Center for Health Policy and Center for Primary Care and Outcomes Research, Department of Medicine, and the Department of Surgery, Stanford University, Stanford, and the Veterans Affairs Palo Alto Health Care System, Palo Alto, California.
Obstet Gynecol. 2013 Oct;122(4):821-829. doi: 10.1097/AOG.0b013e3182a4a085.
To assess the cost-effectiveness of diagnostic laparoscopy, computed tomography (CT), and magnetic resonance imaging (MRI) after indeterminate ultrasonography in pregnant women with suspected appendicitis.
A decision-analytic model was developed to simulate appendicitis during pregnancy taking into consideration the health outcomes for both the pregnant women and developing fetuses. Strategies included diagnostic laparoscopy, CT, and MRI. Outcomes included positive appendectomy, negative appendectomy, maternal perioperative complications, preterm delivery, fetal loss, childhood cancer, lifetime costs, discounted life expectancy, and incremental cost-effectiveness ratios.
Magnetic resonance imaging is the most cost-effective strategy, costing $6,767 per quality-adjusted life-year gained relative to CT, well below the generally accepted $50,000 per quality-adjusted life-year threshold. In a setting where MRI is unavailable, CT is cost-effective even when considering the increased risk of radiation-associated childhood cancer ($560 per quality-adjusted life-year gained relative to diagnostic laparoscopy). Unless the negative appendectomy rate is less than 1%, imaging of any type is more cost-effective than proceeding directly to diagnostic laparoscopy.
Depending on imaging costs and resource availability, both CT and MRI are potentially cost-effective. The risk of radiation-associated childhood cancer from CT has little effect on population-level outcomes or cost-effectiveness but is a concern for individual patients. For pregnant women with suspected appendicitis, an extremely high level of clinical diagnostic certainty must be reached before proceeding to operation without preoperative imaging.
评估在疑似阑尾炎孕妇的超声检查结果不确定时，进行诊断性腹腔镜检查、计算机断层扫描（CT）和磁共振成像（MRI）的成本效益。
我们开发了一个决策分析模型，以模拟妊娠期阑尾炎，同时考虑孕妇和胎儿的健康结果。策略包括诊断性腹腔镜检查、CT 和 MRI。结果包括阳性阑尾切除术、阴性阑尾切除术、产妇围手术期并发症、早产、胎儿丢失、儿童癌症、终生成本、贴现预期寿命和增量成本效益比。
磁共振成像（MRI）是最具成本效益的策略，相对于 CT，每获得一个质量调整生命年的成本为 6767 美元，远低于通常接受的 50000 美元/质量调整生命年的阈值。在 MRI 不可用的情况下，即使考虑到与辐射相关的儿童癌症风险增加（相对于诊断性腹腔镜检查，每获得一个质量调整生命年的成本增加 560 美元），CT 也是具有成本效益的。除非阴性阑尾切除率低于 1%，否则任何类型的影像学检查都比直接进行诊断性腹腔镜检查更具成本效益。
根据影像学成本和资源可用性，CT 和 MRI 都具有潜在的成本效益。CT 引起的与辐射相关的儿童癌症风险对人群水平的结果或成本效益影响不大，但对个别患者来说是一个关注的问题。对于疑似阑尾炎的孕妇，在没有术前影像学检查的情况下直接进行手术，必须达到极高的临床诊断确定性水平。
