Energy and Greenhouse Gas Emission Savings Associated with Implementation of an Abbreviated Cardiac MRI Protocol.

Supplemental material is available for this article. See also the article by Lenkinski and Rofsky in this issue. See also the article by McKee et al in this issue.

Barriers to access and unmet needs to neuromyelitis optica spectrum disorders care in an Argentinean cohort.

INTRODUCTION: Neuromyelitis optica spectrum disorder (NMOSD) is a rare but severe neuroimmunological condition associated with a significant financial burden. NMOSD is also associated with increased health care utilization, including neurology outpatient visits, magnetic resonance imaging (MRI) use, long-term medication, among others. We aimed to evaluate real-world patient experiences in access to care and NMOSD burden in an Argentinean cohort. METHODS: This cross-sectional study used a self-administered survey and was conducted in Argentina (2022). Patients with NMOSD were divided into three groups: private health insurance (PHI), social health insurance (SHI), and public health insurance (PHI, Ministry of Public Health). Differences in access and health care barriers were assessed. RESULTS: One hundred patients with NMOSD (74 women) with a mean age at diagnosis of 38.7 years were included. Their EDSS was 2.8 and they were followed for 5.2 years. Of them, 51%, 11%, and 13% were employed (full-time: 57.5%), currently unemployed and retired by NMOSD, respectively. 55% of them visited between 2-3 specialists before NMOSD diagnosis. Aquaporin-4-antibody and/or myelin oligodendrocyte glycoprotein-antibody testing was requested in 91% (health insurance covered this partially in 15.3% and 32.9% of the time the test was entirely paid by patient/family). Patients with NMOSD receiving private medical care reported greater access to MRI, outpatient visits, and fewer issues to obtain NMOSD medications compared to those treated at public institutions. A longer mean time to MRI and neurology visit was found in the PHI group when compared with the other two subgroups. Regression analysis showed that private insurance (OR=3.84, p=0.01) was the only independent factor associated with appropriate access to NMOSD medications in Argentina. CONCLUSION: These findings suggest that barriers to access and utilization of NMOSD care services in Argentina are common. NMOSD patients experienced problems to receive NMOSD medication properly, especially those from the public sector.

Structurally-constrained optical-flow-guided adversarial generation of synthetic CT for MR-only radiotherapy treatment planning.

The rapid progress in image-to-image translation methods using deep neural networks has led to advancements in the generation of synthetic CT (sCT) in MR-only radiotherapy workflow. Replacement of CT with MR reduces unnecessary radiation exposure, financial cost and enables more accurate delineation of organs at risk. Previous generative adversarial networks (GANs) have been oriented towards MR to sCT generation. In this work, we have implemented multiple augmented cycle consistent GANs. The augmentation involves structural information constraint (StructCGAN), optical flow consistency constraint (FlowCGAN) and the combination of both the conditions (SFCGAN). The networks were trained and tested on a publicly available Gold Atlas project dataset, consisting of T2-weighted MR and CT volumes of 19 subjects from 3 different sites. The network was tested on 8 volumes acquired from the third site with a different scanner to assess the generalizability of the network on multicenter data. The results indicate that all the networks are robust to scanner variations. The best model, SFCGAN achieved an average ME of 0.9   5.9 HU, an average MAE of 40.4   4.7 HU and 57.2   1.4 dB PSNR outperforming previous research works. Moreover, the optical flow constraint between consecutive frames preserves the consistency across all views compared to 2D image-to-image translation methods. SFCGAN exploits the features of both StructCGAN and FlowCGAN by delivering structurally robust and 3D consistent sCT images. The research work serves as a benchmark for further research in MR-only radiotherapy.

Auditory brainstem response prior to MRI compared to standalone MRI in the detection of vestibular schwannoma: A modelling study.

