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Objective: To evaluate the clinical performance and financial costs of breast-specific gamma imaging (BSGI) as a biopsy-reducing problem-solving strategy in patients with inconclusive diagnostic imaging findings., Methods: A retrospective analysis of all patients for whom BSGI was utilized for inconclusive imaging findings following complete diagnostic mammographic and sonographic evaluation between January 2013 and December 2018 was performed. Positive BSGI findings were correlated and biopsied with either US or stereotactic technique with confirmation by clip location and pathology. After a negative BSGI result, patients were followed for a minimum of 24 months or considered lost to follow-up and excluded (22 patients). Results of further imaging studies, biopsies, and pathology results were analyzed. Net savings of avoided biopsies were calculated based on average Medicare charges., Results: Four hundred and forty female patients from 30 to 95 years (mean 55 years) of age were included in our study. BSGI demonstrated a negative predictive value (NPV) of 98.4% (314/319) and a positive predictive value for biopsy of 35.5% (43/121). The overall sensitivity was 89.6% (43/48), and the specificity was 80.1% (314/392). In total, 78 false positive but only 5 false negative BSGI findings were identified. Six hundred and twenty-one inconclusive imaging findings were analyzed with BSGI and a total of 309 biopsies were avoided. Estimated net financial savings from avoided biopsies were $646 897., Conclusion: In the management of patients with inconclusive imaging findings on mammography or ultrasonography, BSGI is a problem-solving imaging modality with high NPV that helps avoid costs of image-guided biopsies., (© Society of Breast Imaging 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Introduction: Accurate localisation of the abnormal hyperfunctioning gland with preoperative imaging has a critical role in parathyroid surgery to obtain a successful outcome. This study aimed to evaluate the diagnostic performance of second-line imaging and their contribution to the treatment success in primary hyperparathyroidism when the first-line methods were negative or discordant., Methods: Among the patients who underwent parathyroidectomy due to primary hyperparathyroidism, 33 who underwent four-dimensional computed tomography and/or four-dimensional magnetic resonance imaging because of negative or discordant first-line imaging results were included. Persistent and recurrent cases were excluded., Results: The majority of the patients were female (84.8%) and the mean age was 59.2 years. Seventeen patients had four-dimensional computed tomography and 25 had four-dimensional magnetic resonance imaging, respectively. Four-dimensional computed tomography and four-dimensional magnetic resonance imaging localised the culprit gland successfully in 52.9% and 84%, respectively. Twenty-five patients in whom single adenoma was detected underwent focused parathyroidectomy. The culprit gland was solitary in 32 cases and one patient had double adenoma. Normocalcaemia was achieved in all cases. Among the 29 patients who completed their postoperative sixth month success rate was 100%., Conclusion: Four-dimensional magnetic resonance imaging had high accuracy with fast dynamic imaging in detecting parathyroid adenomas. When the first-line imaging methods were negative or inconclusive, four-dimensional magnetic resonance imaging should be considered primarily since it is cost effective in Turkey and emits no radiation.

Background: In adults, there is a consensus for standards to diagnose gastroparesis utilizing a gastric emptying study as the key diagnostic modality but there is no consensus for a standard in pediatrics. Additionally, some cost savings might be achieved if symptoms could be utilized to predict patients with gastroparesis. The aims of the current study were to confirm the sensitivity of a 4 h study in the pediatric population and to assess whether the severity of symptoms were predictive of delayed gastric emptying., Study: This was a single site, two part study. In the first part, results were reviewed for all patients who had completed a 4-h, solid gastric emptying study over the course of a 3 year period. In the second portion of the study, participants scheduled for a gastric emptying study, completed a modified GCSI questionnaire., Results: Out of a total of 109 participants, at 2 h, 14 participants (12.8%) had abnormal studies as compared to 26 (23.85%) participants who had abnormal studies at 4 h (p = .0027). Of the 95 participants with normal studies at 2 h, 15% (14/95) were abnormal at 4 h. There were no differences in symptom severity scores between those with slow and those with normal emptying at either 2 h or 4 h., Conclusions: Our study adds independent confirmation that extending studies from 2 to 4 h increases the diagnostic yield and should be the standard in children and adolescents as it is in adults.

Objective: To determine the cost burden of Neuroimaging and its contribution to direct total hospitalization costs (HCs) during one-time admission for first-ever stroke., Methods: The clinical characteristics, direct itemised costs and total HCs for 170 consecutive patients with first-ever stroke, admitted at our public tertiary health facility over a 15-month period were evaluated., Results: The records of 170 stroke subjects were reviewed. The median total HCs for one-time admission per stroke patient was $183.30 with a median daily cost of $15.86. Median cost of radiological investigations was the highest among the categorized hospital costs. Among the radiological investigations, neuroimaging accounted for at least 99% of cost to patients., Conclusion: The financial burden of radiological investigations, particularly neuroimaging, is high during one-time admission of patients with first-ever stroke in our environment.

Introduction: Sentinel lymph node (SLN) biopsy is currently the gold standard of treatment in early breast cancers. Identification of SLNs by preoperative scintigraphy has been carried out to improve the detection of SLNs intraoperatively, but the evidence of its cost-effectiveness is lacking. Here, we analyze the cost-effectiveness of the utilization of scintigraphy in detection of SLNs., Patients and Methods: Clinical and operative details were retrieved from a prospectively maintained database. The resources and cost data from each patient who had undergone SLN biopsy with preoperative scintigraphy were retrieved., Results: From January 2008 to December 2012, 400 patients underwent SLN biopsy for breast cancer. A total of 329 had preoperative SLN mapping with scintigraphy, Baseline patient demographic data for both arms were comparable. The relapse and recurrence rate of both arms were not statistically different. The detection rate of SLNs of both arms was the same (100%), and there were no grade 2 or above lymphedema in both groups of patients. However, the cost of each patient undergoing SLN mapping was USD $345.8., Conclusion: Preoperative SLN mapping does not improve the SLN detection rate. In addition, it does not affect the surgical outcomes in terms of complication, local relapse, and recurrence. The use of preoperative SLN mapping is no longer cost-effective., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: The use of thyrotropin (TSH) in the initial assessment of thyroid nodules is inefficient and leads to unnecessary assessment costs. We compared the total costs of thyroid nodule assessment with or without the use of TSH in the initial assessment., Methods: A total of 1808 patients with thyroid nodules received TSH, fine-needle aspiration (FNA) and thyroid scintigraphy (TS) assessment, including 83 autonomously functioning thyroid nodule (AFTN) cases and 1725 non-AFTN cases. The total costs of the TSH strategy and non-TSH strategies were compared. The ratio of single-use costs of FNA to TS (C FNA / TS ) was used as the main outcome measure., Results: Only when 6·03 ≤ C FNA / TS ≤ 27·17, the lowest total costs were associated with using the conventional TSH strategy. When C FNA / TS <6·03 or C FNA / TS >27·17, the lowest costs were found with FNA and TS, respectively., Conclusion: From the perspective of cost economics, in iodine-sufficient areas, we recommend that the decision on the use of TSH for the initial assessment of thyroid nodules should be based on the testing costs of FNA and TS in that medical unit., (© 2016 John Wiley & Sons Ltd.)

