Accuracy and Cost US versus alternative

2 JDMS XX:xx–xx Month/Month XXXX

Background

The initial application of ultrasound (US) for medical imaging began in the early 1950s.1–4 Although its early use was primarily for cardiac and obstetrical applications, diagnostic ultrasound is now used routinely to image all parts of the body for the diagnosis and treatment of disease. Initially, US was used primarily in the hospital set-ting, but because of the development of less costly, portable equipment and the safe, nonionizing nature of ultrasound, it has expanded to physician offices, trauma settings, and even in space.5–9

Ultrasound (US) has become widely used in clinical medicine for the diagnosis of a variety of disease processes. The unique ability of US to provide accurate information through an effi-cacious, painless, portable, and nonionizing method has expanded its role and application in diverse medical settings. Given the current eco-nomic environment and the related interest in creating the greatest value for health care expenditures, US has been evaluated to com-pare its clinical accuracy/efficacy and cost- effectiveness versus other imaging modalities. The following literature review reports the results of research studies aimed at comparing the accuracy/efficacy and cost of US versus alternative imaging modalities, including mag-netic resonance imaging, computed tomogra-phy, contrast angiography, and single-photon emission computed tomography.

Key words: ultrasound, sonography, ultra-sonography, cost-effective, accuracy

Accuracy and Cost Comparison of Ultrasound Versus Alternative Imaging Modalities, Including CT, MR, PET, and AngiographyS. MICHELLE BIERIG, MPH, RDCS, FASE, FSDMS*

ANNE JONES, RN, BSN, RVT, RDMS, FSVU†

From *Saint Louis University, St Louis, Missouri, and †Severna Park, Maryland.

Correspondence: S. Michelle Bierig, St Louis University, 3635 Vista at Grand Ave FDT-14, St Louis, MO 63110. E-mail: [email protected].

DOI:10.1177/8756479309336240

Journal of Diagnostic Medical Sonography OnlineFirst, published on May 20, 2009 as doi:10.1177/8756479309336240

COMPARISON OF ULTRASOUND VS. ALTERNATE IMAGING MODALITIES / Bierig, Jones 3

The terms sonography and ultrasonography are often used synonymously with ultrasound, but the term ultrasound is the most widely used term in the published literature. This literature review uses the term ultrasound (US) because that term is overwhelmingly used in the references reflected in this article.

The expanded use of US for the diagnosis of a wide variety of abnormalities has translated into an increase in use of the technology. Although its rate of growth is the same as other medical services, this increased utilization has heightened the need to eval-uate the cost-effectiveness of US as an imaging strat-egy rather than to simply evaluate its utilization.10 Interestingly, the increase in spending by Medicare for alternative imaging services has been at a higher growth curve than the increase in the use of US.11 In addition, imaging technologies using magnetic reso-nance (MR) imaging, computed tomography (CT), contrast angiography (CA), and single-photon emis-sion computed tomography (SPECT) are often con-siderably more expensive, include radiation exposure, are less portable, or have an increased risk of compli-cations from contrast media.12

Quality patient care and cost-effectiveness are achieved through a variety of parameters, including patient outcomes, cost, efficiency, experience, pro-ductivity, and accuracy.13 The effective use of US has also been linked to having the US examinations performed by personnel who have demonstrated a minimal level of competency.14–17 While recogniz-ing the complexity of evaluation, this literature review evaluates the accuracy, efficacy, and/or cost- effectiveness components of US versus alternative imaging techniques by comparing the results of studies published in the past 5 years available through MEDLINE archiving. This summary out-lines the results of the literature review covering a variety of US specialties (obstetric, gynecological, abdominal, vascular, and cardiac) as well as the application of US in a variety of settings for diag-nosing specific diseases, including cancer.

Obstetric and Gynecologic

The National Institute of Child Health and Human Development has summarized evidence indicating

that US is the imaging method of choice for preg-nancy because of the “relatively lower cost, real-time capability, safety, and operator comfort and experience.”18 This reinforces current clinical prac-tice using US for obstetric evaluation, fetal monitor-ing, and diagnosis of abnormalities. In patients with bleeding in early pregnancy, US provides an optimal method to determine viability or ectopic location, as well as appropriate medical treatment.19 Alternative testing during pregnancy typically includes either invasive procedures or ionizing radiation, such as serial invasive amniocentesis testing for pregnancies complicated by Rh alloimmunization. US evalua-tion of blood flow in the fetal brain has been shown to be more accurate (85%) than amniotic fluid test-ing (76%). Therefore, in this application, noninva-sive US has been suggested to replace invasive testing in this situation.20