OBJECTIVES: To determine the cost-effectiveness of auditory brainstem response prior to MRI (ABR-MRI) compared to standalone MRI to diagnose vestibular schwannoma. DESIGN: A state transition model was developed to simulate costs and effects (quality-adjusted life years [QALY]) for both diagnostic strategies for patients suspected of a vestibular schwannoma. Model input was derived from literature, hospital databases and expert opinions. Scenario and sensitivity analyses addressed model uncertainty. RESULTS: Over a lifetime horizon, ABR-MRI resulted in a limited cost-saving of €68 or €98 per patient (dependent on MRI sequence) and a health loss of 0.005 QALYs over standalone MRI. ABR-MRI, however, did miss patients with other important pathology (2% of the population) that would have been detected when using standalone MRI. In total, €14 203 or €19 550 could be saved per lost QALY if ABR-MRI was used instead of standalone MRI. The results were sensitive to the detection rate of vestibular schwannoma and health-related quality of life of missed patients. CONCLUSION: The cost-saving with ABR-MRI does not seem to outweigh the number of missed patients with VS and other important pathologies that would have been detected when using standalone MRI.

Imaging of Patients Suspected of SLAP Tear: A Cost-Effectiveness Study.

BACKGROUND. Superior labrum anterior and posterior (SLAP) tears are a common shoulder pathology. Although MRI is the imaging reference standard for diagnosis of this pathology, the cost-effectiveness of common MRI strategies is unclear. OBJECTIVE. The primary objective of our study was to determine the cost-effectiveness of the common MRI-based strategies used for the diagnosis of SLAP tears. METHODS. We created decision analytic models from the perspective of the U.S. health care system over a 2-year time horizon for a hypothetical population of 25-year-old patients with a previous diagnosis of SLAP tear. We used the decision models to compare the differences in incremental cost-effectiveness of the common MRI strategies, which included combinations of 1.5-T and 3-T MR arthrography (MRA) and unenhanced MRI protocols, and the resulting treatment applied for these patients. Input data on cost, probability, and utility estimates were obtained through a comprehensive literature search. The primary effectiveness outcome was quality-adjusted life years. Costs were estimated in 2017 U.S. dollars. RESULTS. When all imaging strategies were considered, the unenhanced 3-T MRI-based imaging strategy was the preferred and dominant option over 3-T MRA and 1.5-T imaging (MRI and MRA). When the model was run without 3-T imaging as an option, 1.5-T MRA was the favored option. Probabilistic sensitivity analyses confirmed the same preferred imaging strategy results. CONCLUSION. An unenhanced 3-T MRI-based strategy is the most cost-effective imaging option for patients with suspected SLAP tear. When 3-T imaging is not available, 1.5-T MRA is more cost-effective than 1.5-T MRI. The main driver of these results is the fact that 3-T MRI and 1.5-T MRA are the most specific tests in these respective scenarios, which results in fewer false-positives, prevents unnecessary surgeries, and leads to decreased costs. CLINICAL IMPACT. Our cost-effectiveness model findings complement prior diagnostic accuracy work, helping produce a more comprehensive approach to define imaging utility for radiologists, clinicians, and patients with SLAP tears who have access to various types of MRI options.

A low-cost and shielding-free ultra-low-field brain MRI scanner.

Magnetic resonance imaging is a key diagnostic tool in modern healthcare, yet it can be cost-prohibitive given the high installation, maintenance and operation costs of the machinery. There are approximately seven scanners per million inhabitants and over 90% are concentrated in high-income countries. We describe an ultra-low-field brain MRI scanner that operates using a standard AC power outlet and is low cost to build. Using a permanent 0.055 Tesla Samarium-cobalt magnet and deep learning for cancellation of electromagnetic interference, it requires neither magnetic nor radiofrequency shielding cages. The scanner is compact, mobile, and acoustically quiet during scanning. We implement four standard clinical neuroimaging protocols (T1- and T2-weighted, fluid-attenuated inversion recovery like, and diffusion-weighted imaging) on this system, and demonstrate preliminary feasibility in diagnosing brain tumor and stroke. Such technology has the potential to meet clinical needs at point of care or in low and middle income countries.

