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1.
Pediatrics ; 144(6)2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31771961

RESUMO

In our state-of-the-art review, we summarize the best-available evidence for the optimal emergency department management of children with minor blunt head trauma. Minor blunt head trauma in children is a common reason for emergency department evaluation, although clinically important traumatic brain injuries (TBIs) as a result are uncommon. Cranial computed tomography (CT) scanning is the reference standard for the diagnosis of TBIs, although they should be used judiciously because of the risk of lethal malignancy from ionizing radiation exposure, with the greatest risk to the youngest children. Available TBI prediction rules can assist with CT decision-making by identifying patients at either low risk for TBI, for whom CT scans may safely be obviated, or at high risk, for whom CT scans may be indicated. For clinical prediction rules to change practice, however, they require active implementation. Observation before CT decision-making in selected patients may further reduce CT rates without missing children with clinically important TBIs. Future work is also needed to incorporate patient and family preferences into these decision-making algorithms when the course of action is not clear.


Assuntos
Serviço Hospitalar de Emergência , Traumatismos Cranianos Fechados/diagnóstico por imagem , Neuroimagem , Tomografia Computadorizada por Raios X , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Criança , Análise Custo-Benefício , Sistemas de Apoio a Decisões Clínicas , Diagnóstico Diferencial , Família , Humanos , Julgamento , Neuroimagem/economia , Tomografia Computadorizada por Raios X/economia
2.
Neuroimaging Clin N Am ; 29(2): 203-211, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30926111

RESUMO

One of the most common reasons that a patient seeks out a health care provider for a neuroscience-related issue is headache. Not all patients can, or probably should, be imaged with headache. We must use an approach that attends to scientific evidence, accepted guidelines, and available resources. This approach should focus on quality, safety, appropriateness, and utilization. This article reviews and discusses the consideration of imaging adult patients with headache.


Assuntos
Efeitos Psicossociais da Doença , Cefaleia/diagnóstico , Cefaleia/economia , Neuroimagem/economia , Neuroimagem/estatística & dados numéricos , Adulto , Humanos
3.
PLoS One ; 14(2): e0211599, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30707721

RESUMO

BACKGROUND: Neuroimaging for headaches is both common and costly. While the costs are well quantified, little is known about the benefit in terms of diagnosing pathology. Our objective was to determine the role of early neuroimaging in the identification of malignant brain tumors in individuals presenting to healthcare providers with headaches. METHODS: This was a retrospective cohort study using administrative claims data (2001-2014) from a US insurer. Individuals were included if they had an outpatient visit for headaches and excluded for prior headache visits, other neurologic conditions, neuroimaging within the previous year, and cancer. The exposure was early neuroimaging, defined as neuroimaging within 30 days of the first headache visit. A propensity score-matched group that did not undergo early neuroimaging was then created. The primary outcome was frequency of malignant brain tumor diagnoses and median time to diagnosis within the first year after the incident headache visit. The secondary outcome was frequency of incidental findings. RESULTS: 22.2% of 180,623 individuals had early neuroimaging. In the following year, malignant brain tumors were found in 0.28% (0.23-0.34%) of the early neuroimaging group and 0.04% (0.02-0.06%) of the referent group (P<0.001). Median time to diagnosis in the early neuroimaging group was 8 (3-19) days versus 72 (39-189) days for the referent group (P<0.001). Likely incidental findings were discovered in 3.17% (3.00-3.34%) of the early neuroimaging group and 0.66% (0.58-0.74%) of the referent group (P<0.001). CONCLUSIONS: Malignant brain tumors in individuals presenting with an incident headache diagnosis are rare and early neuroimaging leads to a small reduction in the time to diagnosis.


