous cell carcinoma was more frequent in men. The overall two- year survival rates for nonsmall cell, small cell and other lung cancers were 24%, 10% and 13%, respectively. In multivariate analysis, stage, thoracic surgery and chemotherapy were significantly associated with survival to two years in nonsmall cell carcinoma; only stage and chemotherapy were significant in small cell carcinoma. CONCLUSIONS: This study provides a Canadian epidemiological perspective, which generally concurs with the North American literature. Continued monitoring of the epidemiology of lung cancer is essential to evaluate the impact of advances in the diagnosis, staging and management of lung cancer. Further clinical and economic analysis, based on data collected on this cohort, is planned.