Purpose: To determine the financial implications of switching technetium (Tc)-99m mercaptoacetyltriglycine (MAG-3) to Tc-99m diethylene triamine penta-acetic acid (DTPA) at certain renal function thresholds before renal scintigraphy., Methods: Institutional review board approval was obtained, and informed consent was waived for this HIPAA-compliant, retrospective, cohort study. Consecutive adult subjects (27 inpatients; 124 outpatients) who underwent MAG-3 renal scintigraphy, in the period from July 1, 2012 to June 30, 2013, were stratified retrospectively by hypothetical serum creatinine and estimated glomerular filtration rate (eGFR) thresholds, based on pre-procedure renal function. Thresholds were used to estimate the financial effects of using MAG-3 when renal function was at or worse than a given cutoff value, and DTPA otherwise. Cost analysis was performed with consideration of raw material and preparation costs, with radiotracer costs estimated by both vendor list pricing and proprietary institutional pricing. The primary outcome was a comparison of each hypothetical threshold to the clinical reality in which all subjects received MAG-3, and the results were supported by univariate sensitivity analysis., Results: Annual cost savings by serum creatinine threshold were as follows (threshold given in mg/dL): $17,319 if ≥1.0; $33,015 if ≥1.5; and $35,180 if ≥2.0. Annual cost savings by eGFR threshold were as follows (threshold given in mL/min/1.73 m(2)): $21,649 if ≤60; $28,414 if ≤45; and $32,744 if ≤30. Cost-savings inflection points were approximately 1.25 mg/dL (serum creatinine) and 60 mL/min/1.73m(2) (eGFR). Secondary analysis by proprietary institutional pricing revealed similar trends, and cost savings of similar magnitude. Sensitivity analysis confirmed cost savings at all tested thresholds., Conclusions: Reserving MAG-3 utilization for patients who have impaired renal function can impart substantial annual cost savings to a radiology department., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Technetium-99m dimercaptosuccinic acid (DMSA) scans are often used in the evaluation of pediatric patients with febrile urinary tract infections (UTIs). Given the prevalence of febrile UTIs, we sought to quantify the cost, radiation exposure, and clinical utility of DMSA scans when compared with dedicated pediatric renal ultrasounds (RUSs)., Materials and Methods: An institutional review board approved retrospective study of children under the age of 18 years evaluated at our institution for febrile UTIs between the years 2004-2013 was conducted. The patients had to meet all of the following inclusion criteria: a diagnosis of vesicoureteral reflux, a fever >38°C, a positive urine culture, and evaluation with a DMSA scan and RUS. A chart review was used to construct a cost analysis of technical and professional fees, radiographic results, and radiation dose equivalents., Results: Overall, 104 children met the inclusion criteria. A total of 122 RUS and 135 DMSA scans were performed. The technical costs of a DMSA scan incurred a 35% cost premium as compared to an RUS. The average effective radiation dose of a single DMSA scan was 2.84 mSv. New radiographic findings were only identified on 7% of those patients who underwent greater than 1 DMSA scan., Conclusions: The utility of the unique information acquired from a DMSA scan as compared to a RUS in the evaluation of febrile UTI must be evaluated on an individual case-by-case basis given the increased direct costs and radiation exposure to the patient., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The prevalence and cost of unnecessary advanced imaging studies (AIS) in the evaluation of long bone cartilaginous lesions have not been studied previously., Methods: A total of 105 enchondromas and 19 chondrosarcomas arising in long bones from July 2008 until April 2012 in 121 patients were reviewed. Advanced imaging was defined as MRI, CT, bone scan, skeletal survey, or CT biopsy. Two blinded radiologists independently reviewed the initial imaging study and determined if further imaging was indicated based on that imaging study alone. The cost of imaging was taken from our institution's global charge list. Imaging was deemed unnecessary if it was not recommended by our radiologists after review of the initial imaging study. The difference in cost was calculated by subtracting the cost of imaging recommended by each radiologist from the cost of unnecessary imaging. The sensitivity and specificity for distinguishing enchondromas from chondrosarcomas was calculated. A minimum of 2 years from diagnosis of an enchondroma was required to monitor for malignant transformation., Results: Of patients diagnosed with an enchondroma, 85 % presented with AIS. The average enchondroma patient presented with one unnecessary AIS. The radiologists' interpretations agreed 85 % of the time for enchondromas and 100 % for chondrosarcomas. The sensitivity and specificity for distinguishing enchondromas from chondrosarcomas was 95 % for one radiologist and 87 and 95 % for the other. The average unnecessary cost per enchondroma patient was $1,346.18., Conclusions: Unnecessary AIS are frequently performed and are a significant source of expense. The imaging algorithms outlined in this study may reduce unnecessary AIS.

We conducted a retrospective study to compare operating times and costs in patients who underwent guided parathyroidectomies with either (1) technetium-99m ((99m)Tc) multiplex ion-beam imaging (MIBI) parathyroid scintigraphy with single-photon emission computed tomography/computed tomography (SPECT/CT) fusion images or (2) sestamibi dual-phase (99m)Tc MIBI planar parathyroid scintigraphy alone preoperatively. Our study population was made up of the first 24 patients at our facility who had undergone SPECT/CT parathyroid imaging with technetium-99m ((99m)Tc) MIBI and a group of 24 patients who had undergone MIBI planar imaging alone. Patient demographics, preoperative laboratory test results, operating times, and hospital charges were analyzed. We found that less operating time was required for the planar MIBI group than in the SPECT/CT group (mean: 135 vs. 158 min), although the difference was not statistically significant. Likewise, the total cost of treatment was lower in the planar MIBI group (mean: $10,035 vs. $11,592); the difference was statistically significant by one measure (p × 0.02, Wilcoxon rank sum test) but not by another (p × 0.06, Student t test). Although SPECT/CT is efficient for patients with small and difficult-to-localize adenomas, it has yet to demonstrate greater efficacy or cost-effectiveness than planar MIBI for routine parathyroidectomy in patients with primary hyperparathyroidism when an easily identifiable parathyroid adenoma is localized.

