Computer-aided X-ray screening for tuberculosis and HIV testing among adults with cough in Malawi (the PROSPECT study): A randomised trial and cost-effectiveness analysis.

BACKGROUND: Suboptimal tuberculosis (TB) diagnostics and HIV contribute to the high global burden of TB. We investigated costs and yield from systematic HIV-TB screening, including computer-aided digital chest X-ray (DCXR-CAD). METHODS AND FINDINGS: In this open, three-arm randomised trial, adults (≥18 years) with cough attending acute primary services in Malawi were randomised (1:1:1) to standard of care (SOC); oral HIV testing (HIV screening) and linkage to care; or HIV testing and linkage to care plus DCXR-CAD with sputum Xpert for high CAD4TBv5 scores (HIV-TB screening). Participants and study staff were not blinded to intervention allocation, but investigator blinding was maintained until final analysis. The primary outcome was time to TB treatment. Secondary outcomes included proportion with same-day TB treatment; prevalence of undiagnosed/untreated bacteriologically confirmed TB on day 56; and undiagnosed/untreated HIV. Analysis was done on an intention-to-treat basis. Cost-effectiveness analysis used a health-provider perspective. Between 15 November 2018 and 27 November 2019, 8,236 were screened for eligibility, with 473, 492, and 497 randomly allocated to SOC, HIV, and HIV-TB screening arms; 53 (11%), 52 (9%), and 47 (9%) were lost to follow-up, respectively. At 56 days, TB treatment had been started in 5 (1.1%) SOC, 8 (1.6%) HIV screening, and 15 (3.0%) HIV-TB screening participants. Median (IQR) time to TB treatment was 11 (6.5 to 38), 6 (1 to 22), and 1 (0 to 3) days (hazard ratio for HIV-TB versus SOC: 2.86, 1.04 to 7.87), with same-day treatment of 0/5 (0%) SOC, 1/8 (12.5%) HIV, and 6/15 (40.0%) HIV-TB screening arm TB patients (p = 0.03). At day 56, 2 SOC (0.5%), 4 HIV (1.0%), and 2 HIV-TB (0.5%) participants had undiagnosed microbiologically confirmed TB. HIV screening reduced the proportion with undiagnosed or untreated HIV from 10 (2.7%) in the SOC arm to 2 (0.5%) in the HIV screening arm (risk ratio [RR]: 0.18, 0.04 to 0.83), and 1 (0.2%) in the HIV-TB screening arm (RR: 0.09, 0.01 to 0.71). Incremental costs were US$3.58 and US$19.92 per participant screened for HIV and HIV-TB; the probability of cost-effectiveness at a US$1,200/quality-adjusted life year (QALY) threshold was 83.9% and 0%. Main limitations were the lower than anticipated prevalence of TB and short participant follow-up period; cost and quality of life benefits of this screening approach may accrue over a longer time horizon. CONCLUSIONS: DCXR-CAD with universal HIV screening significantly increased the timeliness and completeness of HIV and TB diagnosis. If implemented at scale, this has potential to rapidly and efficiently improve TB and HIV diagnosis and treatment. TRIAL REGISTRATION: clinicaltrials.gov NCT03519425.

Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration.

