Evaluating early dementia with and without assessment of regional cerebral metabolism by PET: a comparison of predicted costs and benefits.
Evaluating dementia in patients with early symptoms of cognitive decline is clinically challenging. Growing evidence indicates that appropriate incorporation of PET into the clinical work-up can improve diagnostic and prognostic accuracy with respect to Alzheimer's disease (AD), the most common cause of dementia in the geriatric population. The precise diagnostic role of PET and its economic impact in this context, however, have not been systematically examined previously.


METHODS
We compared the relative value of 2 strategies for assessing whether early AD is responsible for cognitive symptoms in geriatric patients: (a) a conventional approach, based largely on establishing clinical criteria for the presence of dementia and excluding non-AD etiologies that could contribute to the patient's symptoms, and (b) a proposed approach using PET to examine regional cerebral metabolism and look for characteristic patterns of abnormal metabolism. The total costs (measured in dollars) and benefits (measured in number of accurate diagnoses) of diagnostic testing and clinical outcomes accruing to each strategy were calculated using formalized tools of decision analysis. The primary outcome measure by which the strategies were compared was the ratio of costs to benefits obtained following each approach.


RESULTS
Following the proposed approach led to improved accuracy in identifying early AD, without adding to the overall costs of diagnosis and treatment ($3,433 vs. $3,564 per patient approached by the proposed or conventional algorithm, respectively). The strategy making use of PET was associated with a reduced rate of false-negative and false-positive findings compared with the conventional approach (3.1% vs. 8.2% and 12.0% vs. 23.0%, respectively, at a prevalence of 51.6% in the studied symptomatic population) and a cost savings of $1,138 per correct diagnosis rendered ($4,047 vs. $5,185). The lower cost per unit benefit for the proposed strategy was maintained over a wide range of tested values for variables of sensitivity, specificity, costs of PET and long-term care, and varying approaches to the use of structural neuroimaging.


CONCLUSIONS
Appropriate use of PET for evaluating early dementia in geriatric patients can add valuable information to the clinical work-up, without adding to the overall costs of evaluation and management, resulting in a greater number of patients being accurately diagnosed for the same level of financial expenditure. Thus, the opportunity exists for diminishing the morbidity of dementia economically, with earlier institution of more appropriate management in evaluated patients.
Silverman
Daniel H S
DH
Department of Molecular and Medical Pharmacology and Ahmanson Biological Imaging Center, UCLA School of Medicine, University of California, Los Angeles 90095-6942, USA. dsilver@ucla.edu
Gambhir
Sanjiv S
SS
Huang
Hsuan-Wen C
HW
Schwimmer
Judy
J
Kim
Shanna
S
Small
Gary W
GW
Chodosh
Joshua
J
Czernin
Johannes
J
Phelps
Michael E
ME
D000368:Aged; D000465:Algorithms; D000544:Alzheimer Disease / Q000000981:diagnostic imaging* / Q000191:economics / Q000503:physiopathology; D002560:Cerebrovascular Circulation; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D006801:Humans; D012680:Sensitivity and Specificity; D014055:Tomography, Emission-Computed / Q000191:economics