Aim: To detect subclinical peripheral arthritis and disease activity in axial seronegative spondyloarthritis (SpA) patients using bone scintigraphy., Methods: Seronegative SpA patients with an established diagnosis and no clinically evident arthritis at the time of the study were included. After excluding symptomatic cases, 20 patients were recruited; 18 with ankylosing spondylitis (AS) and another two with psoriatic arthritis (PsA). Conventional bone scintigraphy was performed to detect the distribution of increased uptake, blood vascular pool (vascularity) and activity., Results: The peripheral joints in all the patients were asymptomatic with no signs of arthritis on clinical examination. Disease activity was higher in those with hypervascularity and activity (75%) detected by scintigraphy. Scintigraphic activity of the sacroiliac joints was found in 10 patients (50%) with a mean sacroiliac joint index of 2.4 ± 0.6. Subclinical involvement of the hips, knees, shoulders, ankles, small joints of the hands, ankles and sternoclavicular joints, as well as the small joints of the feet were detected with descending frequencies (25%, 25%, 20%, 20%, 15%, 10% and 10%, respectively). Dorsal spine increased uptake was found in 35% and hypervascularity of the skull in two cases. Avascular necrosis of the hip was present in one case with hypovascularity., Conclusion: The spectrum of joint involvement in seronegative SpAs should not be limited to sacroiliitis. Bone scintigraphy provides a cost-effective method for detecting the extent of involvement in this group of autoimmune systemic diseases (axial SpA) without clinical evidence of peripheral arthritis., (© 2014 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd.)

Background: The investigation of stable coronary artery disease (CAD) and its treatment depend on risk stratification for decision-making on the need for cardiac catheterization and revascularization., Objective: To analyze the procedures used in the diagnosis and invasive treatment of patients with CAD, at the Brazilian Unified Health System (SUS) in the cities of Curitiba, São Paulo and at InCor-FMUSP., Methods: Retrospective, descriptive, observational study of the diagnostic and therapeutic itineraries of the Brazilian public health care system patient, between groups submitted or not to prior noninvasive tests to invasive cardiac catheterization. Stress testing, stress echocardiography, perfusion scintigraphy, catheterization and percutaneous or surgical revascularization treatment procedures were quantified and the economic impact of the used strategies., Results: There are significant differences in the assessment of patients with suspected or known CAD in the metropolitan region in the three scenarios. Although functional testing procedures are most often used the direct costs of these procedures differ significantly (6.1% in Curitiba, 20% in São Paulo and 27% in InCor-FMUSP). Costs related to the procedures and invasive treatments represent 59.7% of the direct costs of SUS in São Paulo and 87.2% in Curitiba. In InCor-FMUSP, only 24.3% of patients with stable CAD submitted to CABG underwent a noninvasive test before the procedure., Conclusion: Although noninvasive functional tests are the ones most often requested for the assessment of patients with suspected or known CAD most of the costs are related to invasive procedures/treatments. In most revascularized patients, the documentation of ischemic burden was not performed by SUS.

Objective: The study objective was to assess the impact of a provider-led, technology-enabled radiology medical management program on high-cost imaging use., Methods: This study was performed in the ambulatory setting of an integrated healthcare system. After negotiating a risk contract with a major commercial payer, we created a physician-led radiology medical management program to help address potentially inappropriate high-cost imaging use. The radiology medical management program was enabled by a computerized physician order entry system with integrated clinical decision support and accountability tools, including (1) mandatory peer-to-peer consultation with radiologists before order completion when test utility was uncertain on the basis of order requisition; (2) quarterly practice pattern variation reports to providers; and (3) academic detailing for targeted outliers. The primary outcome measure was intensity of high-cost imaging, defined as the number of outpatient computed tomography (CT), magnetic resonance imaging (MRI), and nuclear cardiology studies per 1000 patient-months in the payer's panel. Chi-square test was used to assess trends., Results: In 1.8 million patient-months from January 2004 to December 2009, 50,336 eligible studies were performed (54.1% CT, 40.3% MRI, 5.6% nuclear cardiology). There was a 12.0% sustained reduction in high-cost imaging intensity over the 5-year period (P < .001). The number of CT studies performed decreased from 17.5 per 1000 patient-months to 14.5 (P < .01); nuclear cardiology examinations decreased from 2.4 to 1.4 (P < .01) per 1000 patient-months. The MRI rate remained unchanged at 11 studies per 1000 patient-months., Conclusion: A provider-led radiology medical management program enabled through health information technology and accountability tools may produce a significant reduction in high-cost imaging use., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background and Purpose: Patients with focal intractable epilepsy and normal MR imaging findings frequently undergo further diagnostic tests to localize the epileptogenic zone. The aim of this study was to determine the cost-effective diagnostic strategy that will identify the epileptogenic zone in patients with suspected focal intractable epilepsy and normal MR imaging findings by using decision analysis., Materials and Methods: A Markov decision model was constructed by using sensitivities and specificities of test strategies, seizure outcomes following surgical and medical treatment, cost, utilities, probabilities, and standardized mortality ratios. We compared 6 diagnostic test strategies: PET, ictal SPECT, and MEG individually; and combinations of PET+SPECT, PET+MEG, and SPECT+MEG. The outcomes measured were health care costs, QALY, and ICER. One-way and probabilistic sensitivity analyses were conducted to adjust for uncertainties in model parameters., Results: The preferred strategies were PET+MEG and SPECT. The health care cost of the baseline strategy (PET+MEG) was $95,612 with 16.30 QALY gained. SPECT cost $97,479 with 16.45 QALY gained and an ICER of $12,934/QALY gained compared with those in PET+MEG. One-way sensitivity analyses showed that the decisions of the model were sensitive to variations in sensitivity and specificity of the test strategies. Probabilistic sensitivity analysis showed that when the willingness to pay was <$10,000, PET+MEG was the favored strategy, but the favored strategy changed to SPECT when the willingness to pay was >$10,000., Conclusions: PET+MEG and SPECT were the preferred strategies in the base case. The choice of test was dependent on the sensitivity and specificity of test strategies and willingness to pay. Further study with a larger sample size is needed to obtain better estimates of sensitivity and specificity of diagnostic tests.

