What is the most cost-effective neuroimaging option for patients presenting to an emergency department with dizziness?
For the study, recently published in the American Journal of Roentgenology, researchers utilized a Markov decision-analytic model to compare the cost-effectiveness of four neuroimaging modalities in the workup of patients presenting with dizziness who are not deemed to be in need of acute intervention. The four modalities included head and neck computed tomography angiography (CTA), non-contrast head computed tomography (CT), conventional brain magnetic resonance imaging (MRI) and specialized MRI, according to the study.
In comparison to non-contrast head CT, the study authors found that specialized MRI (including the use of multiplanar high resolution diffusion-weighted imaging) had a greater cost at $13,477 but the highest quality-adjusted life years (QALYs) at 0.48. The researchers added that conventional brain MRI offered 0.25 QALYs and an incremental cost of $6,756, and head and neck CTA provided 0.13 QALY and an incremental cost of $3,952.
“The findings indicate that when imaging is used to exclude stroke or to clarify a diagnosis for secondary prevention, MRI leads to better long-term outcomes and more cost-effective management. The difference in cost-effectiveness is largely driven by differences in the sensitivity of initial imaging; therefore, specialized high-sensitivity MRI protocols are preferred if feasible,” wrote study co-author Amit Mahajan, M.D., an associate professor of radiology and biomedical imaging at the Yale School of Medicine in New Haven, Ct., and colleagues.
The researchers also emphasized that the expense of long-term care after acute stroke is a significant cost driver in this patient population. However, sensitivity analyses with this study found that variables such as health status after dizziness from peripheral etiologies, age, degree of adherence to secondary stroke prevention measures and likelihood of progression to adverse events such as major stroke do not have an impact on imaging selection.
“MRI, and specialized MRI if possible, remains the optimal imaging choice,” maintained Mahajan and colleagues.
Three Key Takeaways
- Specialized MRI is the most cost-effective imaging for patients who present with dizziness. The study suggests that specialized MRI, particularly with multiplanar high-resolution diffusion-weighted imaging, is the most cost-effective neuroimaging option for patients presenting to an emergency department with dizziness, offering the highest quality-adjusted life years (QALYs) despite a higher upfront cost compared to other modalities.
- Potential long-term cost of care after acute stroke is a consideration in this patient population. Despite potential concerns about the cost of MRI, the study argues that the increased sensitivity of MRI, especially specialized MRI, may help prevent significant expenses related to long-term disability, making it a more cost-effective choice in the long run.
- MRI, particularly specialized MRI, is preferred for better outcomes. The researchers emphasize that, when imaging is used to exclude stroke or clarify a diagnosis for secondary prevention, MRI, and preferably specialized MRI, lead to better long-term outcomes and more cost-effective management. The sensitivity of initial imaging is a key factor, and the study recommends the use of specialized high-sensitivity MRI protocols if feasible.
While the study authors conceded a prevailing perception that MRI significantly contributes to extraneous costs in the assessment of dizziness, they noted that non-contrast brain MRI is over $200 less than head and neck CTA, and the increased sensitivity may help prevent significant expenses related to long-term disability.
“MRI as a stand-alone study can be loss costly in upfront expense as well as over the long-term if foregoing CT in favor of this more sensitive modality, while providing greater potential long-term health benefits,” noted Mahajan and colleagues.
In regard to study limitations, the authors noted that extrapolation of the study findings may be limited at facilities that don’t have urgent or consistent access to MRI. Mahajan and colleagues acknowledged that that the study findings were more reflective of conventional high-field MRI use and may not apply to emerging MRI technologies such as perfusion imaging, synthetic MRI sequences or portable MRI. The study also didn’t account for other less common etiologies for dizziness ranging from intracranial infection to demyelination, according to the study authors.