Angiography for Diagnosing Peripheral Arterial Occlusive Disease
Table 2: Costs of a Peripheral Arterial Occlusive Disease Examination Cost Type
ce-MRA Excluding Consumables
Personnel Equipment Electricity Room, etc.
Administrative
Costs of ‘examination’ Costs ‘other’
Costs for consumables Investigation costs
Costs of technical failures* Total investigation cost
ce-MRA Including Consumables
22.71 22.71 65.48 65.48 4.15 4.15 0.16
0.16
10.00 10.00 102.49 40.00
Excluded 142.49 3.53
146.03
102.49 40.00 59.30
201.79 3.53
205.33
A cost comparison of nce-MRA/FBI and ce-MRA was performed using the example of radiological departments in German hospitals. This analysis shows lower investigation costs for ce-MRA in all scenarios evaluated compared with nce-MRA/FBI, the latter having typical acquisition times ranging from 12 to 32 minutes. Thus, cost differences of between €12 and €61 per examination were found in favour of ce-MRA when excluding costs for consumables. For German hospitals, for example, the differences in total costs for ce-MRA including consumables (list price of €59) and nce-MRA/FBI were found to be in range of +€47 to -€2.
When costs for technical failures – adding investigation costs for standard DSA – were also considered, differences of €17 and up to €118 were found in favour of ce-MRA (excluding consumables). Total individual costs, including local reimbursement practice for consumables, can easily be obtained by adding such costs as far as applicable. When considering maximum costs for consumables for our example, Germany, we found scenarios with cost savings in favour of nce-MRA/FBI of up to €42, but also scenarios with cost savings in favour of ce-MRA of up to €59.
The calculations presented above do not take into account the loss of income consequent upon the lower patient throughput that results from the longer occupation times when nce-MRA/FBI is used compared with ce-MRA. Many radiological departments (excluding research centres) operate their facilities with time windows of 20–40 minutes per patient. If the imaging of a patient with nce-MRA/FBI takes longer than this, fewer patients can be scheduled, and consequently fewer procedures can be reimbursed. The same holds true for repeated examinations. During a second examination the scanner is occupied once again; therefore, in terms of efficiency, more robust procedures are preferred in order to minimise the number of unwanted repetitions.
Our cost analysis has certain limitations. ce-MRA and nce-MRA/FBI have been treated as directly competing techniques, without contraindications being taken into account, Such contraindications would include intolerance to the contrast agent for ce-MRA, and arrhythmia or instability of the patient for nce-MRA/FBI. There are instances where nce-MRA techniques can be clinically advantageous or more cost-effective. For example, in patients at risk of NSF, nce- MRA may be the only clinical alternative. Almost one-third of the MRA studies are performed on patients with no clinically significant occlusive arterial disease, or in a population with a relatively low risk
EUROPEAN CARDIOLOGY
FBI
(12 minutes) 24.57 74.73 4.83 0.19
10.00
114.31 40.00 0.00
154.31 35.33
189.64
FBI
(22 minutes) 27.67 94.86 6.13 0.24
10.00
138.89 40.00 0.00
178.89 35.33
214.22 *20% of cases for non-contrast-enhanced magnetic resonance angiography/fresh blood imaging (nce-MRA/FBI) and 2% of cases for ce-MRA. All costs in €.
Figure 2: Investigation Costs for ce-MRA (with and without Costs for Consumables) and for nce-MRA/FBI with Various Acquisition Times
280 263.53 240 207.09 200 160 120
147.79 146.03 145.49
ce-MRA excluding consumables
ce-MRA including
consumables
The vertical lines represent the cost spreads due to technical failures (1–3% for contrast- enhanced magnetic resonance angiography [ce-MRA]; 6–34% for non-contrast-enhanced magnetic resonance angiography/fresh blood imaging [nce-MRA/FBI]).
of having PAOD. In those patients, nce-MRA may actually perform better in ruling out disease with fewer technical errors. These patient subgroups were not evaluated in our study. Some studies have shown that the sensitivity and specificity of ce-MRA, while good, is not as excellent as is often assumed. In a relatively large study of 400 subjects, Vasbinder et al.35
found that the sensitivity for detecting
renal artery disease is around 60% even for experienced physicians. These data would have an effect on the cost–benefit evaluation. On the one hand, Leiner and Schoenberg36
stated that “most important
contributors to the poor sensitivity were insufficient spatial resolution, motion artefacts due to long acquisition times and a large number of cases of fibromuscular dysplasia”. However, the spatial resolution improved significantly during the last few years. On the other hand, we focused on the peripheral artery occlusive disease and used high-quality clinical trials in this indication as the basis for estimating the diagnostic performance of ce- and nce-MRA. Several assumptions had to be made in the absence of published data. Acquisition times for nce-MRA/FBI have been reported in several publications as being three to eight minutes per sequence. However, personnel times can only be calculated on an indirect basis. We estimated that occupation times for the clinicians are comparable for nce-MRA/FBI and ce-MRA. nce-MRA/FBI does not require a clinician’s presence for placing the needle and supervision of the injection, but it might require more of the clinician’s time for reading the images. Once a procedure fails, DSA, as the reference standard,
59
FBI 12 minutes
FBI 22 minutes
FBI 32 minutes
205.33 204.79
189.64 214.37
164.91 238.95
214.22 189.49
238.80 214.07
FBI
(32 minutes) 30.78
114.98 7.43 0.29
10.00
163.47 40.00 0.00
203.47 35.33
238.80
Cost (€)
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