Quantifying imaging value with the use of cost-effectiveness analyses

December 11, 2019
by John W. Mitchell, Senior Correspondent
A panel of four radiologists made a case for the efficacy of cost-effectiveness analyses (CEA) last week at a Tuesday morning RSNA 2019 session, by presenting calculation models, examples of findings using CEA models, and research supporting the CEA concept.

While the panel readily noted that CEA methods are not perfect, they believe the shifting economic landscape of population health and value-based care demand that medical specialties demonstrate efficiency using them.

“The (CEA) models show the potential,” said Dr. Stella Kang, director, Comparative Effectiveness and Outcomes Research, and assistant professor of radiology, Department of Population Health, NYU Langone Health. "Innovation has really improved our ability to detect abnormalities, but has also increased our costs a lot. Everyone is talking about value these days."

She cited three cost-effectiveness analysis benefits:

– CEA gives insight into how to maximize health outcomes with given options.
– CEA provides an understanding of the incremental benefits provided for resources expended.
– CEA offers a realization that resource allocation decisions must be made to identify options that make economic sense for decision-makers.

Kang reviewed a CEA study on the risk of stroke, based on MR scans of patients with carotid plaque stenosis. The long-standing protocol is not to intervene until the vessel is 70 percent blocked. However, the study demonstrated a positive CEA imaging benefit from intervening sooner.

Another panel member, Dr. Kathryn Lowry, assistant professor, Department of Radiology, University of Washington School of Medicine, presented a case study published in September in the Journal of the National Cancer Institute, (on which she was lead author), comparing CEA of digital breast tomosynthesis in the U.S. as compared to digital mammography.

The study, based on available Medicare data, found that digital breast tomosynthesis procedures added about $56 in cost to an exam with a "very small" reduction in deaths, compared to digital mammography. However, there was a 25 percent drop in false findings with the more sensitive tomosynthesis technology. While there was no mortality benefit, there was a quality of life benefit and follow-up cost savings. Policy experts, Lowry maintained, need such data-based CEAs to make funding decisions.

The lead presenter, Dr. Pari Pandharipande, director of the MGH Institute for Technology Assessment, and abdominal radiologist at Massachusetts General Hospital, stressed that CEAs are not for use at the patient level. Instead, CEA is a tool for physicians to advise policymakers on the sweet spot between costs and outcome benefits.

To illustrate this point, she shared a quote from a 2008 journal article on healthcare costs: “When we dine where the menu has no prices, we should not be surprised by the size of the bill.”

The final speaker, Dr. Andrew Rosenkrantz, director of public policy and professor of radiology and urology, NYU School of Medicine, offered a different take on assessing radiology value. He argued that because the radiologist does not order imaging exams and because they don't necessarily influence the downstream decisions based on the exams, imaging value can be challenging to measure.

But, he said, there are other, more immediate hands-on value strategies available to radiologists. Among the factors that affect value are turnaround times, report accuracy, patient access, use of structured reporting, and participation on hospital committees and tumor boards.

Still, Rosenkrantz agreed that radiologists need to be in the ongoing business of defining their value. The Medicare Payment Advisory Commission that makes healthcare payment recommendations to Congress has a history of viewing medical imaging as a high-cost specialty in need of control. Radiologists, he maintained, need to be their own best advocate for making a CEA case.

He also reminded the attendees that it's essential to be mindful of the patient perspective in any discussion about imaging value. Patients seek caring, professional, pleasant, helpful, and efficient qualities in their care from staff, according to satisfaction surveys. This applies to all staff in imaging operations, from the receptionist to the technologist to the radiologist.