Importance: The Choosing Wisely guidelines indicate that preoperative testing is often unnecessary and wasteful for patients undergoing cataract operations. However, little is known about the impact of these widely disseminated guidelines within the US Veterans Health Administration (VHA) system. Objective: To examine the extent, variability, associated factors, and costs of low-value tests (LVTs) prior to cataract operations in the VHA. Design, Setting, and Participants: This cohort study examined records of all patients receiving cataract operations within the VHA in fiscal year 2017 (October 1, 2016, to September 31, 2017). Records from 135 facilities nationwide supporting both ambulatory and inpatient surgery were included. Exposures: A laboratory test occurring within 30 days prior to cataract surgery and within 30 days after clinic evaluation. Main Outcomes and Measures: Overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days prior to cataract surgery. The patient characteristics, procedure type, and facility-level factors associated with receiving at least 1 test, the number of tests received, and receipt of a bundle of 4 tests (complete blood count, basic metabolic profile, chest radiograph, and electrocardiogram). Results: A total of 69 070 cataract procedures were identified among 50 106 patients (66 282 [96.0%] men; mean [SD] age, 71.7 [8.1] years; 53 837 [77.9%] White, 10 292 [14.9%] Black). Most of the patient population had either overweight (23 292 [33.7%] patients) or obesity (27 799 [40.2%] patients). Approximately 49% of surgical procedures (33 424 procedures) were preceded by 1 or more LVT with an overall LVT cost of $2 597 623. Among patients receiving LVTs, electrocardiography (7434 patients [29.9%]) was the most common, with some patients also receiving more costly tests, including chest radiographs (489 patients [8.2%]) and pulmonary function tests (127 patients [3.4%]). For receipt of any LVT, the intraclass correlation coefficient was 0.61 (P < .001) at the facility level and 0.06 (P < .001) at the surgeon level, indicating the substantial contribution of the facility to amount of tests given. Conclusions and Relevance: Despite existing guidelines, use of LVTs prior to cataract surgery is both common and costly within a large, national integrated health care system. Our results suggest that publishing evidence-based guidelines alone-such as the Choosing Wisely campaign-may not sufficiently influence individual physician behavior, and that system-level efforts to directly deimplement LVTs may therefore necessary to effect sustained change.

Cost benefit analysis of portable chest radiography through glass: Initial experience at a tertiary care centre during COVID-19 pandemic.

INTRODUCTION: Portable chest radiography through glass (TG-CXR) is a novel technique, particularly useful during the COVID-19 (Coronavirus disease 2019) pandemic. The purpose of this study was to understand the cost and benefit of adopting TG-CXR in quantifiable terms. METHODS: Portable or bedside radiographs are typically performed by a team of two technologists. The TG-CXR method has the benefit of allowing one technologist to stay outside of the patient room while operating the portable radiography machine, reducing PPE use, decreasing the frequency of radiography machine sanitization and decreasing technologists' exposures to potentially infectious patients. The cost of implementing this technique during the current COVID-19 pandemic was obtained from our department's operational database. The direct cost of routinely used PPE and sanitization materials and the cost of the time taken by the technologists to clean the machine was used to form a quantitative picture of the benefit associated with TG-CXR technique. RESULTS: Technologists were trained on the TG-CXR method during a 15 min shift change briefing. This translated to a one-time cost of $424.88 USD. There was an average reduction of portable radiography machine downtime of 4 min and 48 s per study. The benefit of adopting the TG-CXR technique was $9.87 USD per patient imaged. This will result in a projected net cost savings of $51,451.84 USD per annum. CONCLUSION: Adoption of the TG-CXR technique during the COVID-19 pandemic involved minimal one-time cost, but is projected to result in a net-benefit of over $51,000 USD per annum in our emergency department.

Is a chest radiograph indicated after chest tube removal in trauma patients? A systematic review.

PURPOSE: The aim of this systematic review was to assess the necessity of routine chest radiographs after chest tube removal in ventilated and nonventilated trauma patients. METHODS: A systematic literature search was conducted in MEDLINE, Embase, CENTRAL, and CINAHL on May 15, 2020. Quality assessment was performed using the Methodological Index for Nonrandomized Studies criteria. Primary outcome measures were abnormalities on postremoval chest radiograph (e.g., recurrence of a pneumothorax, hemothorax, pleural effusion) and reintervention after chest tube removal. Secondary outcome measures were emergence of new clinical symptoms or vital signs after chest tube removal. RESULTS: Fourteen studies were included, consisting of seven studies on nonventilated patients and seven studies on combined cohorts of ventilated and nonventilated patients, all together containing 1,855 patients. Nonventilated patients had abnormalities on postremoval chest radiograph in 10% (range across studies, 0-38%) of all chest tubes and 24% (range, 0-78%) of those underwent reintervention. In the studies that reported on clinical symptoms after chest tube removal, all patients who underwent reintervention also had symptoms of recurrent pathology. Combined cohorts of ventilated and nonventilated patients had abnormalities on postremoval chest radiograph in 20% (range, 6-49%) of all chest tubes and 45% (range, 8-63%) of those underwent reintervention. CONCLUSION: In nonventilated patients, one in ten developed recurrent pathology after chest tube removal and almost a quarter of them underwent reintervention. In two studies that reported on clinical symptoms, all reinterventions were performed in patients with symptoms of recurrent pathology. In these two studies, omission of routine postremoval chest radiograph seemed safe. However, current literature remains insufficient to draw definitive conclusions on this matter, and future studies are needed. LEVEL OF EVIDENCE: Systematic review study, level IV.

