title: Diagnostic strategies in the management of unexplained visual loss. A cost-benefit analysis.
abstract: In the investigation of visual loss from anterior visual pathway disease, it is imperative to differentiate the infrequent compressive from the much more common noncompressive lesions. To determine how relatively low-cost, risk-free, but error-prone visual field examination (VF) and high-cost, risk-prone, but accurate CT Scan (CT) and cerebral angiography (Angio) can be cost-effectively utilized to solve this diagnostic problem, the authors have developed a decision making model for the analysis of three management strategies. The visual field examination precedes and determines the use of neuroradiologic studies in Strategy A (VF-CT-Angio), whereas it follows the neuroradiologic studies in Strategies B (CT-VF-Angio) and C (CT-Angio-VF). The visual field-determined strategy (A) proved most cost-effective, based upon an estimated 6% or lower relative prevalence of chiasmal compressive lesions, a negligible risk in delaying their diagnosis, and a sensitive method of visual field examination. At a visual field sensitivity to chiasmal defects of 84% and a specificity of 88%, Strategy A annually saves $4 million over Strategy B and $27 million over Strategy C. At lower levels of perimetric accuracy, Strategy B is the most cost-effective approach. Strategy C is never cost-effective.
mesh_terms: D002533:Cerebral Angiography / Q000009:adverse effects / Q000191:economics*; D003362:Cost-Benefit Analysis; D003397:Craniopharyngioma / Q000000981:diagnostic imaging; D003657:Decision Making; D006801:Humans; D008579:Meningioma / Q000000981:diagnostic imaging; D010911:Pituitary Neoplasms / Q000000981:diagnostic imaging; D014057:Tomography, X-Ray Computed / Q000191:economics*; D014786:Vision Disorders / Q000000981:diagnostic imaging* / Q000209:etiology