Cost-Effectiveness of Magnetic Resonance Imaging in Prostate Cancer Screening: A Microsimulation Study.

OBJECTIVE: This study aimed to assess the cost-effectiveness of magnetic resonance imaging (MRI) with combinations of targeted biopsy (TBx) and systematic biopsy (SBx) for early prostate cancer detection in Sweden. METHODS: A cost-utility analysis was conducted from a lifetime societal perspective using a microsimulation model. Five strategies included no screening and quadrennial screening for men aged 55 to 69 years using SBx alone, TBx on positive MRI (MRI + TBx), combined TBx/SBx on positive MRI (MRI + TBx/SBx), and SBx on negative MRI with TBx/SBx on positive MRI (MRI - SBx, MRI + TBx/SBx). Test characteristics were based on a recent Cochrane review. We predicted the number of biopsies, costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios. RESULTS: The screening strategies were classified in Sweden as high costs per QALY gained compared with no screening. Using MRI + TBx and MRI + TBx/SBx reduced the number of biopsy episodes across a lifetime by approximately 40% compared with SBx alone. Both strategies showed strong dominance over SBx alone and MRI - SBx, MRI + TBx. Compared with MRI + TBx, the MRI + TBx/SBx strategy had an incremental cost-effectiveness ratio of more than €200 000 per QALY gained, which was classified in Sweden as a very high cost. These predictions were robust in the probabilistic sensitivity analysis. Limitations included generalizability of the model assumptions and uncertainty regarding the health-state values and study heterogeneity from the Cochrane review. CONCLUSIONS: MRI + TBx and MRI + TBx/SBx showed strong dominance over alternative screening strategies. MRI + TBx resulted in similar or marginally lower gains in QALYs and lower costs than MRI + TBx/SBx. MRI + TBx was considered the optimal choice among the screening strategies.

Cost-Effectiveness of Magnetic Resonance Imaging-Guided Thrombolysis for Patients With Stroke With Unknown Time of Onset.

OBJECTIVES: Patients waking up with stroke symptoms are often excluded from intravenous thrombolysis with alteplase (IV-tpa). The WAKE-UP trial, a European multicenter randomized controlled trial, proved the clinical effectiveness of magnetic resonance imaging-guided IV-tpa for these patients. This analysis aimed to assess the cost-effectiveness of the intervention compared to placebo. METHODS: A Markov model was designed to analyze the cost-effectiveness over a 25-year time horizon. The model consisted of an inpatient acute care phase and a rest-of-life phase. Health states were defined by the modified Rankin Scale (mRS). Initial transition probabilities to mRS scores were based on WAKE-UP data and health state utilities on literature search. Costs were based on data from the University Medical Center Hamburg-Eppendorf, literature, and expert opinion. Incremental costs and effects over the patients' lifetime were estimated. The analysis was conducted from a formal German healthcare perspective. Univariate and probabilistic sensitivity analyses were performed. RESULTS: Treatment with IV-tpa resulted in cost savings of €51 009 and 1.30 incremental gains in quality-adjusted life-years at a 5% discount rate. Univariate sensitivity analysis revealed incremental cost-effectiveness ratio being sensitive to the relative risk of favorable outcome on mRS for placebo patients after stroke, the costs of long-term care for patients with mRS 4, and patient age at initial stroke event. In all cases, IV-tpa remained cost-effective. Probabilistic sensitivity analysis proved IV-tpa cost-effective in >95% of the simulations results. CONCLUSIONS: Magnetic resonance imaging-guided IV-tpa compared to placebo is cost-effective in patients with ischemic stroke with unknown time of onset.

Portable, bedside, low-field magnetic resonance imaging for evaluation of intracerebral hemorrhage.