Background and Aim: Scintigraphic gastric emptying study (GES) is the criterion standard for diagnosis of gastroparesis. Adult studies demonstrated that extending GES to 4 hours increases its ability to diagnose delayed gastric emptying. Most pediatric centers assess GES up to 2 hours postmeal. The aim of the present study was to assess the effect of extending GES from 2 to 4 hours in evaluation of children with suspected gastroparesis., Methods: We conducted a chart review of all children who had a 4-hour GES with standard radiolabeled solid meal in 2009-2010. Results of GES at 1, 2, and 4 hours were compared. Patients were diagnosed as having gastroparesis using adult criteria: if gastric retention of meal was >90%, 60%, and 10% at 1, 2 and 4 hours, respectively. A telephone survey assessed GES time at top 20 pediatric gastroenterology centers in the United States. Cost of evaluation of patients diagnosed as having gastroparesis was estimated. Full-time equivalents of nuclear medicine technicians and number of nuclear medicine studies done at Ann & Robert H. Lurie Children's Hospital of Chicago from 2007 to 2010 were examined., Results: A total of 71 patients (32 boys, average age 10.8 years) were studied. Sixty-two percent (n=44) children had abnormal GES; 23% (8/35) of them who had normal values at 2 hours had abnormal GES at 4 hours (P<0.0001). Twenty-eight percent of patients had delayed GES at 1 hour: all persisted to have abnormal GES at 2 and 4 hours. Cost of evaluation of a child for gastroparesis was $9014. Only 5 of the top 20 pediatric gastroenterology centers in the United States conducted 4-hour GES. Transitioning from 2 hours to 4 hours only required scheduling adjustments and did not result in limitation in the number of scheduled patients., Conclusions: Extending GES to 4 hours results in a considerable increase in diagnosis of gastroparesis.

For many years, gastric emptying (GE) studies were performed using various local protocols and different radiolabeled meals. This lack of standardization and normal values made the test results unreliable and difficult to compare from one site to another. A recent consensus has been published that now provides guidance and standardization on how to perform a radiolabeled solid-meal GE study. It is widely recognized, however, that simple measurement of total GE of a solid meal often does not provide an answer to the etiology of symptoms for a large number of patients who present with functional dyspepsia. Advances in our understanding of the different roles of the fundus and antrum and their complex interaction with the proximal small bowel and central nervous system have led to the development of new methods to study gastric motility. This review describes how a more comprehensive approach to studying GE is needed and how this will lead to better diagnosis and treatment for patients referred for GE studies., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Introduction: Current clinical guidelines recommend biannual screening for hepatocarcinoma in cirrhotic patients; however, the cost of this preventive activity is unknown., Objective: To determine the cost of ultrasound screening for hepatocarcinoma in patients with cirrhosis., Patients and Method: Data on patients diagnosed with liver cirrhosis in a population of 245,042 inhabitants were prospectively gathered. The screening tests performed and cases of hepatocarcinoma diagnosed during the annual follow-up were included in the analysis. The cost of these tests was calculated based on the tariffs paid by insurance companies for health coverage of civil servants., Results: In 2009, there were 374 patients with cirrhosis; of these, 99 were aged > 80 years, with a performance status of >2 or associated comorbidities. During the annual follow-up, the remaining patients underwent a total of 602 visits (abdominal ultrasound, blood test), four contrast-enhanced computed tomography scans, nine magnetic resonance scans, two scintigraphies, four aspiration biopsies, four radiographs and six contrast ultrasound scans. In our environment, the total estimated cost of these procedures was 37,946 €, indicating that the cost of a screening program for hepatocellular carcinoma according to the above-mentioned selection criteria is 0.155 € per inhabitant/year. If only cirrhotic patients suitable for screening are included, the annual cost of screening is 138 € per patient., Conclusion: The cost of an ultrasound screening program for hepatocarcinoma is 0.155 € per inhabitant/year. These data should be taken into account when considering population-based screening programs., (2011 Elsevier España, S.L. All rights reserved.)

Aim: The aim of this study is to estimate how much scintigraphy the population will need in a well-developed healthcare system with fairly equitable access to healthcare., Methods: This is a retrospective population-based study. The data used came from Taiwan's National Health Insurance reimbursement claims dataset, the National Account compiled by Taiwan's Statistical Bureau of the Directorate General of Budget, Accounting and Statistics, and the National Health Account by Taiwan's Department of Health from 2001 to 2005. Frequency and expenditure variables were derived from these datasets., Results: The annual scintigraphy use rate in Taiwan was 13.57/1000 people from 2001-2005. On average, expenditures for scintigraphy accounted for 0.24% of National Health Insurance expenditures, 0.13% of the nation's total health expenditures and 0.00008% of the gross domestic product of Taiwan. The ratio of scintigraphy to computed tomography use was 0.37 and the scintigraphy to magnetic resonance imaging ratio was 1.14. The ratio of expenditures for scintigraphy and computed tomography was 0.23 and that for scintigraphy and magnetic resonance imaging was 0.36., Conclusion: A comparative approach is useful for assessing healthcare needs. Although the Taiwanese experience might not apply to all countries, the results of this study can serve as an international benchmark for assessing the need for scintigraphy in countries around the world.

Background: Concordant parathyroid localization with sestamibi and ultrasound scans allows minimally invasive parathyroidectomy (MIP) to be performed in patients with non-familial primary hyperparathyroidism (PHPT)., Aim: To investigate the financial implications of scan-directed parathyroid surgery., Methods: Analysis of hospital records for a cohort of consecutive unselected patients treated in a tertiary referral centre., Results: Two hundred patients (138F:62M, age 18-91years) were operated for non-familial PHPT between Jan 2003 and Oct 2007. MIP was performed in 129 patients, with a mean operative time was 35 +/- 18min. Some 75 patients were discharged the same day and the others had a total of 72 in-patient days. Bilateral neck exploration (BNE) was performed in 71 patients with negative/non-concordant scans. Mean operative time was 58 +/- 25min. Only nine patients were discharged the same day and a total of 93 in-patient days were used ( approximately 1.3days/patient). The estimated total costs incurred were pound215,035 ( approximately 290,000). These costs would have been covered by the National Tariff ( pound2,170 per parathyroidectomy) but were higher than those possibly incurred if all 200 patients would have undergone BNE without any radiological investigations ( pound166,000 approximately 224,100euro)., Conclusion: Shorter operative time and day-case admission for MIP generate costs savings that compensate only partially for the additional costs associated with parathyroid imaging studies.

