search text   Advanced Search

This Article Full Text Full Text (PDF) P3Rs: Submit a response P3Rs: View responses Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Medina, L. S. Articles by Kuntz, K. M. Search for Related Content PubMed Articles by Medina, L. S. Articles by Kuntz, K. M. Related Collections Musculoskeletal System

Newborns With Suspected Occult Spinal Dysraphism: A Cost-Effectiveness Analysis of Diagnostic Strategies

L. Santiago Medina, MD, MPH^*, Kerry Crone, MD and Karen M. Kuntz, ScD

^* International Health Outcomes and Economics Center, and Division of Neuroradiology, Department of Radiology, Miami Children’s Hospital, Miami, Florida
Department of Neurosurgery, Children’s Hospital Medical Center, Cincinnati, Ohio
Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts

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.

Conclusion. 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.

Key Words: cost-effectiveness analysis • occult spinal dysraphism • newborns • MRI • ultrasound

Abbreviations: MRI, magnetic resonance imaging • QALY, quality-adjusted life year • US, ultrasound • LE, life expectancy

P³Rs:

	Home | My Pediatrics | Journal Information | Current Issue | Past Issues | Subscriptions & Services | Contact Us Click here for faster international access © 2001 American Academy of Pediatrics. All rights reserved.