Less is Not Always Better

This issue of Molecular Imaging Insight focuses on test accuracy, cost and outcomes—all very key topics in 2012.

The role of non-invasive cardiac imaging for determining the significance of coronary artery disease is discussed in the context of healthcare costs and effectiveness. Several modalities including SPECT and PET stress/rest myocardial perfusion imaging, coronary CT angiography (CCTA) and MRI accomplish this task. There are profound “cultural differences” in the use of these tools, with a much higher number of invasive angiographic assessments performed in Europe, but a much higher number of non-invasive tests completed in the U.S.

Diagnostic modalities should be used only if a significant impact on patient management and outcome can be documented. Such improvements need to be achieved at reasonable costs. Sometimes, the best approach is “doing more” as suggested by preliminary data from the EVINCI trial. The combination of CCTA with SPECT perfusion imaging was superior to and less expensive than other imaging strategies. Thus, what appears to be a less expensive strategy (the use of a single modality) might, in fact, turn out to be more expensive and less effective than a combination of two tests.

Such cost-effectiveness considerations also apply to the use of “more expensive” hybrid imaging technologies including SPECT/CT and PET/CT. SPECT/CT radio-iodine imaging of thyroid cancer patients has become routine in many clinics. Although SPECT/CT scanners are more expensive than SPECT systems, more accurate identification and localization of disease sites can result in improved outcomes and, by avoiding redundant exams, in reduced healthcare expenditures.

The Advanced Multimodality Image-Guided Operating suite at Brigham and Women’s Hospital in Boston is an example of an advanced integrated imaging approach for specialized academic institutions. One would assume that such approach cannot be cost-effective. However, when used to its best capabilities, this may result in improved management of patients with cardiovascular, oncological and neurological diseases, which might very well prove to be cost-effective. Intra-operative management of patients might markedly improve and so might that of patients undergoing targeted radiation interventions. Carefully designed prospective comparative studies will determine whether this approach will result in improved, cost-effective patient care.

We appreciate your readership, and any feedback is always welcome.