Radiological examination of the brain is a critical determinant of stroke care pathways. Accessible neuroimaging is essential to detect the presence of intracerebral hemorrhage (ICH). Conventional magnetic resonance imaging (MRI) operates at high magnetic field strength (1.5-3 T), which requires an access-controlled environment, rendering MRI often inaccessible. We demonstrate the use of a low-field MRI (0.064 T) for ICH evaluation. Patients were imaged using conventional neuroimaging (non-contrast computerized tomography (CT) or 1.5/3 T MRI) and portable MRI (pMRI) at Yale New Haven Hospital from July 2018 to November 2020. Two board-certified neuroradiologists evaluated a total of 144 pMRI examinations (56 ICH, 48 acute ischemic stroke, 40 healthy controls) and one ICH imaging core lab researcher reviewed the cases of disagreement. Raters correctly detected ICH in 45 of 56 cases (80.4% sensitivity, 95%CI: [0.68-0.90]). Blood-negative cases were correctly identified in 85 of 88 cases (96.6% specificity, 95%CI: [0.90-0.99]). Manually segmented hematoma volumes and ABC/2 estimated volumes on pMRI correlate with conventional imaging volumes (ICC = 0.955, p = 1.69e-30 and ICC = 0.875, p = 1.66e-8, respectively). Hematoma volumes measured on pMRI correlate with NIH stroke scale (NIHSS) and clinical outcome (mRS) at discharge for manual and ABC/2 volumes. Low-field pMRI may be useful in bringing advanced MRI technology to resource-limited settings.

Analysis of Medicare Payments and Patient Outcomes With Pre-Operative Imaging for Carotid Endarterectomy.

OBJECTIVE: The use of radiographic evaluation of carotid disease may vary, and current guidelines do not strongly recommend the use of cross-sectional imaging (CSI) prior to surgical intervention. We sought to describe the trends in preoperative carotid imaging and evaluate the associated clinical outcomes and Medicare payments for patients undergoing carotid endarterectomy (CEA) for asymptomatic carotid disease. METHODS: We used a 20% Medicare sample from 2006 to 2014 identifying patients undergoing CEA for asymptomatic disease. We evaluated preoperative carotid ultrasound and CSI use: CT or MRI of the neck prior to CEA. We calculated average payments of each study from the carrier file and revenue center file. Imaging payments included both the professional component (PC) and the technical component (TC). Claims with a reimbursement of $0 and studies where payment for both the TC and PC could not be identified were excluded from the overall calculation to determine average payment per study. Inpatient reimbursements according to DRG 37-39 were calculated. We compared hospital length of stay (LOS), in hospital stroke, carotid re-exploration, and mortality according to CSI use. RESULTS: A total of 58,993 CEAs were identified with pre-operative carotid imaging. The average age was 74.8 ± 7.5 years, and 56.0% were men. A total of 19,678 (33%) patients had ultrasound alone with an average of (2.4 ± 1.9) exams prior to CEA. A total of 39,315 patients underwent CSI prior to CEA with 2.5 ± 2.1 ultrasounds, 0.95 ± 0.86 neck CTs and 0.47 ± 0.7 MRIs per patient. The average payment for ultrasound was $140 ± 40, $282 ± 94 for CT and $410 ± 146 for MRI. The average inpatient reimbursements were $7,413 ± 4,215 for patients without CSI compared with $7,792 ± 3,921 for patients with CSI, P < 0.001. The average LOS during CEA admission was 2.5 ± 3.7days. Patients with CSI had a slightly lower percentage of patients being discharged by postoperative day 2 compared with ultrasound alone (88.9% vs. 91.5%, respectively, P < 0.001). The overall in-hospital stroke rate was 0.38% and carotid re-exploration rate was 1.0% and there was no statistical significant difference between groups. Median follow-up was 3.9 years, and mortality at 8 years was 50% and did not statistically differ between groups. CONCLUSIONS: Our analysis found preoperative imaging to include CSI in nearly two-thirds of patients prior to CEA for asymptomatic disease. As imaging and inpatient payments were higher with patients with CSI further work is needed to understand when CSI is appropriate prior to surgical intervention to appropriately allocate healthcare resources.

Cost-Effectiveness of Advanced Neuroimaging for Transient and Minor Neurological Events in the Emergency Department.

