How we do it: shifting MR arthrogram compounding from the fluoroscopy suite to the sterile pharmacy.

OBJECTIVE: To assess the impact of shifting arthrogram injectate compounding from the fluoroscopy suite to the main hospital sterile pharmacy on cost, examination delays, and infection rates. MATERIALS AND METHODS: All arthrograms from the 12 months before (629 in total) and the 12 months after (699 in total) the change in arthrogram preparation procedure were compared to identify differences in examination delays and infection rate. The arthrogram formulation was sent to the Compounder's International Analytical Laboratory for stability testing. Finally, cost per injection analysis was performed to compare fluoroscopy suite with sterile pharmacy compounding. RESULTS: In the 699 arthrograms performed in the 12 months following transfer of arthrogram preparation to the main hospital pharmacy, there were 0 reported examination delays, 0 reported infections, and a 53% decrease in the material cost per arthrogram. There were three recorded instances of fluoroscopy suite preparation of arthrogram injectate due to unexpected add-on patients. Outside stability testing determined that the arthrogram injectate retained at least 90% potency 30 h post-preparation. CONCLUSION: Shifting the compounding of the arthrogram injectate from the fluoroscopy room to the main hospital sterile pharmacy provides a modest cost saving and can be accomplished without examination delays or any increase in infection rate. It brought our practice into compliance with USP797, which is the current guideline for compounding practitioners, by transferring the compounding preparation of the arthrogram injectate from a procedure room to the sterile pharmacy.

A cost-effectiveness analysis of the diagnostic strategies for differentiating focal nodular hyperplasia from hepatocellular adenoma.

OBJECTIVES: We evaluated the cost-effectiveness of a gadoxetic acid-enhanced MRI (EOB-MRI) strategy compared with conventional MRI strategy and biopsy to differentiate focal nodular hyperplasia (FNH) from hepatocellular adenoma (HCA). METHODS: A decision tree model was constructed to compare the cost-effectiveness of EOB-MRI, conventional MRI with extracellular contrast agents, and biopsy as the initial diagnostic modality in patients with incidentally detected focal liver lesions suspected of being FNH or HCA. We analysed the cost and effectiveness, i.e. probability of successful diagnosis of each strategy. Costs were based on utilisation rates and Medicare reimbursements in the USA and South Korea. RESULTS: In the base case analysis of our decision tree model, the effectiveness of the three strategies was similar. The cost of the EOB-MRI strategy ($1283 in USA, $813 in South Korea) was lowest compared with the biopsy strategy ($1725 in USA, $847 in South Korea) and the conventional MRI strategy ($1750 in USA, $962 in South Korea). One-way, two-way and probabilistic sensitivity analysis showed unchanged results over an acceptable range. CONCLUSIONS: EOB-MRI strategy is the most cost-effective strategy for differentiating FNH from HCA in patients with incidentally detected focal liver lesions in a non-cirrhotic liver. KEY POINTS: • The effectiveness of the three strategies was similar. • The cost of the EOB-MRI strategy was lowest. • EOB-MRI strategy is the most cost-effective for differentiating FNH from HCA.

Cost evaluation of gadoxetic acid-enhanced magnetic resonance imaging in the diagnosis of colorectal-cancer metastasis in the liver: Results from the VALUE Trial.