The Food and Drug Administration has described their view of the role that imaging will play in the approval, and perhaps postapproval, use of new therapeutic drugs. The therapeutic drug industry and regulatory authorities have turned to imaging to help them achieve better efficiency and efficacy. We must extend this initiative by demonstrating that molecular imaging can also improve the efficiency and efficacy of routine treatment with these same drugs. The role of molecular imaging in personalized medicine, using targeted drugs in oncology, is very attractive because of the regional information that it provides (in many cases, with a functional or dynamic component), which cannot be provided by in vitro methods ("regional proteomics"). There is great potential for molecular imaging to play a major role in selecting appropriate patients and providing early proof of response, which is critical to addressing the conflict between the high price of treatment and limited reimbursement budgets. This is a new venture in both molecular imaging and targeted drugs. However, there are various regulatory, financial, and practical barriers that must be overcome to achieve this aim, in addition to the normal scientific challenges of drug discovery. There is an urgent need to reduce the cost (i.e., time and money) of developing imaging agents for routine clinical use. The mismatch between the current regulations and personalized medicine includes molecular imaging and requires the engagement of the regulatory authorities to correct. Therapeutic companies must be engaged early in the development of new targeted drugs and molecular imaging agents to improve the fit between the two drug types. Clinical trials must be performed to generate data that not only shows the efficacy of imaging plus therapy in a medical sense, but also in a financial sense. Molecular imaging must be accepted as not just good science but also as central to routine patient management in the personalized medicine of the future.

Unlabelled: (99m)Tc-labeled red blood cell scintigraphy is a powerful detection and localization tool that may be confounded by false-positive and false-negative findings. Subtraction scintigraphy has been used in the evaluation of acute lower gastrointestinal tract hemorrhage (LGIH) to reduce the impact of interpretive confounders. The aim of this investigation was to evaluate the cost-effectiveness of the addition of subtraction scintigraphy in the evaluation of patients with acute LGIH., Methods: The clinical phase of this research was a retrospective clinical study with a repeated-measures design including randomized control and experimental groups. A total of 49 patient studies were included in the sample. Studies were randomized and interpreted by 4 independent physicians. Decision-tree analysis was used to model direct costs and the potential risks of procedures for 2 diagnostic strategies for patients with acute LGIH: conventional scintigraphy alone and conventional scintigraphy combined with subtraction scintigraphy. The transition probabilities (or branching fraction at each decision node) for scintigraphy were based on the clinical results of this investigation. All other transition probabilities were derived from previously cited data., Results: Combining subtraction techniques with conventional scintigraphy reduced the overall costs of procedures for patients with acute LGIH by $74 per patient and reduced deaths by 17.6% and complications by 15.7%. For conventional scintigraphy alone, 8.8% of patients presenting for scintigraphic evaluation of acute LGIH would undergo unnecessary angiograms, and 2.8% would have unnecessary surgery. These figures were reduced to just 5.4% and 1.8%, respectively, with the addition of subtraction scintigraphy., Conclusion: The use of subtraction scintigraphy as an adjunct to conventional scintigraphy for patients with acute LGIH may provide both cost and outcome benefits.

A new diagnosis of prostate cancer presents to both the patient and physician questions regarding the best approach for further assessing the extent of disease prior to selecting a treatment strategy. In addition to the initial clinical data such as serum prostate-specific antigen level, findings on digital rectal examination, and core biopsy Gleason score, several procedures and imaging modalities are available to further stage newly diagnosed prostate cancer. A substantial percentage of the cost of managing prostate cancer is directly related to staging evaluations. Often, staging evaluations are performed that have limited test performance characteristics, subject the patient to unnecessary morbidity, or simply do not provide additional useful clinical information. It is important that the physician be familiar with the indications for the available staging modalities as well as the test performance characteristics in order to proceed appropriately and in an economically judicious fashion. This paper reviews the literature on this topic and summarizes previous experiences with procedures and imaging modalities for staging newly diagnosed prostate cancer.

Background: The indication for a radionuclide bone scan in patients with newly diagnosed, untreated prostate cancer remains controversial., Patients and Methods: In this retrospective study we examined 406 patients who had received a staging bone scan irrespective of their PSA serum level and histology. We evaluated different guidelines and recommendations with respect to their usefulness. The costs were calculated according to EBM and GOA. We evaluated the classification systems of bone metastases according to Soloway, Crawford, and Rigaud., Results: The bone scan was positive in 41 (10%) of 406 patients. The EAU guidelines turned out to be useful with respect to both clinical value and cost efficiency. The Rigaud classification of bone metastases predicted outcome better than the Soloway or Crawford classification., Conclusions: The EAU guidelines from 2005 are a useful tool to decide whether to perform a bone scan in patients with newly diagnosed, untreated prostate cancer. A bone scan should be performed if PSA levels exceed 20 ng/ml in patients with a G1/G2 histology, and in patients with G3 histology and locally advanced disease irrespective of PSA level. Bone scan metastases should be classified according to Rigaud.

The Dutch national guidelines for the diagnosis of patients with clinically suspected pulmonary embolism (from 1992 en 1998) are poorly followed in clinical practice, due especially to practical objections. A large multicentre trial to investigate the diagnostic accuracy of the available modalities and of recently developed techniques such as D-dimer determination, (99m)Tc-gas-scintigraphy and spiral CT scanning was started in I997. In the first phase, the diagnostic value was assessed of: spiral CT (sensitivity 69%, specificity 84%; sensitivity for segmental and larger pulmonary embolisms (PE) 86% and for subsegmental PE 21%), (99m)Tc-gas-ventilation scintigraphy (no improvement compared to conventional ventilation scintigraphy), D-dimer determination (sensitivity for segmental PE 93% and for subsegmental PE 53%, specificity 63%), clinical decision rules (in combination with D-dimer determination; sensitivity 100%, specificity 11%) and echography of the deep venous system (sensitivity 26% for segmental PE and 7% for subsegmental PE, specificity 97%). In the second phase, the feasibility of two new potentially cost-effective diagnostic algorithms was evaluated on the basis of the results obtained in the first phase and data in the literature. In 631 patients, a clinical risk estimate was made and D-dimer determination was done, followed by a ventilation-perfusion scan and serial compression echography of the leg veins. An apparent recurrence of PE occurred in 6 of 466 patients in whom no PE had been found originally (1.3%; 95% CI: 0.5-2.8). The average costs were 812 Euro,--per patient. In 510 patients, a spiral CT followed by compression echography was performed. Recurrent PE occurred in 3 of 378 patients with initial normal tests (0.8%; 95% CI: 0.2-2.3). The average costs were 883 Euro,--per patient. A combination of both strategies can be cost-effective with a cost 674 Euro,--per patient (recurrence rate: 1.9%). Both the strategy starting with a clinical-risk estimate and a D-dimer determination as well as the strategy consisting of spiral CT and serial echography were safe and cost-effective. According to the results of a survey of hospital directors, internists and pulmonologists, both are well accepted in clinical practice.