Assuntos
Neoplasias Encefálicas/diagnóstico por imagem , Cefaleia/diagnóstico por imagem , Neuroimagem/economia , Adolescente , Adulto , Idoso , Estudos de Coortes , Bases de Dados Factuais , Feminino , Cefaleia/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/diagnóstico por imagem , Neuroimagem/métodos , Exame Neurológico/métodos , Estudos Retrospectivos , Fatores de Tempo
5.
Pediatr Res ; 84(6): 799-806, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30315272

RESUMO

The aim is to review the evidence about the utility of term-equivalent age (TEA) magnetic resonance imaging (MRI) in predicting neurodevelopmental outcomes for preterm neonates. Preterm birth accounts for ~12% of all deliveries in the United States and is the leading cause of neurologic disabilities in children. From the neonatologist perspective, it is critically important to identify preterm infants at risk of subsequent neurodevelopmental disability who may benefit from early intervention services. However "the choose wisely campaign" also emphasizes the need to have ongoing cost/benefit discussions regarding care of preterm newborns to avoid waste that comes from subjecting infants to procedures that do not help. We performed a MEDLINE EMBASE database review from 2000 to 2018 to account for the technical evolution in the cranial ultrasound machines and introduction of MRI imaging in the NICU. Studies were graded based on the strength of their design using the GRADE guidelines and summarized with respect to brain MRI vs. cranial US (1) detection of white matter injury; (2) cerebellar hemorrhage; (3) long-term neurodevelopmental outcomes and impact on parental anxiety. We conclude with a hospital-specific guideline algorithm for performing TEA MRI based on risk evaluations ≤32 weeks.


Assuntos
Encéfalo/diagnóstico por imagem , Cerebelo/patologia , Imagem por Ressonância Magnética/métodos , Ultrassonografia/métodos , Algoritmos , Ansiedade , Lesões Encefálicas/diagnóstico por imagem , Hemorragia Cerebral/diagnóstico por imagem , Sistemas de Apoio a Decisões Clínicas , Custos de Cuidados de Saúde , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Doenças do Prematuro , Unidades de Terapia Intensiva Neonatal , Terapia Intensiva Neonatal , Imagem por Ressonância Magnética/economia , Transtornos do Neurodesenvolvimento , Neuroimagem/economia , Prognóstico , Risco , Ultrassonografia/economia , Estados Unidos , Substância Branca/lesões
6.
Neurocirugia (Astur) ; 29(6): 267-274, 2018.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-30145034

RESUMO

OBJECTIVE: to evaluate the results and costs of surgical treatment against endovascular in non ruptured aneurysms. MATERIAL AND METHODS: retrospective study of a consecutive series non ruptured aneurysms from a single-center treated endovascularly (EV) and surgically (SC). A descriptive study of demographic (age, sex) charqacteristics of the patients and the radiological aspects of the aneurysms have been carried out. Clinical results (GOS at 6 months), angiographic data (occlusion classification) and economic costs have been evaluated in both globally, and in each of the groups. RESULTS: 89 patients treated between 2010 and 2015 were reviewed. Most of them were treated endovascularly (74%). There were no statiscally significant differences between EV and SC groups. 89% of the patients presented favourable GOS (4-5) at six months, being this percentage similar in both groups. Complete occlusion was much higher in SC group (96%) than in EV (55%). Retreatment rate was 24% in EV group and 0% in SC group. The retreatments were more frequent in anterior circulation aneurysms and bigger aneurysms (> 10 mm). The expenses in the SC group come mainly from hospital stay, meanwhile in the EV group is due to embolisation materials. The average length of stay (ALOS) are higher in SC group but costs of first admission are higher in EV group (14% more). When the costs of retreatments and follow up are included the costs of endovascular treatment is much higher than the surgical (61% more expensive). CONCLUSIONS: results of both types of treatment are comparable. The grade of aneurysmal occlusion of the SC group was higher than the EV, as well as the stability of the treatment, requiring fewer retreatments. Althoug the ALOS in SC group were longer, the costs of the EV group were significantly higher than the SC group due to the costs of embolisation materials, follow up that they need and the rate of retreatment. Adequate selection of candidates for endovascular coiling could improve angiographic outcomes, reduce retraction rates, and save costs.


