Pershad Jay, Taylor Andrew, Hall M Kennedy, Klimo Paul
Departments of Pediatrics and
Emergency Medicine, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee.
Pediatrics. 2017 Aug;140(2). doi: 10.1542/peds.2016-4263. Epub 2017 Jul 11.
We compared cost-effectiveness of cranial computed tomography (CT), fast sequence magnetic resonance imaging (fsMRI), and ultrasonography measurement of optic nerve sheath diameter (ONSD) for suspected acute shunt failure from the perspective of a health care organization.
We modeled 4 diagnostic imaging strategies: (1) CT scan, (2) fsMRI, (3) screening ONSD by using point of care ultrasound (POCUS) first, combined with CT, and (4) screening ONSD by using POCUS first, combined with fsMRI. All patients received an initial plain radiographic shunt series (SS). Short- and long-term costs of radiation-induced cancer were assessed with a Markov model. Effectiveness was measured as quality-adjusted life-years. Utilities and inputs for clinical variables were obtained from published literature. Sensitivity analyses were performed to evaluate the effects of parameter uncertainty.
At a previous probability of shunt failure of 30%, a screening POCUS in patients with a normal SS was the most cost-effective. For children with abnormal SS or ONSD measurement, fsMRI was the preferred option over CT. Performing fsMRI on all patients would cost $269 770 to gain 1 additional quality-adjusted life-year compared with POCUS. An imaging pathway that involves CT alone was dominated by ONSD and fsMRI because it was more expensive and less effective.
In children with low pretest probability of cranial shunt failure, an ultrasonographic measurement of ONSD is the preferred initial screening test. fsMRI is the more cost-effective, definitive imaging test when compared with cranial CT.
我们从医疗保健机构的角度比较了头颅计算机断层扫描（CT）、快速序列磁共振成像（fsMRI）和超声测量视神经鞘直径（ONSD）对疑似急性分流失败的成本效益。
我们建立了4种诊断成像策略模型：（1）CT扫描，（2）fsMRI，（3）首先使用床旁超声（POCUS）筛查ONSD，然后结合CT，（4）首先使用POCUS筛查ONSD，然后结合fsMRI。所有患者均接受了初始的普通X线分流系列检查（SS）。采用马尔可夫模型评估辐射诱发癌症的短期和长期成本。有效性以质量调整生命年衡量。临床变量的效用和输入数据来自已发表的文献。进行敏感性分析以评估参数不确定性的影响。
在先前分流失败概率为30%的情况下，SS正常的患者进行POCUS筛查是最具成本效益的。对于SS或ONSD测量异常的儿童，与CT相比，fsMRI是首选选项。与POCUS相比，对所有患者进行fsMRI检查将花费269,770美元以获得1个额外的质量调整生命年。仅涉及CT的成像途径在成本效益上不如ONSD和fsMRI，因为它更昂贵且效果更差。
在颅骨分流失败预测试概率较低的儿童中，超声测量ONSD是首选的初始筛查测试。与头颅CT相比，fsMRI是更具成本效益的确定性成像测试。