Utility and validity of dynamic chest radiography in cystic fibrosis (dynamic CF): an observational, non-controlled, non-randomised, single-centre, prospective study.

INTRODUCTION: Dynamic chest radiography (DCR) uses novel, low-dose radiographic technology to capture images of the thoracic cavity while in motion. Pulmonary function testing is important in cystic fibrosis (CF). The tolerability, rapid acquisition and lower radiation and cost compared with CT imaging may make DCR a useful adjunct to current standards of care. METHODS AND ANALYSIS: This is an observational, non-controlled, non-randomised, single-centre, prospective study. This study is conducted at the Liverpool Heart and Chest Hospital (LHCH) adult CF unit. Participants are adults with CF. This study reviews DCR taken during routine CF Annual Review (n=150), validates DCR-derived lung volumes against whole body plethysmography (n=20) and examines DCR at the start and end of pulmonary exacerbations of CF (n=20). The primary objectives of this study are to examine if DCR provides lung function information that correlates with PFT, and lung volumes that correlate whole body plethysmography. ETHICS AND DISSEMINATION: This study has received the following approvals: HRA REC (11 December 2019) and LHCH R&I (11 October 2019). Results are made available to people with CF, the funders and other researchers. Processed, anonymised data are available from the research team on request. TRIAL REGISTRATION NUMBER: ISRCTN 64994816.

Improving Billing Accuracy Through Enterprise-Wide Standardized Structured Reporting With Cross-Divisional Shared Templates.

OBJECTIVE: We describe our experience in implementing enterprise-wide standardized structured reporting for chest radiographs (CXRs) via change management strategies and assess the economic impact of structured template adoption. METHODS: Enterprise-wide standardized structured CXR reporting was implemented in a large urban health care enterprise in two phases from September 2016 to March 2019: initial implementation of division-specific structured templates followed by introduction of auto launching cross-divisional consensus structured templates. Usage was tracked over time, and potential radiologist time savings were estimated. Correct-to-bill (CTB) rates were collected between January 2018 and May 2019 for radiography. RESULTS: CXR structured template adoption increased from 46% to 92% in phase 1 and to 96.2% in phase 2, resulting in an estimated 8.5 hours per month of radiologist time saved. CTB rates for both radiographs and all radiology reports showed a linearly increasing trend postintervention with radiography CTB rate showing greater absolute values with an average difference of 20% throughout the sampling period. The CTB rate for all modalities increased by 12%, and the rate for radiography increased by 8%. DISCUSSION: Change management strategies prompted adoption of division-specific structured templates, and exposure via auto launching enforced widespread adoption of consensus templates. Standardized structured reporting resulted in both economic gains and projected radiologist time saved.

Mass screening for active case finding of pulmonary tuberculosis in the Russian Federation: how to save costs.

