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Evidence-based Practice |
1 From the Institute for Technology Assessment, Massachusetts General Hospital, Zero Emerson Place, Suite 2H, Boston, MA 02114 (P.M.M., G.S.G.); Doctoral Program in Health Policy, Harvard University, Cambridge, Mass (P.M.M., S.S.A., E.A.S.); Program on the Economic Evaluation of Medical Technology, Harvard Center for Risk Analysis, Cambridge, Mass (S.S.A., E.A.S., P.J.N.); and Harvard School of Public Health, Boston, Mass (P.J.N., G.S.G.). P.M.M. supported in part by the National Cancer Institute grant 1 R25 CA92203-01A1 and the National Library of Medicine grant 5 T-15 LM07092. P.M.M. and G.S.G. supported in part by the U.S. Department of the Army under DAMD grant 17-99-2-9001. Received July 24, 2002; revision requested September 18; revision received September 25; accepted October 25. Address correspondence to G.S.G. (e-mail: scott@mgh-ita.org).
PURPOSE: To evaluate the cost-effectiveness of positron emission tomography (PET) in the diagnosis of Alzheimer disease (AD) in community-dwelling patients with mild or moderate dementia who present to specialized AD centers.
MATERIALS AND METHODS: A decision-analytic model was used to compare costs and quality-adjusted life years (QALYs) associated with strategies involving single photon emission computed tomography (SPECT), dynamic susceptibility-weighted contrast material–enhanced magnetic resonance (MR) imaging, and PET as functional imaging adjuncts to the standard clinical work-up. Sensitivity analyses were performed to examine changes in test characteristics, health-related quality-of-life survey instruments, therapeutic effectiveness, and treatment rules.
RESULTS: The use of PET to confirm the results of the standard clinical work-up cost more but yielded fewer benefits than a strategy in which dynamic susceptibility-weighted contrast-enhanced MR imaging was substituted for the typically performed structural computed tomography. This relationship remained stable in scenarios in which standard diagnostic work-up accuracy, drug treatment effectiveness, and version of the Health Utilities Index were altered. Dynamic susceptibility-weighted contrast-enhanced MR imaging cost $598,800 per QALY gained (range, $74,400 to $1.9 million per QALY), compared with the cost of the standard diagnostic work-up. Treating all patients with dementia was the dominant imaging strategy, except when side effects in patients with non–AD-related dementia were modeled. In all scenarios, SPECT yielded fewer benefits than other strategies at a higher cost.
CONCLUSION: PET may have high diagnostic accuracy, but adding it to the standard diagnostic regimen at AD clinics would yield limited, if any, benefits at very high costs.
Index terms: Alzheimer disease, 10.83 • Brain, PET, 10.12163 • Cost-effectiveness • Dementia, 10.83 • Positron emission tomography (PET), 10.12163
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