Assuntos
Craniotomia , Embolização Terapêutica , Procedimentos Endovasculares , Aneurisma Intracraniano/terapia , Adulto , Idoso , Cateteres/economia , Angiografia Cerebral/economia , Craniotomia/economia , Custos Diretos de Serviços , Embolização Terapêutica/economia , Embolização Terapêutica/instrumentação , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Achados Incidentais , Aneurisma Intracraniano/economia , Aneurisma Intracraniano/cirurgia , Tempo de Internação , Angiografia por Ressonância Magnética/economia , Masculino , Pessoa de Meia-Idade , Neuroimagem/economia , Estudos Retrospectivos , Espanha/epidemiologia , Stents/economia , Resultado do Tratamento
9.
Neurosciences (Riyadh) ; 23(2): 122-128, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29664453

RESUMO

OBJECTIVE: To determine the cost burden of Neuroimaging and its contribution to direct total hospitalization costs (HCs) during one-time admission for first-ever stroke. METHODS: The clinical characteristics, direct itemised costs and total HCs for 170 consecutive patients with first-ever stroke, admitted at our public tertiary health facility over a 15-month period were evaluated. RESULTS: The records of 170 stroke subjects were reviewed. The median total HCs for one-time admission per stroke patient was $183.30 with a median daily cost of $15.86. Median cost of radiological investigations was the highest among the categorized hospital costs. Among the radiological investigations, neuroimaging accounted for at least 99% of cost to patients. CONCLUSION: The financial burden of radiological investigations, particularly neuroimaging, is high during one-time admission of patients with first-ever stroke in our environment.


Assuntos
Custos Hospitalares , Neuroimagem/economia , Acidente Vascular Cerebral/diagnóstico por imagem , Idoso , Feminino , Humanos , Imagem por Ressonância Magnética/economia , Masculino , Pessoa de Meia-Idade , Nigéria , Admissão do Paciente/economia , Admissão do Paciente/estatística & dados numéricos , Radiografia/economia , Cintilografia/economia , Acidente Vascular Cerebral/economia
10.
BMC Med Inform Decis Mak ; 18(1): 20, 2018 03 12.
Artigo em Inglês | MEDLINE | ID: mdl-29530029

RESUMO

BACKGROUND: The frequency of head computed tomography (CT) imaging for mild head trauma patients has raised safety and cost concerns. Validated clinical decision rules exist in the published literature and on-line sources to guide medical image ordering but are often not used by emergency department (ED) clinicians. Using simulation, we explored whether the presentation of a clinical decision rule (i.e. Canadian CT Head Rule - CCHR), findings from malpractice cases related to clinicians not ordering CT imaging in mild head trauma cases, and estimated patient out-of-pocket cost might influence clinician brain CT ordering. Understanding what type and how information may influence clinical decision making in the ordering advanced medical imaging is important in shaping the optimal design and implementation of related clinical decision support systems. METHODS: Multi-center, double-blinded simulation-based randomized controlled trial. Following standardized clinical vignette presentation, clinicians made an initial imaging decision for the patient. This was followed by additional information on decision support rules, malpractice outcome review, and patient cost; each with opportunity to modify their initial order. The malpractice and cost information differed by assigned group to test the any temporal relationship. The simulation closed with a second vignette and an imaging decision. RESULTS: One hundred sixteen of the 167 participants (66.9%) initially ordered a brain CT scan. After CCHR presentation, the number of clinicians ordering a CT dropped to 76 (45.8%), representing a 21.1% reduction in CT ordering (P = 0.002). This reduction in CT ordering was maintained, in comparison to initial imaging orders, when presented with malpractice review information (p = 0.002) and patient cost information (p = 0.002). About 57% of clinicians changed their order during study, while 43% never modified their imaging order. CONCLUSION: This study suggests that ED clinician brain CT imaging decisions may be influenced by clinical decision support rules, patient out-of-pocket cost information and findings from malpractice case review. TRIAL REGISTRATION: NCT03449862 , February 27, 2018, Retrospectively registered.