BACKGROUND: In Russia, mass chest X-ray (CXR) screening for tuberculosis (TB) is mandatory.OBJECTIVE: To compare the yield and the cost per TB case detected and the total cost of CXR screening, passive case finding and contact tracing among adolescents and adults in the Arkhangelsk Oblast, Russian Federation, 2013-2017.DESIGN: This was an analysis of costing strategies using aggregated data. Costing information was obtained from the Finance Department of the Arkhangelsk Clinical TB Dispensary, Arkhangelsk, and the Territorial Fund of Mandatory Medical Insurance, Arkhangelsk, Russian Federation.RESULTS: TB cases were detected using CXR screening (n = 684, 46%), contact tracing (n = 61, 4%) and passive case finding (n = 743, 46%). The number of cases detected using CXR screening, contact tracing and passive case finding was respectively 28,753 and 960/100 000. The mean costs/test were respectively US$3.54 (US$12 541/case), US$20.28 (US$2693/case) and US$11.85 (US$1235/case) using CXR screening, contact tracing and passive case finding The number of cases/100 000 in targeted groups was as follows: HIV-positive persons, 645; homeless persons, 461; and migrants, 441. The cost/TB case detected was respectively US$549, US$768 and US$803.CONCLUSION: Mass CXR screening (excluding HIV-positive, migrant and homeless populations) has low yield and high cost per TB case detected. It should be stopped and resources should instead be used to strengthen the screening of targeted high-risk groups, contacts and passive case finding.

Evaluation of an Intervention to Reduce Low-Value Preoperative Care for Patients Undergoing Cataract Surgery at a Safety-Net Health System.

Importance: Preoperative testing for cataract surgery epitomizes low-value care and still occurs frequently, even at one of the nation's largest safety-net health systems. Objective: To evaluate a multipronged intervention to reduce low-value preoperative care for patients undergoing cataract surgery and analyze costs from various fiscal perspectives. Design, Setting, and Participants: This study took place at 2 academic safety-net medical centers, Los Angeles County and University of Southern California (LAC-USC) (intervention, n = 469) and Harbor-UCLA (University of California, Los Angeles) (control, n = 585), from April 13, 2015, through April 12, 2016, with 12 additional months (April 13, 2016, through April 13, 2017) to assess sustainability (intervention, n = 1002; control, n = 511). To compare pre- and postintervention vs control group utilization and cost changes, logistic regression assessing time-by-group interactions was used. Interventions: Using plan-do-study-act cycles, a quality improvement nurse reviewed medical records and engaged the anesthesiology and ophthalmology chiefs with data on overuse; all 3 educated staff and trainees on reducing routine preoperative care. Main Outcomes and Measures: Percentage of patients undergoing cataract surgery with preoperative medical visits, chest x-rays, laboratory tests, and electrocardiograms. Costs were estimated from LAC-USC's financially capitated perspective, and costs were simulated from fee-for-service (FFS) health system and societal perspectives. Results: Of 1054 patients, 546 (51.8%) were female (mean [SD] age, 60.6 [11.1] years). Preoperative visits decreased from 93% to 24% in the intervention group and increased from 89% to 91% in the control group (between-group difference, -71%; 95% CI, -80% to -62%). Chest x-rays decreased from 90% to 24% in the intervention group and increased from 75% to 83% in the control group (between-group difference, -75%; 95% CI, -86% to -65%). Laboratory tests decreased from 92% to 37% in the intervention group and decreased from 98% to 97% in the control group (between-group difference, -56%; 95% CI, -64% to -48%). Electrocardiograms decreased from 95% to 29% in the intervention group and increased from 86% to 94% in the control group (between-group difference, -74%; 95% CI, -83% to -65%). During 12-month follow-up, visits increased in the intervention group to 67%, but chest x-rays (12%), laboratory tests (28%), and electrocardiograms (11%) remained low (P < .001 for all time-group interactions in both periods). At LAC-USC, losses of $42 241 in year 1 were attributable to intervention costs, and 3-year projections estimated $67 241 in savings. In a simulation of a FFS health system at 3 years, $88 151 in losses were estimated, and for societal 3-year perspectives, $217 322 in savings were estimated. Conclusions and Relevance: This intervention was associated with sustained reductions in low-value preoperative testing among patients undergoing cataract surgery and modest cost savings for the health system. The findings suggest that reducing low-value care may be associated with cost savings for financially capitated health systems and society but also with losses for FFS health systems, highlighting a potential barrier to eliminating low-value care.