Aim: To evaluate the diagnostic sensitivity and accuracy and the cost-effectiveness of this technique in the detection of gastroenteropancreatic carcinoid tumors and their metastases in comparison with conventional imaging methods., Methods: Somatostatin receptor scintigraphy (SRS) was performed in 24 patients with confirmed carcinoids and 7 under investigation. The results were compared with those of conventional imaging methods (chest X-ray, upper abdominal ultrasound, chest CT, upper and lower abdominal CT). Also a cost-effectiveness analysis was performed comparing the cost in Euro of several combinations of SRS with conventional imaging modalities., Results: SRS visualized primary or metastatic sites in 71.0% of cases and 61.3% of conventional imagings. The diagnostic sensitivity of the method was higher in patients with suspected lesions (85.7% vs 57.1%). SRS was less sensitive in the detection of metastatic sites (78.9% vs 84.2%). The undetectable lesions by SRS metastatic sites were all in the liver. Between several imaging combinations, the combinations of chest X-ray/upper abdominal CT/SRS and chest CT/upper abdominal CT/SRS showed the highest sensitivity (88.75%) in terms of the number of detected lesions. The combinations of chest X-ray/upper abdominal US/SRS and chest CT/upper abdominal ultrasound /SRS yielded also a quite similar sensitivity (82%). Compared to the cost of the four sensitive combinations the combination of chest X-ray/upper abdominal ultrasound/SRS presented the lower cost, 1183.99 Euro vs 1251.75 Euro for chest CT/upper abdominal ultrasound/SRS, 1294.93 Euro for chest X/ray/upper abdominal CT/SRS and 1362.75 Euro for chest CT/upper abdominal CT/SRS., Conclusion: SRS imaging is a very sensitive method for the detection of gastroenteropancreatic carcinoids but is less sensitive than ultrasound and CT in the detection of liver metastases. Between several imaging combinations, the combination of chest X-ray/upper abdominal CT/SRS shows the highest sensitivity with a cost of 1294.93 Euro.

Ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), venography, lymphoscinti-graphy (LS) and contrast lymphography are frequently utilized in the evaluation of lower limb oedema but no clinical data from the Caribbean have been published on the role of LS despite its well-recognized clinical application. The successful clinical application of CT, colour doppler sonography and MRI in differentiating the various causes of lower limb oedema is well understood. Lymphoscintigraphy has found less acceptability especially in the Caribbean where nuclear imaging techniques are only now currently being developed. This paper describes the initial experience with this technique in 15 patients over a five-year period and discusses its value when lower limb lymphoedema is suspected. Scintigrams were analyzed for visualization of lymph vessels and lymph nodes, dilatation of lymphatic vessels, collaterals and dermal back flow. Lymphoscintigrams were classified as normal (n = 5) or consistent with lymphoedema (n = 10). Failure to visualize lymphatic vessels occurred in two cases of suspected primary lymphoedema. In the remaining eight cases of secondary lymphoedema, a positive study based on altered lymphatic flow and anatomy was recorded. An alternative explanation was offered in three out of five cases in which a normal lymphoscintigram was obtained.

Objectives: The present study sought to determine the value of fractional flow reserve (FFR) compared with stress perfusion scintigraphy (SPS) in patients with recent unstable angina/non-ST-segment elevation myocardial infarction (UA/NSTEMI)., Background: Fractional flow reserve, an invasive index of stenosis severity, is a reliable surrogate for SPS in patients with normal left ventricular function. An FFR > or = 0.75 can distinguish patients after myocardial infarction (MI) with a positive SPS from those with a negative SPS. However, the use of FFR has not been investigated after UA/NSTEMI., Methods: Seventy patients who had recent UA/NSTEMI and an intermediate single-vessel stenosis were randomized to either SPS (n = 35) or FFR (n = 35). Patients in the SPS group were discharged if the SPS revealed no ischemia, whereas those in the FFR group were discharged if the FFR was > or = 0.75. Patients with a positive SPS and those with an FFR <0.75 underwent percutaneous transluminal coronary angioplasty. The use of FFR markedly reduced the duration and cost of hospitalization compared with SPS (11 +/- 2 h vs. 49 +/- 5 h [-77%], p < 0.001; and 1,329 US dollars +/- 44 US dollars vs. 2,113 US dollars +/- 120 US dollars, respectively, p < 0.05). There were no significant differences in procedure time, radiation exposure time, or event rates during follow-up, including death, MI, or revascularization., Conclusions: These data indicate that: 1) the use of FFR in patients with recent UA/NSTEMI markedly reduces the duration and cost of hospitalization compared with SPS; and 2) these benefits are not associated with an increase in procedure time, radiation exposure time, or clinical event rates.

In a German cohort of 661 melanoma patients the performance, costs and survival benefits of staging methods (history and physical examination; chest X-ray; ultrasonography of the abdomen; high resolution sonography of the peripheral lymph nodes) were assessed at initial staging and during follow-up of stage I/II+III disease. At initial staging, 74% (23 out of 31) of synchronous metastases were first detected by physical examination followed by sonography of the lymph nodes revealing 16% (5 out of 31). Other imaging methods were less efficient (Chest X-ray: one out of 31; sonography of abdomen: two out of 31). Nearly 24% of all 127 first recurrences and 18% of 73 second recurrences developed in patients not participating in the follow-up programme. In follow-up patients detection of first or second recurrence were attributed to history and physical examination on a routine visit in 47 and 52% recurrences, respectively, and to routine imaging procedures in 21 and 17% of cases, respectively. Lymph node sonography was the most successful technical staging procedure indicating 13% of first relapses, but comprised 24% of total costs of follow-up in stage I/II. Routine imaging comprised nearly 50% of total costs for follow-up in stage I/II and in stage III. The mode of detecting a relapse ('patient vs. doctor-diagnosed' or 'symptomatic vs asymptomatic') did not significantly influence patients overall survival. Taken together, imaging procedures for routine follow-up in stage I/II and stage III melanoma patients were inefficient and not cost-efficient.