Background Accurate diagnosis of patients with transient or minor neurological events can be challenging. Recent studies suggest that advanced neuroimaging can improve diagnostic accuracy in low-risk patients with transient or minor neurological symptoms, but a cost-effective emergency department diagnostic evaluation strategy remains uncertain. Methods and Results We constructed a decision-analytic model to evaluate 2 diagnostic evaluation strategies for patients with low-risk transient or minor neurological symptoms: (1) obtain advanced neuroimaging (magnetic resonance imaging brain and magnetic resonance angiography head and neck) on every patient or (2) current emergency department standard-of-care clinical evaluation with basic neuroimaging. Main probability variables were: proportion of patients with true ischemic events, strategy specificity and sensitivity, and recurrent stroke rate. Direct healthcare costs were included. We calculated incremental cost-effectiveness ratios, conducted sensitivity analyses, and evaluated various diagnostic test parameters primarily using a 1-year time horizon. Cost-effectiveness standards would be met if the incremental cost-effectiveness ratio was less than willingness to pay. We defined willingness to pay as $100 000 US dollars per quality-adjusted life year. Our primary and sensitivity analyses found that the advanced neuroimaging strategy was more cost-effective than emergency department standard of care. The incremental effectiveness of the advanced neuroimaging strategy was slightly less than the standard-of-care strategy, but the standard-of-care strategy was more costly. Potentially superior diagnostic approaches to the modeled advanced neuroimaging strategy would have to be >92% specific, >70% sensitive, and cost less than or equal to standard-of-care strategy's cost. Conclusions Obtaining advanced neuroimaging on emergency department patient with low-risk transient or minor neurological symptoms was the more cost-effective strategy in our model.

PriMa: A low-cost, modular, open hardware, and 3D-printed fMRI manipulandum.

Motor actions in fMRI settings require specialized hardware to monitor, record, and control the subjects behavior. Commercially available options for such behavior tracking or control are very restricted and costly. We present a novel grasp manipulandum in a modular design, consisting of MRI-compatible, 3D printable buttons and a chassis for mounting. Button presses are detected by the interruption of an optical fiber path, which is digitized by a photodiode and subsequent signal amplification and thresholding. Two feedback devices (manipulanda) are constructed, one for macaques (Macaca mulatta) and one for human use. Both devices have been tested in their specific experimental setting and possible improvements are reported. Design files are shared under an open hardware license.

An assessment of prevalence and expenditure associated with discharge brain MRI in preterm infants.

To assess national expenditure associated with preterm-infant brain MRI and potential impact of reduction per Choosing Wisely campaign 2015 recommendation to "avoid routine screening term-equivalent or discharge brain MRIs in preterm-infants". Cross-sectional U.S. trend data from the Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID) database (2006, 2009, 2012, 2016) was used to estimate overall national expenditure associated with brain MRI among infants with gestational age (GA) ≤36 weeks, and also when classified as 'not indicated' (NI-MRI) i.e., equivalent to routine use without clinical indications and regarded as low-value service (LVS). Associated cost was determined by querying CMS-database for physician-fee-schedules to find the highest global procedure-cost per cycle, then adjusting for inflation. Sensitivity-analyses were conducted to account for additional clinical charges associated with NI-MRI. 3,768 (0.26%) of 1,472,236 preterm-infants had brain MRI across all cycles (inflation-adjusted total $3,690,088). Overall proportion of brain MRIs increased across 2006-2012 from 0.25%-0.33% but decreased in 2016 to 0.16% (P<0.001). Inflation-adjusted overall expenditure by cycle was: 2006, $1,299,130 (95% CI: $987,505, $1,610,755); 2009, $1,194,208 (95% CI: $873,487, $1,516,154); 2012, $931,836 (95% CI: $666,114, $1,197,156); and 2016, $264,648 (95% CI: $172,061, $357,280). Prevalence for NI-MRI in 2006, 2009, 2012 and 2016 was 86% (n = 809), 88% (n = 940), 89% (n = 1028) and 50% (n = 299), respectively; and 70% were in infants 35-36 weeks GA. NI-MRI prevalence was not different over time by payer-type (Medicaid, private), sex or race/ethnicity (white, black, Hispanic); larger hospital size was significantly associated across 2006-2012 but this declined for all sizes in 2016, with most decline in larger hospitals (P for interaction <0.05). NI-MRI expenditure sensitivity-analysis with addition of cycle median total-admission-charge to inflation-adjusted CMS-fee was $1,190,919/$518,343, for 2012/2016 cycles respectively. National MRI prevalence in preterm infants (both overall and LVS) and associated expenditure decreased substantially post recommendation; however, annual savings are modest and unlikely to be >$1.2 million.