Cost-Effectiveness of a Guided Peripherally Inserted Central Catheter Placement System: A Single-Center Cohort Study.

PURPOSE: To assess the cost-effectiveness of peripherally inserted central catheter (PICC) placements using an ultrasound and electrocardiogram-guided system versus external measurements and confirmatory chest X-rays (CXRs). MATERIALS AND METHODS: Sixty-eight guided PICC placements were performed in 63 outpatients (mean age, 43 ± 13 years; 50% male) and compared to 68 propensity score-matched PICC placements (mean age, 44 ± 13 years; 56% male) performed using external measurements by the same operators. Post-placement CXRs were used to confirm final catheter tip positioning. Cohorts were compared in terms of repositioning rates, desired tip positioning rates (in the lower third of the superior vena cava or at the cavoatrial junction), and estimated cost per PICC positioned as desired using manufacturer quotes, Medicare reimbursement rates, and hourly wages for staff time. Agreement between tip positioning according to the guided system versus CXR was also assessed. RESULTS: Guided PICC placements required less repositioning (1.5% vs 10.3%, P = .03) and resulted in more catheters positioned as desired (86.8% vs 67.6%, P = .01) than the external measurement approach. The cost per PICC positioned as desired was lower for guided placements ($318.54 vs $381.44), suggesting that the guided system was cost-effective in this clinical setting. Guided system-CXR agreement for tip position was poor (κ=0.25, P = .002) due to tips being slightly farther from the cavoatrial junction on CXR than indicated by the guided system. CONCLUSIONS: The guided PICC placement system was cost-effective in outpatients treated by a single division of interventional radiology at an academic institution.

Modelling the impact of chest X-ray and alternative triage approaches prior to seeking a tuberculosis diagnosis.

BACKGROUND: Tuberculosis is a major challenge to health in the developing world. Triage prior to diagnostic testing could potentially reduce the volume of tests and costs associated with using the more accurate, but costly, Xpert MTB/RIF assay. An effective methodology to predict the impact of introducing triage prior to tuberculosis diagnostic testing could be useful in helping to guide policy. METHODS: The development and use of operational modelling to project the impact on case detection and health system costs of alternative triage approaches for tuberculosis, with or without X-ray, based on data from Porto Alegre City, Brazil. RESULTS: Most of the triage approaches modelled without X-ray were predicted to provide no significant benefit. One approach based on an artificial neural network applied to patient and symptom characteristics was projected to increase case detection (82% vs. 75%) compared to microscopy, and reduce costs compared to Xpert without triage. In addition, use of X-ray before diagnostic testing for HIV-negative patients could maintain diagnostic yield of using Xpert without triage, and reduce costs. CONCLUSION: A model for the impact assessment of alternative triage approaches has been tested. The results from using the approach demonstrate its usefulness in informing policy in a typical high burden setting for tuberculosis.

Emergency Department Resource Use in Pediatric Pneumonia: Point-of-Care Lung Ultrasonography versus Chest Radiography.

OBJECTIVES: Point-of-care lung ultrasonography (US) is an alternative to chest radiography for imaging of suspected community-acquired pneumonia (CAP) in children. We compared pediatric emergency department (ED) time metrics between children who received point-of-care lung US versus chest radiography. Secondary objectives were comparisons of health system costs and other resources in these imaging groups. METHODS: This work was a retrospective matched cohort study of children aged 0 to 18 years in an academic urban pediatric ED who were imaged for suspected CAP with either point-of-care lung US or chest radiography. RESULTS: A total of 202 patients (101 in each group) were included in the study. The point-of-care lung US group spent a mean of 75.9 (SE, 14.3) minutes less from physician assessment to discharge (P < .0001) and 60.9 (SE, 18.1) minutes less in the overall ED length of stay (P = .0008). Physician billings and facility fees were both significantly lower (P < .0001) in the point-of-care lung US group, for a mean health systems savings of CAN$187.1 (SE, CAN$21.9). CONCLUSIONS: In children undergoing imaging for suspected CAP in our pediatric ED, point-of-care lung US by pediatric emergency medicine physicians was associated with decreased time and cost compared with chest radiography.