OBJECTIVES: To assess the costs of diagnostic workup and surgery of three strategies for patients with colorectal cancer liver-metastases (CRCLM): gadoxetic-acid-enhanced MRI (Gd-EOB-DTPA-MRI), MRI with extracellular contrast-media (ECCM-MRI) or contrast-enhanced MDCT (CE-MDCT). METHODS: The within-trial cost evaluation was modelled as a decision-tree to calculate the cost of diagnosis and surgery. The model used clinical outcomes and resource utilization data from a prospective randomized multicentre study. Analyses were performed for the 354-patient safety population from eight participating countries. RESULTS: The diagnostic workup cost using Gd-EOB-DTPA-MRI upfront resulted in savings compared to ECCM-MRI in all countries except Thailand (difference <2 %). Compared to CE-MDCT, initial imaging with Gd-EOB-DTPA-MRI was less costly in all countries except Korea and Spain (differences 4 and 8 %, respectively). Significantly more patients in the Gd-EOB-DTPA-MRI group were eligible for surgery (39.3 % (48/122) vs. 31.0 % (36/116) and 26.7 % (31/116) for ECCM-MRI and CE-MDCT, respectively), allowing more patients to undergo potentially curative surgery, but resulting in higher treatment costs for the strategy starting with Gd-EOB-DTPA-MRI. CONCLUSIONS: The benefits of Gd-EOB-DTPA-MRI due to less additional imaging and similar diagnostic workup costs in the three groups suggest that Gd-EOB-DTPA-MRI should be the preferred initial imaging procedure to evaluate hepatic resectability in patients with CRCLM. KEY POINTS: • Diagnostic imaging cost to evaluate resectability was similar among the groups • Cost for imaging was rather small compared to the cost of surgery • Significantly more patients in the Gd-EOB-DTPA-MRI arm were eligible for surgery • Gd-EOB-DTPA-MRI is recommended for evaluating hepatic resectability in patients with CRCLM.

Whole-body MR imaging versus sequential multimodal diagnostic algorithm for staging patients with rectal cancer: cost analysis.

PURPOSE: To compare the direct costs of two diagnostic algorithms for pretherapeutic TNM staging of rectal cancer. MATERIALS AND METHODS: In a study including 33 patients (mean age: 62.5 years), the direct fixed and variable costs of a sequential multimodal algorithm (rectoscopy, endoscopic and abdominal ultrasound, chest X-ray, thoracic/abdominal CT in the case of positive findings in abdominal ultrasound or chest X-ray) were compared to those of a novel algorithm of rectoscopy followed by MRI using a whole-body scanner. MRI included T 2w sequences of the rectum, 3D T 1w sequences of the liver and chest after bolus injection of gadoxetic acid, and delayed phases of the liver. The personnel work times, material items, and work processes were tracked to the nearest minute by interviewing those responsible for the process (surgeon, gastroenterologist, two radiologists). The costs of labor and materials were determined from personnel reimbursement data and hospital accounting records. Fixed costs were determined from vendor pricing. RESULTS: The mean MRI time was 55 min. CT was performed in 19/33 patients (57%) causing an additional day of hospitalization (costs 374 euro). The costs for equipment and material were higher for MRI compared to sequential algorithm (equipment 116 vs. 30 euro; material 159 vs. 60 euro per patient). The personnel costs were markedly lower for MRI (436 vs. 732 euro per patient). Altogether, the absolute cost advantage of MRI was 31.3% (711 vs. 1035 euro for sequential algorithm). CONCLUSION: Substantial savings are achievable with the use of whole-body MRI for the preoperative TNM staging of patients with rectal cancer.

Health-economic evaluation of three imaging strategies in patients with suspected colorectal liver metastases: Gd-EOB-DTPA-enhanced MRI vs. extracellular contrast media-enhanced MRI and 3-phase MDCT in Germany, Italy and Sweden.

The purpose of this study was to perform an economic evaluation of hepatocyte-specific Gd-EOB-DTPA enhanced MRI (PV-MRI) compared to extracellular contrast-media-enhanced MRI (ECCM-MRI) and three-phase-MDCT as initial modalities in the work-up of patients with metachronous colorectal liver metastases. The economic evaluation was performed with a decision-tree model designed to estimate all aggregated costs depending on the initial investigation. Probabilities on the need for further imaging to come to a treatment decision were collected through interviews with 13 pairs of each a radiologist and a liver surgeon in Germany, Italy and Sweden. The rate of further imaging needed was 8.6% after initial PV-MRI, 18.5% after ECCM-MRI and 23.5% after MDCT. Considering the cost of all diagnostic work-up, intra-operative treatment changes and unnecessary surgery, a strategy starting with PV-MRI with 959 Euro was cost-saving compared to ECCM-MRI (1,123 Euro) and MDCT (1,044 Euro) in Sweden. In Italy and Germany, PV-MRI was cost-saving compared to ECCM-MRI and had total costs similar to MDCT. In conclusion, our results indicate that PV-MRI can lead to cost savings by improving pre-operative planning and decreasing intra-operative changes. The higher cost of imaging with PV-MRI is offset in such a scenario by lower costs for additional imaging and less intra-operative changes.