Assuntos
Lesões Encefálicas/diagnóstico por imagem , Tomada de Decisão Clínica , Traumatismos Craniocerebrais/diagnóstico por imagem , Serviço Hospitalar de Emergência/normas , Imperícia , Neuroimagem/normas , Tomografia Computadorizada por Raios X/normas , Adulto , Lesões Encefálicas/economia , Canadá , Traumatismos Craniocerebrais/economia , Método Duplo-Cego , Serviço Hospitalar de Emergência/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neuroimagem/economia , Simulação de Paciente , Tomografia Computadorizada por Raios X/economia
11.
Pediatr Dermatol ; 35(1): 30-42, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29034507

RESUMO

Infants with a high-risk distribution of port-wine stains are commonly screened for Sturge-Weber syndrome using brain magnetic resonance imaging. There is no consensus about which port-wine stain phenotypes to screen, optimal timing, screening sensitivity, or whether presymptomatic diagnosis improves neurodevelopmental outcomes. This state-of-the-art review examines the evidence in favor of screening for Sturge-Weber syndrome, based on its effect on neurodevelopmental outcomes, against the risks and limitations of screening magnetic resonance imaging and electroencephalography. A literature search of PubMed/MEDLINE was conducted between January 2005 and May 2017 using key search terms. Relevant articles published in English were reviewed; 34 articles meeting the search criteria were analyzed according to the following outcome measures: neurodevelopmental outcome benefit of screening, diagnostic yield, financial costs, procedural risks, and limitations of screening magnetic resonance imaging and electroencephalography. There is no evidence that a presymptomatic Sturge-Weber syndrome diagnosis with magnetic resonance imaging results in better neurodevelopmental outcomes. The utility of electroencephalographic screening is also unestablished. In Sturge-Weber syndrome, neurodevelopmental outcomes depend on prompt recognition of neurologic red flags and early seizure control. Small numbers and a lack of prospective randomized controlled trials limit these findings. For infants with port-wine stain involving skin derived from the frontonasal placode (forehead and hemifacial phenotypes), we recommend early referral to a pediatric neurologist for parental education, counselling, and monitoring for neurologic red flags and seizures and consideration of electroencephalography regardless of whether magnetic resonance imaging is performed or its findings.


Assuntos
Eletroencefalografia/métodos , Imagem por Ressonância Magnética/métodos , Programas de Rastreamento/métodos , Mancha Vinho do Porto/etiologia , Síndrome de Sturge-Weber/diagnóstico , Encéfalo/patologia , Eletroencefalografia/economia , Humanos , Lactente , Imagem por Ressonância Magnética/economia , Programas de Rastreamento/economia , Neuroimagem/economia , Neuroimagem/métodos , Convulsões/diagnóstico , Convulsões/tratamento farmacológico , Convulsões/etiologia
14.
Neuro Oncol ; 19(9): 1271-1278, 2017 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-28204572

RESUMO

Background: Conventional MRI is the standard method to diagnose recurrence of brain metastases after radiation. However, following radiation therapy, reactive transient blood-brain barrier alterations with consecutive contrast enhancement can mimic brain metastasis recurrence. Recent studies have suggested that O-(2-18F-fluoroethyl)-L-tyrosine (FET) PET improves the correct differentiation of brain metastasis recurrence from radiation injury. Based on published evidence and clinical expert opinion, we analyzed effectiveness and cost-effectiveness of the use of FET PET in addition to MRI compared with MRI alone for the diagnosis of recurrent brain metastases. Methods: A decision-tree model was designed to compare the 2 diagnostic strategies from the perspective of the German Statutory Health Insurance (SHI) system. Effectiveness was defined as correct diagnosis of recurrent brain metastasis and was compared between FET PET with MRI and MRI alone. Costs were calculated for a baseline scenario and for a more expensive scenario. Robustness of the results was tested using sensitivity analyses. Results: Compared with MRI alone, FET PET in combination with MRI increases the rate of correct diagnoses by 42% (number needed to diagnose of 3) with an incremental cost-effectiveness ratio of €2821 (baseline scenario) and €4014 (more expensive scenario) per correct diagnosis. The sensitivity analyses confirmed the robustness of the results. Conclusions: The model suggests that the additional use of FET PET with conventional MRI for the diagnosis of recurrent brain metastases may be cost-effective. Integration of FET PET has the potential to avoid overtreatment with corresponding costs as well as unnecessary side effects.