Variation of preoperative chest radiography utilization in Switzerland and its influencing factors: a multilevel study with claims data.

Clinical recommendations discourage routine use of preoperative chest radiography (POCR). However, there remains much uncertainty about its utilization, especially variation across small areas. We aimed to assess the variation of POCR use across small regions, and to explore its influencing factors. Patients undergoing inpatient surgery during 2013 to 2015 were identified from insurance claims data. Possible influencing factors of POCR included socio-demographics, health insurance choices, and clinical characteristics. We performed multilevel modelling with region and hospital as random effects. We calculated 80% interval odds ratios (IOR-80) to describe the effect of hospital type, and median odds ratios (MOR) to assess the degree of higher level variation. Utilization rates of POCR varied from 2.5% to 44.4% across regions. Higher age, intrathoracic pathology, and multi-morbidity were positively associated with the use of POCR. Female gender, choice of high franchise and supplementary hospital insurance showed a negative association. MOR was 1.25 and 1.69 for region and hospital levels, respectively. IOR-80s for hospital type were wide and covered the value of one. We observed substantial variation of POCR utilization across small regions in Switzerland. Even after controlling for multiple factors, variation across small regions and hospitals remained. Underlying mechanisms need to be studied further.

Value of chest X-ray in TB diagnosis in HIV-infected children living in resource-limited countries: the ANRS 12229-PAANTHER 01 study.

OBJECTIVE: To evaluate inter-reader agreement and diagnostic accuracy of chest radiography (CXR) in the diagnosis of tuberculosis (TB) in children with human immunodeficiency virus (HIV) infection. DESIGN: HIV-infected children with clinically suspected TB were enrolled in a prospective study conducted in Burkina Faso, Cambodia, Cameroon and Viet Nam from April 2010 to December 2014. Three readers-a local radiologist, a paediatric pulmonologist and a paediatric radiologist-independently reviewed the CXRs. Inter-reader agreement was then assessed using the κ coefficient. Diagnostic accuracy of CXR was assessed in culture-confirmed cases and controls. RESULTS: A total of 403 children (median age 7.3 years, interquartile range 3.5-9.7; 49.6% males) were enrolled. Inter-reader agreement was as follows: between local radiologist and paediatric pulmonologist, κ = 0.36 (95%CI 0.27-0.45); local radiologist and paediatric radiologist, κ = 0.16 (95%CI 0.08-0.24); and paediatric pulmonologist and paediatric radiologist, κ = 0.30 (95%CI 0.21-0.40). Among 51 cases and 151 controls, after a consensus, CXR had a sensitivity of 71.4% (95%CI 58.8-84.1) and a specificity of 50.0% (95%CI 41.9-58.1). Alveolar opacities and enlarged lymph nodes on CXR had limited specificity for TB (64.7% and 70.2%, respectively). Miliary and/or nodular opacities patterns on CXR were more specific to TB (specificity 94.3%). CONCLUSION: CXR showed poor-to-fair inter-reader agreement and limited diagnostic accuracy for TB in HIV-infected children, likely due to comorbidities. Radiological criteria for this specific population require further investigation.

Improving childhood tuberculosis detection and treatment through facility-based screening in rural Pakistan.

SETTING: Many children with tuberculosis (TB) remain undiagnosed due to the absence of services, lack of child-friendly diagnostics and underappreciation of TB as a common cause of childhood illness. OBJECTIVE: To show the impact of systematic verbal screening and contact tracing with appropriate management services on TB case finding in pediatric populations. DESIGN: Between October 2014 and March 2016, children were verbally screened at the pediatric out-patient departments of four public hospitals in Jamshoro District, Pakistan. Children with symptoms or risk of TB were referred for clinical evaluation and free chest X-ray and bacteriological tests. Children with TB were started on treatment and their care givers asked to bring household members to the hospital for screening. RESULTS: Over 105 000 children were verbally screened and 5880 presumptive childhood TB patients were identified; 1417 children (prevalence 1.3%) were diagnosed with TB; 43% were female. The median age was 5 years; 82% had pulmonary TB. An additional 390 children with TB were diagnosed through contact tracing. These activities resulted in a three-fold increase in pediatric TB case notifications. CONCLUSION: Systematic verbal screening with clinical evaluation and free diagnostics can identify children with TB who may otherwise be missed in rural health settings.