Cost-effective diagnosis of acoustic neuromas: a philosophical, macroeconomic, and technological decision.

OBJECTIVE: Our goals were to define the most sensitive techniques of acoustic neuroma diagnosis, to examine their relative costs, and to propose diagnostic modality selection given the rarity of acoustic neuroma incidence and given the other costs that society faces in more commonly encountered diseases. METHODS: We conducted a MEDLINE search of the English language from 1966 to 2001 using the following keywords: acoustic neuroma, acoustic tumor, vestibular schwannoma, diagnosis, cost effectiveness, MRI, auditory brainstem response, brainstem audiometric evoked response, incidence, and prevalence. RESULTS: Although magnetic resonance imaging with gadolinium remains the most sensitive diagnostic modality in the discovery of acoustic neuromas, its cost may be prohibitive for some societies. CONCLUSION: Which modality to use in acoustic neuroma diagnosis is just as much a philosophical and macroeconomic question as a technological one. CLINICAL SIGNIFICANCE: The cost of a timely diagnosis of acoustic neuromas must be weighed against using resources for other, more pressing, health concerns.

Utilization of "used" vials: cost-effective technique for MR arthrography.

Because full vials of commercially available MR arthrographic contrast are expensive, we hypothesized that the small residual contrast in a "used" vial would be adequate for MR arthrography. After sterility testing and quantity analysis of the residual contrast in 28 vials, this method was successfully used in 10 patients. J. Magn. Reson. Imaging 2000;12:953-955.

Arterial-phase three-dimensional gadolinium magnetic resonance angiography of the renal arteries. Strategies for timing and contrast media injection: original investigation.

RATIONALE AND OBJECTIVES: The authors review different imaging and contrast-media infusion strategies for arterial-phase three-dimensional (3D) gadolinium-enhanced magnetic resonance angiography (Gd-MRA). METHODS: The influence of physicochemical factors on the infusion of contrast media, including viscosity, flow rate, inline pressure, and cannula size, is assessed. The combination of manual or automated contrast-media administration with timing-dependent or -independent 3D Gd-MRA techniques is reviewed regarding the aspects of effectiveness, robustness, image quality, and costs. RESULTS: For effective bolus delivery with high flow rates, the type and temperature of the contrast media, the size of the cannula, and an immediate saline flush must be considered. Timing-dependent techniques based on a test bolus and using automated contrast-media infusion as well as timing independent techniques such as MR SmartPrep or multiphase 3D Gd-MRA by using a manual injection with a SmartSet tubing set, are all effective procedures for arterial phase 3D Gd-MRA. CONCLUSIONS: Manual contrast-media injection with a tubing set can be used for timing-independent MRA techniques. The multiphase 3D Gd-MRA approach seems to be favorable for different MR systems, robustness, and speed.

[Optimal use of MRI mammography from the economic viewpoint]. / Der optimale Einsatz der MR-Mammographie (MRM) unter wirtschaftlichen Gesichtspunkten.

With the introduction of the contrast agent gadolinum DTPA there were hopes that "MRM" would prove to be the investigatory technique that would largely solve the problems of breast diagnostics. However, after the early years of acceptance, the new method of investigation became a subject of controversy. Nonetheless, MRM today occupies a recognized place in diagnostics for certain indications. It is still true, however, that reliable use of this procedure requires a great deal of experience, since there is a relatively large area of overlap between benign and malignant tumors. Further, the costs are significantly higher than those for conventional methods of investigation. New studies that have been conducted at the Charité, Campus Virchow Medical Center in Berlin, suggest that, if one takes the relevant indications into account, MRM can be economic and contribute significantly to cost reduction. Application of a newly developed software package has shown that the good discrimination in a suspect area resulting from contrast agent enhancement makes possible a reliable differentiation between malignant and benign tissue changes. A further result was that, when certain boundary conditions are satisfied, a contrast agent bolus of 0.1 mmol/kg BW is sufficient, making a double dose (0.2 mmol/kg BW) unnecessary.