Purpose: To determine the individual technical costs of general diagnostic radiographic, ultrasonographic (US), computed tomographic (CT), magnetic resonance (MR) imaging, and scintigraphic examinations and interventional radiology., Materials and Methods: The Radiology Cost and Productivity Benchmarking Study method of the University HealthSystem Consortium, a cooperative group of academic medical centers, was modified and extended to the six imaging modalities in a tertiary care academic setting. Hospital billing and cost records were analyzed for fiscal year 1996. Costs were divided into labor and nonlabor categories and were allocated to individual imaging modalities on the basis of resources consumed. Physician cost and hospital overhead were not included. Unit costs were analyzed per technical relative value unit (RVU) and per examination., Results: The costs per technical RVU for diagnostic radiography, US, CT, MR imaging, scintigraphy, and interventional radiology were $65. 06, $28.74, $20.95, $17.69, $42.19, and $89.03, respectively. The technical costs per examination for diagnostic radiography, US, CT, MR imaging, scintigraphy, and interventional radiology were $41.92, $50.28, $112.32, $266.96, $196.88, and $692.60, respectively., Conclusion: The method of unit cost analysis for individual imaging modalities was successfully tested in a tertiary care setting. The method should be adopted to allow cost comparison across many institutions, which will permit the promotion of best practices.

Background: There is a controversy regarding the investigation of patients with suspected acute pulmonary embolism (PE)., Aims: To compare the cost-effectiveness of alternative methods of diagnosing acute PE. Chest helical computed tomography (CT) alone and in combination with venous ultrasound (US) of legs and pulmonary angiography (PA) were compared to a conventional algorithm using ventilation-perfusion (V/Q) scintigraphy supplemented in selected cases by US and PA., Methods: A decision-analytical model was constructed to model the costs and effects of the three diagnostic strategies in a hypothetical cohort of 1000 patients each. Transition probabilities were based on published data. Life years gained by each strategy were estimated from published mortality rates. Schedule fees were used to estimate costs., Results: The V/Q protocol is both more expensive and more effective than CT alone resulting in 20.1 additional lives saved at a (discounted) cost of $940 per life year gained. An additional 2.5 lives can be saved if CT replaces V/Q scintigraphy in the diagnostic algorithm but at a cost of $23,905 per life year saved., Conclusions: The more effective diagnostic strategies are also more expensive. In patients with suspected PE, the incremental cost-effectiveness of the V/Q based strategy over CT alone is reasonable in comparison with other health interventions. The cost-effectiveness of the supplemented CT strategy is more questionable.

The potential impact of Sestamibi scintimammography (SSMM) on the cost effective management of women with dense breasts is not known. This study addresses this issue quantitatively by examining the impact of SSMM based screening strategies on the approximately 3,000,000 women over 40 with very dense breasts (DY patterns) without palpable masses and who have had one or more prior mammograms, who undergo routine screening each year. Quantitative decision tree sensitivity analysis was used to compare the conventional mammography (MM) strategy (strategy A), which does not subject patients with negative mammograms to any further examination until their next screening, with two decision strategies for screening with SSMM; SSMM after a negative mammogram (strategy B) or SSMM as the only screening test for women already identified as having dense breasts by a previous mammogram (strategy C). Cost effectiveness was measured by calculating the incremental cost effectiveness ratio (ICER) of strategies B and C, which is the cost of achieving an additional year of life in the screening population by choosing a SSMM based decision strategy rather than the conventional strategy. Strategies B and C reduced the number of false negative diagnoses by 62% and 8%, respectively. The ICER was $632,000 and $3.18M per life year for strategy B and C, respectively. To be cost effective, the pre-test probability of cancer in the study population must be greater than 3% for strategy B or the cost of SSMM must be less than $50 for strategy C. These results show the ICER of an SSMM based breast cancer screening strategy in the management of patients with dense breasts is not currently within the range (approximately $50,000 per year life saved) of other commonly performed medical interventions that are considered cost effective.

The guidelines for publishing economic evaluations require a statement of the economic importance of the analysis and the viewpoint from which it has been carried out, as well as specification of at least two alternative programmes or interventions, the form of economic evaluation, the outcome measure, the method of costing, the time horizon and adjustment for timing of costs and benefits (e.g. by a discount factor), and the allowance for uncertainties (e.g. by implementation of a sensitivity analysis). The decision analysis can be based on clinical trial data, on retrospective or administrative databases, or on modelling. The choice of outcome measures is the key issue in an economic evaluation. In cost-effectiveness analysis, benefits are usually measured in natural units. This is the form of economic evaluation most frequently used in nuclear medicine. Endpoints of effectiveness applied in studies in this field have been procedures avoided, procedures initiated, cardiac events, survival probability, morbidity, quality of life and protracted or failed surgical procedures. In other instances, surrogate endpoints have been used such as metastases detected, staging, viability or tumour response. This, however, limits comparability of cost-effectiveness considerably, as proof of a change in the health outcome cannot be obtained. Measures of utility such as QALYs (quality-adjusted life years) have so far only been applied for decision tree analysis. Useful examples of economic evaluation studies in nuclear medicine are presented here for fluorodeoxyglucose positron emission tomography (FDG-PET) in the preoperative staging of non-small cell lung cancer, for FDG-PET in differentiating indeterminate solitary pulmonary nodules, for somatostatin receptor scintigraphy in detecting metastases of carcinoid tumours, for routine preoperative scintigraphy with sestamibi in patients with parathyroid adenoma, for periodic measurement of thyroid-stimulating hormone in detecting mild thyroid failure, for diagnostic algorithms including a lung scan in patients with suspected pulmonary embolism, for myocardial perfusion imaging as an incremental prognostic factor in patients with coronary artery disease, and for the use of radioiodine as first-line therapy of Graves' hyperthyroidism and of toxic nodular goitres. Further evaluations of effectiveness or utility should be carried out within a multidisciplinary framework to ensure that nuclear medical procedures are included in the general management guidelines.