Assuntos
Neoplasias Encefálicas/diagnóstico por imagem , Neoplasias Encefálicas/secundário , Recidiva Local de Neoplasia/diagnóstico por imagem , Neuroimagem/métodos , Tomografia por Emissão de Pósitrons/economia , Análise Custo-Benefício , Árvores de Decisões , Radioisótopos de Flúor , Humanos , Neuroimagem/economia , Tomografia por Emissão de Pósitrons/métodos , Compostos Radiofarmacêuticos
15.
J Pediatr ; 173: 76-83.e1, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-26995699

RESUMO

OBJECTIVE: To quantify intercenter cost variation for perinatal hypoxic ischemic encephalopathy (HIE) treated with therapeutic hypothermia across children's hospitals. STUDY DESIGN: Prospectively collected data from the Children's Hospitals Neonatal Database and Pediatric Health Information Systems were linked to evaluate intercenter cost variation in total hospitalization costs after adjusting for HIE severity, mortality, length of stay, use of extracorporeal support or nitric oxide, and ventilator days. Secondarily, costs for intensive care unit bed, electroencephalography (EEG), and laboratory and neuroimaging testing were also evaluated. Costs were contextualized by frequency of favorable (survival with normal magnetic resonance imaging) and adverse (death or need for gastric tube feedings at discharge) outcomes to identify centers with relative low costs and favorable outcomes. RESULTS: Of the 822 infants with HIE treated with therapeutic hypothermia at 19 regional neonatal intensive care units, 704 (86%) survived to discharge. The median cost/case for survivors was $58 552 (IQR $32 476-$130 203) and nonsurvivors $29 760 (IQR $16 897-$61 399). Adjusting for illness severity and select interventions, intercenter differences explained 29% of the variation in total hospitalization costs. The widest cost variability across centers was EEG use, although low cost and favorable outcome centers ranked higher with regards to EEG costs. CONCLUSIONS: There is marked intercenter cost variation associated with treating HIE across regional children's hospitals. Our investigation may help establish references for cost and enhance quality improvement and resource utilization projects related to HIE.


Assuntos
Custos Hospitalares/estatística & dados numéricos , Hospitalização/economia , Hipotermia Induzida/economia , Hipóxia-Isquemia Encefálica/economia , Bases de Dados Factuais , Eletroencefalografia/economia , Feminino , Hospitais Pediátricos , Humanos , Hipóxia-Isquemia Encefálica/epidemiologia , Hipóxia-Isquemia Encefálica/terapia , Recém-Nascido , Unidades de Terapia Intensiva Neonatal/economia , Masculino , Neuroimagem/economia , Admissão do Paciente/estatística & dados numéricos , Estados Unidos/epidemiologia
16.
PLoS One ; 11(2): e0148106, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26840397

RESUMO

BACKGROUND: Thrombolytic treatment (tissue-type plasminogen activator [tPA]) is only recommended for acute ischemic stroke patients with stroke onset time <4.5 hours. tPA is not recommended when stroke onset time is unknown. Diffusion-weighted MRI (DWI) and fluid attenuated inversion recovery (FLAIR) MRI mismatch information has been found to approximate stroke onset time with some accuracy. Therefore, we developed a micro-simulation model to project health outcomes and costs of MRI-based treatment decisions versus no treatment for acute wake-up stroke patients. METHODS AND FINDINGS: The model assigned simulated patients a true stroke onset time from a specified probability distribution. DWI-FLAIR mismatch estimated stroke onset <4.5 hours with sensitivity and specificity of 0.62 and 0.78, respectively. Modified Rankin Scale (mRS) scores reflected tPA treatment effectiveness accounting for patients' true stroke onset time. Discounted lifetime costs and benefits (quality-adjusted life years [QALYs]) were projected for each strategy. Incremental cost-effectiveness ratios (ICERs) were calculated for the MRI-based strategy in base-case and sensitivity analyses. With no treatment, 45.1% of simulated patients experienced a good stroke outcome (mRS score 0-1). Under the MRI-based strategy, in which 17.0% of all patients received tPA despite stroke onset times >4.5 hours, 46.3% experienced a good stroke outcome. Lifetime discounted QALYs and costs were 5.312 and $88,247 for the no treatment strategy and 5.342 and $90,869 for the MRI-based strategy, resulting in an ICER of $88,000/QALY. Results were sensitive to variations in patient- and provider-specific factors such as sleep duration, hospital travel and door-to-needle times, as well as onset probability distribution, MRI specificity, and mRS utility values. CONCLUSIONS: Our model-based findings suggest that an MRI-based treatment strategy for this population could be cost-effective and quantifies the impact that patient- and provider-specific factors, such as sleep duration, hospital travel and door-to-needle times, could have on the optimal decision for wake-up stroke patients.