Risk-Targeted Lung Cancer Screening: A Cost-Effectiveness Analysis.

Background: Targeting low-dose computed tomography (LDCT) for lung cancer screening to persons at highest risk for lung cancer mortality has been suggested to improve screening efficiency. Objective: To quantify the value of risk-targeted selection for lung cancer screening compared with National Lung Screening Trial (NLST) eligibility criteria. Design: Cost-effectiveness analysis using a multistate prediction model. Data Sources: NLST. Target Population: Current and former smokers eligible for lung cancer screening. Time Horizon: Lifetime. Perspective: Health care sector. Intervention: Risk-targeted versus NLST-based screening. Outcome Measures: Incremental 7-year mortality, life expectancy, quality-adjusted life-years (QALYs), costs, and cost-effectiveness of screening with LDCT versus chest radiography at each decile of lung cancer mortality risk. Results of Base-Case Analysis: Participants at greater risk for lung cancer mortality were older and had more comorbid conditions and higher screening-related costs. The incremental lung cancer mortality benefits during the first 7 years ranged from 1.2 to 9.5 lung cancer deaths prevented per 10 000 person-years for the lowest to highest risk deciles, respectively (extreme decile ratio, 7.9). The gradient of benefits across risk groups, however, was attenuated in terms of life-years (extreme decile ratio, 3.6) and QALYs (extreme decile ratio, 2.4). The incremental cost-effectiveness ratios (ICERs) were similar across risk deciles ($75 000 per QALY in the lowest risk decile to $53 000 per QALY in the highest risk decile). Payers willing to pay $100 000 per QALY would pay for LDCT screening for all decile groups. Results of Sensitivity Analysis: Alternative assumptions did not substantially alter our findings. Limitation: Our model did not account for all correlated differences between lung cancer mortality risk and quality of life. Conclusions: Although risk targeting may improve screening efficiency in terms of early lung cancer mortality per person screened, the gains in efficiency are attenuated and modest in terms of life-years, QALYs, and cost-effectiveness. Primary Funding Source: National Institutes of Health (U01NS086294).

A doubly robust approach for cost-effectiveness estimation from observational data.

Estimation of common cost-effectiveness measures, including the incremental cost-effectiveness ratio and the net monetary benefit, is complicated by the need to account for informative censoring and inherent skewness of the data. In addition, since the two components of these measures, medical costs and survival are often collected from observational claims data, one must account for potential confounders. We propose a novel doubly robust, unbiased estimator for cost-effectiveness based on propensity scores that allow the incorporation of cost history and time-varying covariates. Further, we use an ensemble machine learning approach to obtain improved predictions from parametric and non-parametric cost and propensity score models. Our simulation studies demonstrate that the proposed doubly robust approach performs well even under mis-specification of either the propensity score model or the outcome model. We apply our approach to a cost-effectiveness analysis of two competing lung cancer surveillance procedures, CT vs. chest X-ray, using SEER-Medicare data.

Double Scan CT Rates: An Opportunity for Facility-Based Radiologist Measures in the Quality Payment Program.