Background: The appropriate roles for several diagnostic tests for coronary disease are uncertain., Objective: To evaluate the cost-effectiveness of alternative approaches to diagnosis of coronary disease., Design: Meta-analysis of the accuracy of alternative diagnostic tests plus decision analysis to assess the health outcomes and costs of alternative diagnostic strategies for patients at intermediate pretest risk for coronary disease., Data Sources: Studies of test accuracy that met inclusion criteria; published information on treatment effectiveness and disease prevalence., Target Population: Men and women 45, 55, and 65 years of age with a 25% to 75% pretest risk for coronary disease., Time Horizon: 30 years., Perspective: Societal., Interventions: Diagnostic strategies were initial angiography and initial testing with one of five noninvasive tests--exercise treadmill testing, planar thallium imaging, single-photon emission computed tomography (SPECT), stress echocardiography, and positron emission tomography (PET)--followed by coronary angiography if noninvasive test results were positive. Testing was followed by observation, medical treatment, or revascularization., Outcome Measures: Life-years, quality-adjusted life-years (QALYs), costs, and costs per QALY., Results of Base-Case Analysis: Life expectancy varied little with the initial diagnostic test; for a 55-year-old man, the best-performing test increased life expectancy by 7 more days than the worst-performing test. More sensitive tests increased QALYs more. Echocardiography improved health outcomes and reduced costs relative to stress testing and planar thallium imaging. The incremental cost-effectiveness ratio was $75,000/QALY for SPECT relative to echocardiography and was greater than $640,000 for PET relative to SPECT. Compared with SPECT, immediate angiography had an incremental cost-effectiveness ratio of $94,000/QALY., Results of Sensitivity Analysis: Qualitative findings varied little with age, sex, pretest probability of disease, or the test indeterminancy rate. Results varied most with sensitivity to severe coronary disease., Conclusions: Echocardiography, SPECT, and immediate angiography are cost-effective alternatives to PET and other diagnostic approaches. Test selection should reflect local variation in test accuracy.

Background: Physicians use myocardial perfusion imaging to a variable extent in patients presenting with possible coronary artery disease. There are few clinical data on the most cost-effective strategy although computer models predict that routine use of myocardial perfusion imaging is cost-effective., Objectives: To measure the cost-effectiveness of four diagnostic strategies in patients newly presenting with possible coronary artery disease, and to compare cost-effectiveness in centres that routinely use myocardial perfusion imaging with those that do not., Methods: We have studied 396 patients presenting to eight hospitals for the diagnosis of coronary artery disease. The hospitals were regular users or non-users of myocardial perfusion imaging with one of each in four countries (France, Germany, Italy, United Kingdom). Information was gathered retrospectively on presentation, investigations, complications, and clinical management, and patients were followed-up for 2 years in order to assess outcome. Pre- and post-test probabilities of coronary artery disease were computed for diagnostic tests and each test was also assigned as diagnostic or part of management. Diagnostic strategies defined were: 1: Exercise electrocardiogram/coronary angiography, 2: exercise electrocardiogram/myocardial perfusion imaging/coronary angiography, 3: myocardial perfusion imaging/coronary angiography, 4: coronary angiography. Primary outcome measures were the cost and accuracy of diagnosis, the cost of subsequent management, and clinical outcome. Secondary measures included prognostic power, normal angiography rate, and rate of angiography not followed by revascularization., Results: Mean diagnostic costs per patient were: strategy 1: 490 Pounds, 2: 409 Pounds, 3: 460 Pounds, 4: 1253 Pounds (P < 0.0001). Myocardial perfusion imaging users: 529 Pounds, non-users 667 Pounds (P = 0.006). Mean probability of the presence of coronary artery disease when the final clinical diagnosis was coronary artery disease present were, strategy 1: 0.85, 2: 0.82, 3: 0.97, 4: 1.0 (P < 0.0001), users 0.93, non-users 0.88 (P = 0.02), and when coronary artery disease was absent, 1: 0.26, 2: 0.22, 3: 0.16, 4: 0.0 (P < 0.0001), users 0.21, non-users 0.20 (P = ns). Total 2-year costs (coronary artery disease present/absent) were: strategy 1: 4453 Pounds/710 Pounds, 2: 3842 Pounds/478 Pounds, 3: 3768 Pounds/574 Pounds, 4: 5599 Pounds/1475 Pounds (P < 0.05/0.0001), users: 5563 Pounds/623 Pounds, non-users: 5428 Pounds/916 Pounds (P = ns/0.001). Prognostic power at diagnosis was higher (P < 0.0001) and normal coronary angiography rate lower (P = 0.07) in the scintigraphic centres and strategies. Numbers of soft and hard cardiac events over 2 years and final symptomatic status did not differ between strategy or centre., Conclusion: Investigative strategies using myocardial perfusion imaging are cheaper and equally effective when compared with strategies that do not use myocardial perfusion imaging, both for cost of diagnosis and for overall 2 year management costs. Two year patient outcome is the same.

Nuclear imaging is assuming an increasing role in the management of patients with cancer. A variety of new radiopharmaceuticals, several antibody or peptide based, as well as innovative uses of existing radiopharmaceuticals, mean that most nuclear medicine departments equipped with standard imaging devices can image the single photon imaging agents without difficulty.

Objective: To evaluate the cost-effectiveness of magnetic resonance imaging (MRI) compared with radionuclide bone scan in the evaluation of patients with clinically suspected hip fractures., Design: The medical records of all patients who had been seen in the emergency room over a 4 1/2 year period with a clinically suspected hip fracture, negative or equivocal plain films, and either a subsequent bone scan or MRI examination were retrospectively reviewed. The time to diagnosis, admission rate, and time to surgery were determined. A two-sample t-test was used to assess the statistical significance of the results. A theoretical cost analysis was performed using current charges to estimate all expenses., Patients: Forty patients (11 male, 29 female; age 28-99 years) satisfied our inclusion criteria., Results and Conclusions: Twenty-one patients had bone scans (six with fractures), and 19 had MRI (four with fractures). The time to diagnosis was 2.24 +/- 1.30 days for bone scanning and 0.368 +/- 0.597 days for MRI (P < 0.0001). Twenty patients in the bone scan group were admitted compared with 13 in the MRI group. The time to surgery was at least 1 day longer in patients undergoing bone scanning. Bone scanning resulted in higher patient costs compared with MRI because of the delay in diagnosis. In the evaluation of patients with suspected hip fractures, early MRI is more cost-effective than delayed bone scanning. Further prospective studies comparing the cost-effectiveness of early MRI with early bone scanning are needed.