Dwamena B A, Kloos R T, Fendrick A M, Gross M D, Francis I R, Korobkin M T, Shapiro B
Department of Internal Medicine, School of Public Health, The University of Michigan, and Department of Veteran Affairs Medical Centers, Ann Arbor 48105, USA.
J Nucl Med. 1998 Apr;39(4):707-12.
The goal of this study was to examine the clinical and economic outcomes of alternative diagnostic strategies for differentiating benign from malignant adrenal masses.
We used cost-effectiveness assessment derived from decision analysis and the economic perspective of the payer of health care services. One-time evaluation with fine-needle aspiration (FNA) and combinations of chemical-shift MRI, noncontrast CT, 131I-6beta-iodomethylnorcholesterol (NP-59) scintigraphy, with or without FNA, in a hypothetical cohort of 1000 patients with incidentally discovered unilateral, nonhypersecretory adrenal masses. We calculated and compared the diagnostic effectiveness, costs and cost-effectiveness of the alternative strategies based on estimates from published literature and institutional charge data.
At an assumed baseline malignancy rate of 0.25, diagnostic utility varied from 0.31 (CT0) to 0.965 (NP-59) and diagnostic accuracy from 0.655 [noncontrast CT using a cut-off attenuation value of > or = 0 (CT0)] to 0.983 (NP-59). The average cost per patient per strategy ranged from $746 (NP-59) to $1745 (MRI +/- FNA). The best and worst potential cost-to-diagnostic utility ratios were 773 (NP-59) and 2839 (CT0) and 759 (NP-59) and 1982 (MRI +/- FNA) for cost and diagnostic accuracy, respectively. The NP-59 strategy was the optimal choice regardless of the expected outcome examined: cost, diagnostic utility, diagnostic accuracy or cost-effectiveness. Varying the prevalence of malignancy did not alter the cost-effectiveness advantage of NP-59 over the other diagnostic modalities.
Based on available estimates of reimbursement costs and diagnostic test performance and using reasonable clinical assumptions, our results indicate that the NP-59 strategy is the most cost-effective diagnostic tool for evaluating adrenal incidentalomas over a wide range of malignancy rates and that additional clinical studies are warranted to confirm this cost-effectiveness advantage.
本研究的目的是检验鉴别肾上腺良性与恶性肿块的替代诊断策略的临床和经济结果。
我们采用了源自决策分析和医疗服务支付方经济视角的成本效益评估方法。对1000例偶然发现的单侧、无高分泌功能的肾上腺肿块患者的假设队列，进行细针穿刺抽吸活检（FNA）以及化学位移磁共振成像（MRI）、平扫计算机断层扫描（CT）、131I-6β-碘甲基胆固醇（NP-59）闪烁扫描单独或联合FNA的一次性评估。我们根据已发表文献的估计值和机构收费数据，计算并比较了替代策略的诊断有效性、成本和成本效益。
在假定的基线恶性率为0.25时，诊断效用从0.31（CT0）到0.965（NP-59）不等，诊断准确性从0.655[使用截断衰减值≥0的平扫CT（CT0）]到0.983（NP-59）。每种策略的人均平均成本从746美元（NP-59）到1745美元（MRI±FNA）不等。就成本和诊断准确性而言，最佳和最差的潜在成本与诊断效用比分别为773（NP-59）和2839（CT0），以及759（NP-59）和1982（MRI±FNA）。无论考察的预期结果是成本、诊断效用、诊断准确性还是成本效益，NP-59策略都是最佳选择。改变恶性率并未改变NP-59相对于其他诊断方式的成本效益优势。
基于报销成本和诊断测试性能的现有估计，并使用合理的临床假设，我们的结果表明，NP-59策略是在广泛的恶性率范围内评估肾上腺偶发瘤最具成本效益的诊断工具，需要进行更多临床研究以确认这种成本效益优势。