PURPOSE: The Medicare Access and CHIP Reauthorization Act (MACRA) provides CMS flexibility to evaluate radiologists using hospital outpatient quality measures in place of conventional physician measures. We explore radiologist characteristics associated with variation in performance in two such measures: abdomen and chest CT "double scan" rates (percentage of total examinations performed both with and without intravenous contrast). METHODS: Radiologists' claims for abdomen and chest CT examinations in a facility setting were identified using 2014 Medicare Physician and Other Supplier data. Individual radiologist double scan rates were computed. Associations were explored between rates and radiologist characteristics extracted from the CMS public data sets using multivariable regression with cross-validation. RESULTS: Radiologists' double scan rates averaged 5.9% ± 10.0% (0.0% for 52.8% of radiologists) for abdomen CT (19,867 radiologists) and 1.0% ± 4.7% (0.0% for 91.3% of radiologists) for chest CT (18,684). At multivariable analysis, abdomen rates were best predicted by geography (lowest in Northeast, greatest in West), practice size (greatest for small practices), and specialty practice pattern (lowest for general radiologists; greatest for nuclear medicine physicians). Agreement for double scan rates among radiologists within the same practice was moderate, though slightly higher for chest (intraclass correlation = 0.70) than abdomen (0.59). CONCLUSION: Radiologists' facility double scan rates vary systematically based on an array of professional characteristics. MACRA grants CMS the authority to use these measures for evaluating radiologists, thereby aligning Medicare's hospital and physician performance programs and better incentivizing population radiation dose and cost reduction. Greater variation in abdomen CT double scan rates, compared with ubiquitously excellent chest CT performance, supports a particular role for abdomen rates in distinguishing disparities in radiologist performance.

No longer any role for routine follow-up chest x-rays in men with stage I germ cell cancer.

Following radical orchidectomy for testicular cancer, most patients undergo protocolled surveillance to detect tumour recurrences rather than receive adjuvant chemotherapy. Current United Kingdom national and most international guidelines recommend that patients require a chest x-ray (CXR) and serum tumour markers at each follow-up visit as well as regular CT scans; there is however, variation among cancer centres with follow-up protocols. Seminomas often do not cause tumour marker elevation; therefore, CT scans are the main diagnostic tool for detecting relapse. For non-seminomatous tumours, serum beta-HCG (HCG) and AFP levels are a very sensitive harbinger of relapse, but this only occurs in 50% of patients [1], and therefore, imaging remains as important. CXRs are meant to aid in the detection of lung recurrences and before the introduction of modern cross-sectional imaging in the early 1980s, CXRs would have been the only method of identifying lung metastasis. We examined the Thames Valley and Mount Vernon Cancer Centre databases to evaluate the role of CXRs in the 21st century for the follow-up of men with stage I testicular cancer between 2003 and 2015 to assess its value in diagnosing relapsed germ cell tumours. From a total of 1447 patients, we identified 159 relapses. All relapses were detected either by rising tumour markers or planned follow-up CT scans. Not a single relapse was identified on CXR. We conclude that with timely and appropriate modern cross-sectional imaging and tumour marker assays, the CXR no longer has any value in the routine surveillance of stage I testicular cancer and should be removed from follow-up guidelines and clinical practice. Omitting routine CXR from follow-up schedules will reduce anxiety as well as time that patients spend at hospitals and result in significant cost savings.

Evaluation of Cardiopulmonary Complication Rates after Port Insertion: Is a Postoperative X-Ray Needed?

It is customary for a postoperative chest radiograph to be obtained after fluoroscopic guided port insertion to exclude acute complications. In this review, we provide a cost-benefit analysis by examination of acute postoperative complications detected by postoperative port insertion chest films at our institution. We conducted a retrospective chart review of complications associated with port insertion procedures performed over a 5-year period. Our study included only ultrasound-assisted internal jugular venous or landmark guided subclavian ports placed with the assistance of fluoroscopy. A total of 519 port insertions were reviewed and there was noted to be a postoperative complication rate of 0.58 per cent. The operative note for each complication described a procedural abnormality that suggested a chest film would be of medical benefit. The total price of postoperative chest radiographs was $179,400. Performing chest X-ray films on asymptomatic patients after fluoroscopic guided placement of ports proved to be of no medical advantage to 516 out of 519 patients. Given the extremely low complication rate and financial burden placed on the patient population, we propose discontinuing routine use of postoperative port placement chest radiographs as a way to alleviate unwarranted medical cost.