Gynecologic US applications evaluate patients with a variety of symptoms. Transvaginal US is a cost-minimizing screening tool for perimeno-pausal and postmenopausal women with vaginal bleeding.21 Its use decreases the need for invasive diagnostic procedures for women without abnor-malities, and US increases the sensitivity of detecting abnormalities in women with pathologic conditions. US is recommended as the initial imaging modality (rather than MR or X-ray) in the diagnosis of women with uterine tumors because it is the least invasive and most cost- effective imaging tool for this purpose.22 In patients with congenital abnormalities, 3D US is accurate for the diagnosis compared with hyst-eroscopy. Furthermore, it has been suggested that US may become the only necessary evaluation in patients with recurrent miscarriage.23

Abdominal

Imaging the abdomen with US allows for the evaluation and visualization of abnormalities in the abdominal aorta, liver, pancreas, kidney, adre-nal, gallbladder, stomach, and bowel. Patients suspected of having an abdominal aortic aneurysm (AAA) have been traditionally screened with US because of its nonionizing nature, accuracy, and efficiency. Randomized controlled trials have

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proved that not only is there mortality benefit from the use of US in this application, but the cost-ef-fectiveness also is approximately $19,500 per life year gained.24 Because US evaluation of AAA cor-responds so well to the gold standard (CT; r = 0.98), the recommendation has been accepted to use US as a standard method of screening patients suspected of AAA.25

Using a new type of US (endoscopic) in patients with gallstones over traditional X-ray imaging, an estimated 14% reduction in procedures could be seen with a 1-year cost savings of $66,014 per hospital.26 This type of US also reduces cost ($742 Canadian dollars per patient) of care in patients with severe acute biliary pancreatitis. In the non-severe cases of biliary pancreatitis, it may be asso-ciated with higher costs but fewer complications.27 In patients with acute cholecystitis, US has been shown to be more accurate (94%) than MR (71%) in detecting gallbladder thickening.28 In the evalu-ation of adrenal masses, US accuracy was found to be comparable (with a sensitivity and specificity of 100% and 82%) to CT and MRI.29 This study concluded that US may be the preferred imaging method because of the lower cost of ultrasound.

US provides an alternative to colonoscopy for the evaluation of colon cancer, with reported 100% sensitivity and specificity in diagnosis.30 When compared to MR and CT for diagnosing inflammatory bowel disease (IBD), US had simi-lar accuracy. Patients with IBD often require fre-quent reimaging, so it has been recommended that a nonionizing modality such as US be used to avoid excessive radiation exposure.31

Vascular

In addition to visualizing structure, US provides the added benefit of evaluating flow. This has made US invaluable for vascular applications evaluating venous and arterial flow. Large ran-domized clinical trials have determined that US methods can be as accurate in the diagnosis of disease as the more expensive imaging modalities. For example, in a comparison of patients with suspected venous thromboembolism (VTE), US was as sensitive and specific as CT,32 suggesting

that the less expensive imaging technology can be used without compromising patient safety. Literature reviews evaluating patients with deep vein thrombus conclude that US is the most fre-quently used diagnostic test because of its accu-racy and low cost.33 MR and CT may be used with the known shortfall of limited availability and increased cost.34

US is the initial imaging modality of choice when evaluating the upper extremity venous sys-tem. When US findings are equivocal or nondiag-nostic, particularly in evaluating the central deep veins, MR is the suggested second method of evalu-ation. US provides an accurate, rapid, low-cost, portable, noninvasive method for evaluation, map-ping, and surveillance of the upper extremity venous system.35 Cost-effectiveness modeling has been performed to evaluate the use of US in obtain-ing venous access. Studies indicate that US can avoid complications and save financial resources.36

In patients with peripheral arterial disease (PAD), US had higher cost effectiveness at a lower cost per quality-adjusted life year over MR, CT, and angiog-raphy.37 In addition, the use of US to detect periph-eral arterial occlusive disease has been found to be a cost-effective alternative to angiography.38 Recent studies in Europe on patients being evaluated for peripheral arterial disease indicated that MR and CT provide higher cost alternatives to US due to the fewer number of reimaging studies sometimes required, but no differences were found in patient outcomes or quality of life.39,40 US also provides an accurate assessment of peripheral vascular disease (PVD), especially in the setting of patients under-going interventions. US is often superior to angiog-raphy and MR in this diagnosis, and the use of US provides lower costs and significantly shortens the patient’s hospital stay.41

The use of US to evaluate patients with signs of cerebral ischemia due to significant carotid stenosis has been found to be cost-effective in determining the need for carotid endarterectomy. In one study, using MR only slightly increases the ability to make this determination but at a dispro-portionately higher cost.42 Furthermore, intraop-erative use of US in patients undergoing carotid endarterectomy is more cost-effective than either


angiography or no imaging ($397 vs. $841 vs. $721, respectively) while also resulting in lower rates of perioperative stroke and mortality.43

Cardiac (Echocardiography)