Benefit, Harm, and Cost-effectiveness Associated With Magnetic Resonance Imaging Before Biopsy in Age-based and Risk-stratified Screening for Prostate Cancer.

Importance: If magnetic resonance imaging (MRI) mitigates overdiagnosis of prostate cancer while improving the detection of clinically significant cases, including MRI in a screening program for prostate cancer could be considered. Objective: To evaluate the benefit-harm profiles and cost-effectiveness associated with MRI before biopsy compared with biopsy-first screening for prostate cancer using age-based and risk-stratified screening strategies. Design, Setting, and Participants: This decision analytical model used a life-table approach and was conducted between December 2019 and July 2020. A hypothetical cohort of 4.48 million men in England aged 55 to 69 years were analyzed and followed-up to 90 years of age. Exposures: No screening, age-based screening, and risk-stratified screening in the hypothetical cohort. Age-based screening consisted of screening every 4 years with prostate-specific antigen between the ages of 55 and 69 years. Risk-stratified screening used age and polygenic risk profiles. Main Outcomes and Measures: The benefit-harm profile (deaths from prostate cancer, quality-adjusted life-years, overdiagnosis, and biopsies) and cost-effectiveness (net monetary benefit, from a health care system perspective) were analyzed. Both age-based and risk-stratified screening were evaluated using a biopsy-first and an MRI-first diagnostic pathway. Results were derived from probabilistic analyses and were discounted at 3.5% per annum. Results: The hypothetical cohort included 4.48 million men in England, ranging in age from 55 to 69 years (median, 62 years). Compared with biopsy-first age-based screening, MRI-first age-based screening was associated with 0.9% (1368; 95% uncertainty interval [UI], 1370-1409) fewer deaths from prostate cancer, 14.9% (12 370; 95% UI, 11 100-13 670) fewer overdiagnoses, and 33.8% (650 500; 95% UI, 463 200-907 000) fewer biopsies. At 10-year absolute risk thresholds of 2% and 10%, MRI-first risk-stratified screening was associated with between 10.4% (7335; 95% UI, 6630-8098) and 72.6% (51 250; 95% UI, 46 070-56 890) fewer overdiagnosed cancers, respectively, and between 21.7% fewer MRIs (412 100; 95% UI, 411 400-412 900) and 53.5% fewer biopsies (1 016 000; 95% UI, 1 010 000-1 022 000), respectively, compared with MRI-first age-based screening. The most cost-effective strategies at willingness-to-pay thresholds of £20 000 (US $26 000) and £30 000 (US $39 000) per quality-adjusted life-year gained were MRI-first risk-stratified screening at 10-year absolute risk thresholds of 8.5% and 7.5%, respectively. Conclusions and Relevance: In this decision analytical model of a hypothetical cohort, an MRI-first diagnostic pathway was associated with an improvement in the benefit-harm profile and cost-effectiveness of screening for prostate cancer compared with biopsy-first screening. These improvements were greater when using risk-stratified screening based on age and polygenic risk profile and may warrant prospective evaluation.

Quantitative magnetic resonance imaging for chronic liver disease.