Assuntos
Modelos Econômicos , Modelos Neurológicos , Neuroimagem/economia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/terapia , Neuroimagem/métodos
17.
Neurology ; 85(18): 1614-22, 2015 Nov 03.
Artigo em Inglês | MEDLINE | ID: mdl-26446063

RESUMO

OBJECTIVE: To determine the availability, accessibility, and affordability of EEG, EMG, CSF analysis, head CT, and brain MRI for neurologic disorders across countries. METHODS: An online, 60-question survey was distributed to neurology practitioners in 2014 to assess the presence, wait time, and cost of each test in private and public health sectors. Data were stratified by World Bank country income group. Affordability was calculated with reference to the World Health Organization's definition of catastrophic health expenditure as health-related out-of-pocket expenditure of >40% of disposable household income, and assessment of providers' perceptions of affordability to the patient. RESULTS: Availability of EEG and EMG is correlated with higher World Bank income group (correlation coefficient 0.38, test for trend p = 0.046; 0.376, p = 0.043); CSF, CT, and MRI did not show statistically significant associations with income groups. Patients in public systems wait longer for neurodiagnostic tests, especially MRI, EEG, and urgent CT (p < 0.0001). The mean cost per test, across all tests, was lower in the public vs private sector (US $55.25 vs $214.62, p < 0.001). Each drop in World Bank income group is associated with a 29% decrease in the estimated share of the population who can afford a given test (95% confidence interval -33.4, 25.2; p < 0.001). In most low-income countries surveyed, only the top 10% or 20% of the population was able to afford tests below catastrophic levels. In surveyed lower-middle-income countries, >40% of the population, on average, could not afford neurodiagnostic tests. CONCLUSIONS: Neurodiagnostic tests are least affordable in the lowest income settings. Closing this "diagnostic gap" for countries with the lowest incomes is essential.


Assuntos
Técnicas de Diagnóstico Neurológico/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Imagem por Ressonância Magnética/estatística & dados numéricos , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Líquido Cefalorraquidiano , Técnicas de Diagnóstico Neurológico/economia , Eletroencefalografia/economia , Eletroencefalografia/estatística & dados numéricos , Gastos em Saúde , Acesso aos Serviços de Saúde/economia , Humanos , Renda , Imagem por Ressonância Magnética/economia , Neuroimagem/economia , Neuroimagem/estatística & dados numéricos , Setor Privado/economia , Setor Privado/estatística & dados numéricos , Setor Público/economia , Setor Público/estatística & dados numéricos , Punção Espinal/economia , Punção Espinal/estatística & dados numéricos , Inquéritos e Questionários , Tomografia Computadorizada por Raios X/economia , Nações Unidas , Organização Mundial da Saúde
18.
AJR Am J Roentgenol ; 204(4): 804-9, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25794070

RESUMO

OBJECTIVE: Targeting redundancy within MRI can improve its cost-effective utilization. We sought to quantify potential redundancy in our brain MRI protocols. MATERIALS AND METHODS: In this retrospective review, we aggregated 207 consecutive adults who underwent brain MRI and reviewed their medical records to document clinical indication, core diagnostic information provided by MRI, and its clinical impact. Contributory imaging abnormalities constituted positive core diagnostic information whereas absence of imaging abnormalities constituted negative core diagnostic information. The senior author selected core sequences deemed sufficient for extraction of core diagnostic information. For validating core sequences selection, four readers assessed the relative ease of extracting core diagnostic information from the core sequences. Potential redundancy was calculated by comparing the average number of core sequences to the average number of sequences obtained. RESULTS: Scanning had been performed using 9.4±2.8 sequences over 37.3±12.3 minutes. Core diagnostic information was deemed extractable from 2.1±1.1 core sequences, with an assumed scanning time of 8.6±4.8 minutes, reflecting a potential redundancy of 74.5%±19.1%. Potential redundancy was least in scans obtained for treatment planning (14.9%±25.7%) and highest in scans obtained for follow-up of benign diseases (81.4%±12.6%). In 97.4% of cases, all four readers considered core diagnostic information to be either easily extractable from core sequences or the ease to be equivalent to that from the entire study. With only one MRI lacking clinical impact (0.48%), overutilization did not seem to contribute to potential redundancy. CONCLUSION: High potential redundancy that can be targeted for more efficient scanner utilization exists in brain MRI protocols.


