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Newborns with suspected occult spinal dysraphism: a cost-effectiveness analysis of diagnostic strategies
L S Medina1, K Crone, K M Kuntz
1International Health Outcomes and Economics Center, and Division of Neuroradiology, Department of Radiology, Miami Children's Hospital, Miami, Florida 33155, USA. smedina@post.harvard.edu
Insights
Choosing the right diagnostic imaging for newborns with suspected occult spinal dysraphism is crucial. Ultrasound (US) is often cost-effective for low-risk cases, while magnetic resonance imaging (MRI) is preferred for higher-risk infants, optimizing outcomes and reducing costs.
Area of Science:
- Pediatric Radiology
- Medical Economics
- Diagnostic Imaging
Background:
- Occult spinal dysraphism (OSD) presents diagnostic challenges in newborns.
- Early diagnosis and intervention are critical for improving patient outcomes.
- Evaluating the cost-effectiveness of various diagnostic strategies is essential for resource allocation.
Purpose of the Study:
- To compare the clinical and economic impacts of different diagnostic approaches for newborns with suspected OSD.
- To determine the optimal imaging strategy based on patient risk stratification.
- To inform clinical decision-making regarding the use of MRI, US, plain radiographs, and no imaging.
Main Methods:
- A decision-analytic model was developed to simulate costs and health outcomes.
- Literature review provided data on morbidity, mortality, sensitivity, and specificity of imaging modalities.
- Hospital cost accounting and Medicaid fee schedules were used for cost estimations.
Main Results:
- Diagnostic strategy effectiveness varied by OSD risk. Ultrasound (US) was most effective for low-risk infants (intergluteal dimple, diabetic mothers).
- For intermediate-risk infants (low anorectal malformation), US was cost-effective, but MRI offered better outcomes at a higher incremental cost.
- In high-risk infants (high anorectal malformation, cloacal malformation, exstrophy), MRI was cost-saving. Cost and performance of MRI and US influenced strategy choice.
Conclusions:
- Selecting the appropriate diagnostic strategy and patient cohort for suspected OSD can enhance quality-adjusted life expectancy.
- Optimizing diagnostic work-up for OSD in newborns can lead to significant cost reductions.
- Clinical expertise with specific modalities like MRI or US may influence the optimal diagnostic pathway.
Objective:
To assess the clinical and economic consequences of different diagnostic strategies in newborns with suspected occult spinal dysraphism.
Methods:
A decision-analytic model was constructed to project the cost and health outcomes of magnetic resonance imaging (MRI), ultrasound (US), plain radiographs, and no imaging in newborns with suspected occult spinal dysraphism. Morbidity and mortality rates of early versus late diagnosis of dysraphism and the sensitivity and specificity of MRI, US, and plain radiographs were obtained from the literature. Cost estimates were obtained from a hospital cost accounting database and from the Medicaid fee schedule.
Results:
We found that the choice of imaging strategy depends on the underlying risk of occult spinal dysraphism. In low-risk children with intergluteal dimple or newborns of diabetic mothers (pretest probability: 0.3%-0.34%), US was the most effective strategy with an incremental cost-effectiveness ratio of $55 100 per quality-adjusted life year gained. For children with lumbosacral dimples, who have a higher pretest probability of 3.8%, US was less costly and more effective than the other 3 strategies considered. In intermediate-risk newborns with low anorectal malformation (pretest probability: 27%), US was more effective and less costly than radiographs and no imaging. However, MRI was more effective than US at an incremental cost-effectiveness of $1000 per quality-adjusted life year gained. In the high-risk group that included high anorectal malformation, cloacal malformation, and exstrophy (pretest probability: 44%-46%), MRI was actually cost-saving when compared with the other diagnostic strategies. For the intermediate-risk group, we found our analysis to be sensitive to the costs and diagnostic performances (sensitivity and specificity) of MRI and US. Lower MRI cost or greater MRI diagnostic performance improved the cost-effectiveness of the MRI strategy, whereas lower US cost or greater US diagnostic performance worsened the cost-effectiveness of the MRI strategy. Therefore, individual or institutional expertise with a specific diagnostic modality (MRI versus US) may influence the optimal diagnostic strategy.
Conclusions:
In newborns with suspected occult dysraphism, appropriate selection of patients and diagnostic strategy may increase quality-adjusted life expectancy and decrease cost of medical work-up.