Chronic liver disease (CLD) has rapidly increased in prevalence over the past two decades, resulting in significant morbidity and mortality worldwide. Historically, the clinical gold standard for diagnosis, assessment of severity, and longitudinal monitoring of CLD has been liver biopsy with histological analysis, but this approach has limitations that may make it suboptimal for clinical and research settings. Magnetic resonance (MR)-based biomarkers can overcome the limitations by allowing accurate, precise, and quantitative assessment of key components of CLD without the risk of invasive procedures. This review briefly describes the limitations associated with liver biopsy and the need for non-invasive biomarkers. It then discusses the current state-of-the-art for MRI-based biomarkers of liver iron, fat, and fibrosis, and inflammation.

Cost-effectiveness analysis of multiple imaging modalities in diagnosis and follow-up of intermediate complex cystic renal lesions.

OBJECTIVES: To compare health-economic aspects of multiple imaging modalities used to monitor renal cysts, the present study evaluates costs and outcomes of patients with Bosniak IIF and III renal cysts detected and followed-up by either contrast-enhanced computed tomography (ceCT), contrast-enhanced magnetic resonance imaging (ceMRI), or contrast-enhanced ultrasonography (CEUS). PATIENTS AND METHODS: A simulation using Markov models was implemented and performed with 10 cycles of 1 year each. Proportionate cohorts were allocated to Markov models by a decision tree processing specific incidences of malignancy and levels of diagnostic performance. Costs of imaging and surgical treatment were investigated using internal data of a European university hospital. Multivariate probabilistic sensitivity analysis was performed to confirm results considering input value uncertainties. Patient outcomes were measured in quality-adjusted life years (QALY), and costs as averages per patient including costs of imaging and surgical treatment. RESULTS: Compared to the 'gold standard' of ceCT, ceMRI was more effective but also more expensive, with a resulting incremental cost-effectiveness ratio (ICER) >€70 000 (Euro) per QALY gained. CEUS was dominant compared to ceCT in both Bosniak IIF and III renal cysts in terms of QALYs and costs. Probabilistic sensitivity analysis confirmed these results in the majority of iterations. CONCLUSION: Both ceMRI and CEUS can be used as alternatives to ceCT in the diagnosis and follow-up of intermediately complex cystic renal lesions without compromising effectiveness, while CEUS is clearly cost-effective. The economic results apply to a large university hospital and must be adapted for smaller hospitals.

Utility and value of pre-operative CT and MRI for cochlear implantation in the elderly.

PURPOSE: To determine the utility and value of pre-operative imaging among the elderly population ≥70 y.o. with bilateral progressive sensorineural hearing loss undergoing cochlear implantation. MATERIALS AND METHODS: A retrospective, cross-sectional review was performed at a tertiary referral center between 2010 and 2018 including patients ≥70 y.o. with bilateral presbycusis who underwent preoperative imaging and cochlear implantation. Primary outcome was whether pre-operative imaging changed the surgeon's surgical plan such as side of implant or abort procedure entirely. Patient characteristics including age, sex, side of implant, imaging modality, whether imaging changed surgical plan, and surgical complications were reviewed. One-way analysis of variance with post-hoc tests using the Bonferroni and Fisher's exact test were used to examine differences between groups. Secondary outcome was cost of preoperative imaging. RESULTS: One hundred thirty-three patients (mean age 79.38 [5.51 SD]) who underwent a total of 142 surgical cases and 147 total scans. There were 92, 27, and 14 patients who underwent CT, MRI, or both, respectfully (n=133). Of the 142 implants that were placed, preoperative imaging did not reveal a contraindication to placing implant on one side over another. Total cost of imaging was $29,694. Estimated cost if 20% of cochlear implant eligible patients ≥70 y.o. underwent imaging is $7,763,490. CONCLUSION: Decreasing unnecessary preoperative imaging can potentially decrease cost in cochlear implantation. In this sample, preoperative imaging did not affect the surgeon's choice of which side to operate on. However, imaging may provide an anatomic roadmap and contribute to either surgical confidence or caution. With the increasing amount of cochlear implant eligible elderly adults, preoperative imaging needs to be more clearly defined in this unique population.