title: Diagnostic evaluation of the adrenal incidentaloma: decision and cost-effectiveness analyses.
abstract: The goal of this study was to examine the clinical and economic outcomes of alternative diagnostic strategies for differentiating benign from malignant adrenal masses.
  
  
  METHODS
  We used cost-effectiveness assessment derived from decision analysis and the economic perspective of the payer of health care services. One-time evaluation with fine-needle aspiration (FNA) and combinations of chemical-shift MRI, noncontrast CT, 131I-6beta-iodomethylnorcholesterol (NP-59) scintigraphy, with or without FNA, in a hypothetical cohort of 1000 patients with incidentally discovered unilateral, nonhypersecretory adrenal masses. We calculated and compared the diagnostic effectiveness, costs and cost-effectiveness of the alternative strategies based on estimates from published literature and institutional charge data.
  
  
  RESULTS
  At an assumed baseline malignancy rate of 0.25, diagnostic utility varied from 0.31 (CT0) to 0.965 (NP-59) and diagnostic accuracy from 0.655 [noncontrast CT using a cut-off attenuation value of > or = 0 (CT0)] to 0.983 (NP-59). The average cost per patient per strategy ranged from $746 (NP-59) to $1745 (MRI +/- FNA). The best and worst potential cost-to-diagnostic utility ratios were 773 (NP-59) and 2839 (CT0) and 759 (NP-59) and 1982 (MRI +/- FNA) for cost and diagnostic accuracy, respectively. The NP-59 strategy was the optimal choice regardless of the expected outcome examined: cost, diagnostic utility, diagnostic accuracy or cost-effectiveness. Varying the prevalence of malignancy did not alter the cost-effectiveness advantage of NP-59 over the other diagnostic modalities.
  
  
  CONCLUSIONS
  Based on available estimates of reimbursement costs and diagnostic test performance and using reasonable clinical assumptions, our results indicate that the NP-59 strategy is the most cost-effective diagnostic tool for evaluating adrenal incidentalomas over a wide range of malignancy rates and that additional clinical studies are warranted to confirm this cost-effectiveness advantage.
authors.affiliation: Department of Internal Medicine, School of Public Health, The University of Michigan, and Department of Veteran Affairs Medical Centers, Ann Arbor 48105, USA.
authors.forename: B A
authors.initials: BA
authors.lastname: Dwamena
authors.forename: R T
authors.initials: RT
authors.lastname: Kloos
authors.forename: A M
authors.initials: AM
authors.lastname: Fendrick
authors.forename: M D
authors.initials: MD
authors.lastname: Gross
authors.forename: I R
authors.initials: IR
authors.lastname: Francis
authors.forename: M T
authors.initials: MT
authors.lastname: Korobkin
authors.forename: B
authors.initials: B
authors.lastname: Shapiro
mesh_terms: D000301:Adosterol; D000310:Adrenal Gland Neoplasms / Q000175:diagnosis* / Q000191:economics*; D000311:Adrenal Glands / Q000000981:diagnostic imaging / Q000473:pathology; D018246:Adrenocortical Adenoma / Q000175:diagnosis / Q000191:economics; D001707:Biopsy, Needle / Q000191:economics; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003937:Diagnosis, Differential; D006801:Humans; D007457:Iodine Radioisotopes; D008279:Magnetic Resonance Imaging / Q000191:economics; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed / Q000191:economics
chemical_list: D007457:Iodine Radioisotopes; D019275:Radiopharmaceuticals; D000301:Adosterol