The use of cardiac US has been found to be a cost-effective and accurate imaging modality. Although some computer models have predicted that alternative imaging may be more cost- effective in the emergency department,44 this has not been found to be true in actual cost comparison studies. US has been shown to provide a cost savings of $900 per patient in patients presenting to the emer-gency department with chest pain.45 Furthermore, using stress echocardiography (SE) decreases the cost ($803) of evaluating patients when compared to SPECT ($1634) and angiography ($29,999).46 This finding has been reinforced when comparing SE to exercise electrocardiogram (ECG) testing in patients presenting to the emergency department with chest pain, showing that SE was more accu-rate, and the cost for detection of disease was less ($366 vs. $515) than using exercise ECG testing.47 Using echocardiography results in a shorter length of hospital stay (23 vs. 31 hours), resulting in lower costs ($1026 vs $1329).48 SE provides a more cost-effective testing strategy over exercise SPECT nuclear imaging in low-risk patients with suspected coronary disease.49 SE provides a lower cost per quality-adjusted life year ($31,500) when compared to exercise SPECT ($326,000) when screening patients for coronary artery disease.50 In addition, SE has been shown to be effective in predicting cardiac death as well as demonstrating good outcomes in patients with a normal examina-tion.51 Meta-analysis of published reports compar-ing ECG, SPECT, and SE to evaluate patients prior to surgery found that SE had the highest sen-sitivity (85%) and specificity (70%) for predicting perioperative cardiac death and nonfatal myocar-dial infarction. SE has the added benefit of being able to evaluate valvular and left ventricular dys-function.52 In patients with heart failure, the use of echocardiography for assessment of symptoms when compared to other diagnostic methods resulted in a cost reduction (up to €1083).53

In addition to SE applications evaluating isch-emia, transesophageal echocardiography (TEE) pro-vides the benefits of portability and real-time results. When evaluating patients for aortic dissection, TEE has been found to be equally as accurate as CT and MR imaging but with the added benefit of providing a more expeditious diagnosis and treatment.54

Emergency Application

Patients presenting with urgent symptoms often require immediate diagnosis and treatment. US provides greater accuracy in detecting lung contu-sion in patients with trauma when compared to chest X-ray. In addition, US is as accurate as CT while providing an easy and efficient way to make the diagnosis without moving the patient.55 US can be an effective tool in the diagnosis of pneumotho-rax and has been shown to be as accurate as lung CT while also providing additional information over X-ray pertaining to extension of disease.56 Due to the portability, lower cost, and lack of exposure to ionizing radiation, utilization of US has increased significantly in evaluating acute injury. Studies indicate that US lends itself well to quickly evaluating meniscal tears and that it cor-relates well with the traditional gold-standard imaging such as MR imaging.57

Disease Diagnosis

The cost-benefit of using US in diagnosing and evaluating abnormalities has been clearly demon-strated in a variety of applications. In patients with musculoskeletal disorders requiring evaluation, studies indicate that if US were used rather than MR imaging, this change would lead to a savings of more than $6.9 billion.58 When evaluating shoulder and elbow abnormalities, US is as reli-able as MR in detecting epicondylitis and tears.59 US provides the added benefit of being more read-ily available and cost-effective. Although US has a lower diagnostic sensitivity than MR for evalu-ating hand and foot arthritis, studies indicate that the lower cost and acceptable specificity of US justify its use for evaluating joints.60 In pediatric patients with hip dysplasia, patients receiving US


evaluation actually had a lower health cost ($1298 vs. $1488) when compared to those patients get-ting only clinical assessment.61

In a cost model evaluating detection and cure for patients with hyperparathyroidism, US resulted in lower cost ($6030) when compared to the use of SPECT ($7131) and bilateral neck exploration ($8384).62 Additional cost models suggest that more invasive biopsy methods cost more than US but provide increased accuracy.63 Further studies will be required to evaluate the cost-effectiveness of these modalities in clinical practice.

Cancer

US has been found to be comparable to MR for staging certain kinds of cancer. For example, when evaluating endometrial cancer, results suggest that because of the high cost of MR, it should only be used when US is nondiagnostic.64 US was found to be more cost-effective (€14,645) than scintigraphy (€19,922) and just as effective in detecting cancer in patients with Graves disease. Recommendations generated from studies evaluating this application included the use of US as the method of choice for diagnosis, and recommendations have been made that scintigraphy only be used in cases where US was not diagnostic.65 Other studies diagnosing and staging pancreatic cancer suggest that a combined CT and US approach may be the most effective, yielding the highest accuracy.66,67 In a meta-analysis of published articles evaluating patients with rectal cancer, US was found to be the most accu-rate imaging technology and was suggested for use in screening patients.68

Conclusion

US provides the ability to rapidly evaluate and diagnose abnormalities throughout the spectrum of clinical medicine. Its accuracy and cost-effectiveness in a variety of applications have led to its wide-spread adoption and use. The use of US compared to the use of alternative imaging methods leads to increased cost-efficiency in the diagnosis and man-agement of patients. Continued research and evalu-ation are required to provide optimization of patient

care through analysis of cost, efficiency, experi-ence, accuracy, disease states, and patient out-comes.

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Accuracy and Cost US versus alternative

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