title: Children with headache suspected of having a brain tumor: a cost-effectiveness analysis of diagnostic strategies.
abstract: OBJECTIVE
  To assess the clinical and economic consequences of 3 diagnostic strategies-magnetic resonance imaging (MRI), computed tomography followed by MRI for positive results (CT-MRI), and no neuroimaging with close clinical follow-up-in the evaluation of children with headache suspected of having a brain tumor. Three risk groups based on clinical variables were evaluated.
  
  
  METHODS
  A decision-analytic Markov model and cost-effectiveness analysis was performed incorporating the risk group prior probability, MRI and CT sensitivity and specificity, tumor survival, progression rates, and cost per strategy. Outcomes were based on quality-adjusted life year (QALY) gained and incremental cost per QALY gained.
  
  
  RESULTS
  For low-risk children with chronic nonmigraine headaches of >6 months' duration as the sole symptom (prior probability of brain tumor 0.01%), no neuroimaging with close clinical follow-up was less costly and more effective than the 2 neuroimaging strategies. For the intermediate-risk children with migraine headache and normal neurologic examination (prior probability of brain tumor 0.4%), CT-MRI was the most effective strategy but cost >$1 million per QALY gained compared with no neuroimaging. For high-risk children with headache of <6 months' duration and other clinical predictors of a brain tumor such as an abnormal neurologic examination (prior probability of brain tumor 4%), the most effective strategy was MRI, with cost-effectiveness ratio of $113 800 per QALY gained compared with no imaging.
  
  
  CONCLUSIONS
  Our analysis suggests that MRI maximizes QALY gained at a reasonable cost-effectiveness ratio in children with headache at high risk of having a brain tumor. Conversely, the strategy of no imaging with close clinical follow-up is cost saving in low-risk children. Although the CT-MRI strategy maximizes QALY gained in the intermediate-risk patients, its additional cost per QALY gained is high. In children with headache, appropriate selection of patients and diagnostic strategy may maximize quality-adjusted life expectancy and decrease costs of medical workup.
authors.affiliation: Neuroradiology, and Health Outcomes and Policy Section, Department of Radiology, Children's Hospital Medical Center, Cincinnati, Ohio, USA. smedina@post.harvard.edu
authors.forename: L S
authors.initials: LS
authors.lastname: Medina
authors.forename: K M
authors.initials: KM
authors.lastname: Kuntz
authors.forename: S
authors.initials: S
authors.lastname: Pomeroy
mesh_terms: D000328:Adult; D000367:Age Factors; D001932:Brain Neoplasms / Q000175:diagnosis* / Q000191:economics / Q000453:epidemiology; D002648:Child; D003362:Cost-Benefit Analysis; D005500:Follow-Up Studies; D006261:Headache / Q000175:diagnosis* / Q000191:economics / Q000453:epidemiology; D017048:Health Care Costs; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000009:adverse effects / Q000191:economics* / Q000706:statistics & numerical data; D015397:Program Evaluation / Q000379:methods; D019057:Quality-Adjusted Life Years; D012307:Risk Factors; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed / Q000009:adverse effects / Q000191:economics* / Q000706:statistics & numerical data