Assuntos
Encefalopatias/diagnóstico , Imagem por Ressonância Magnética/métodos , Neuroimagem/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Imagem por Ressonância Magnética/economia , Imagem por Ressonância Magnética/instrumentação , Masculino , Pessoa de Meia-Idade , Neuroimagem/economia , Neuroimagem/instrumentação , Estudos Retrospectivos
19.
PLoS One ; 10(2): e0118155, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25723558

RESUMO

OBJECTIVE: Neuroimaging is an important diagnostic tool in the assessment of neurological disease, but often unmasks Incidental Findings (IFs). The negative impacts of IFs, such as 'patient' anxiety, present neurologists with management dilemmas, largely due to the limited knowledge base surrounding the medical significance of these IFs. In particular, the lack of evidence-based clinical trials investigating the efficacy of treatments for subclinical IFs makes management protocols challenging. The objective was to determine the impact IFs may have on neurologists' workloads and healthcare budgets and to examine neurologists' concerns regarding the clinical management of these 'patients'. METHODS: Qualitative research based on constructivist grounded theory. Data was collected through semi-structured interviews of purposively sampled neurologists, coded, and concurrent comparative analysis performed. A substantive theory of the 'IF impacts' was developed after concept saturation. RESULTS: Neurologists managed the escalating workload caused by an increased number of referrals of 'patients' with IFs found during neuroimaging; however it was unclear whether this was sustainable in the future. Neurologists experienced IF management dilemmas and spent more time with 'patients' affected by anxiety. The lack of information provided to those undergoing neuroimaging by the referring clinician regarding the possibility of discovering IFs was highlighted. CONCLUSION: The impact of IFs upon the neurologist, 'patient' and the health institution appeared considerable. Further research determining the natural history of subclinical IFs and the efficacy of intervention will help to alleviate these issues.


Assuntos
Achados Incidentais , Neuroimagem/estatística & dados numéricos , Neurologia/estatística & dados numéricos , Carga de Trabalho/estatística & dados numéricos , Adulto , Idoso , Humanos , Pessoa de Meia-Idade , Neuroimagem/economia , Neurologia/economia , Neurologia/métodos , Carga de Trabalho/economia
20.
Neurosurgery ; 76(1): 1-5; quiz 6, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25255253

RESUMO

Multiple national initiatives seek to curb spending to address increasing healthcare costs in the United States. The Choosing Wisely initiative is a popular initiative that focuses on reducing healthcare spending by setting guidelines to limit tests and procedures requested by patients and ordered by physicians. To reduce spending on neuroimaging, the Choosing Wisely initiative and other organizations have offered guidelines to limit neuroimaging for headaches. Although the intentions are laudable, these guidelines are inconsistent with the neurosurgeon's experience with patients with brain tumor. If adopted by governing or funding organizations, these guidelines threaten to negatively affect the care and outcomes of patients with brain tumors, who frequently present with minimal symptoms or isolated headaches syndromes. As physicians grapple with the difficult conflict between evidence-based cost-cutting guidelines and individualized patient-tailored medicine, they must carefully balance the costs and benefits of discretionary services such as neuroimaging for headaches. By participating in the development of validated clinical decision rules on neuroimaging for headaches, neurosurgeons can advocate for their patients and improve their patients' outcomes.


Assuntos
Neoplasias Encefálicas/diagnóstico , Cefaleia/etiologia , Neuroimagem , Neoplasias Encefálicas/complicações , Controle de Custos , Humanos , Neuroimagem/economia , Seleção de Pacientes , Papel do Médico , Guias de Prática Clínica como Assunto , Estados Unidos
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