title: Accuracy, risk and the intrinsic value of diagnostic imaging: a review of the cost-utility literature.
abstract: OBJECTIVE
  The aim of this study was to systematically review the reporting of the value of imaging unrelated to treatment consequences and test characteristics in all imaging-related published cost-utility analyses (CUAs) in the medical literature.
  
  
  METHODS
  All CUAs published between 1976 and 2008 evaluating diagnostic imaging technologies contained in the CEA Registry, a publicly available comprehensive database of health related CUAs, were screened. Publication characteristics, imaging modality, and the inclusion of test characteristics including accuracy, costs, risks, and the potential value unrelated to treatment consequences (eg, reassurance or anxiety) were assessed.
  
  
  RESULTS
  Ninety-six published CUAs evaluating 155 different imaging technologies were included in the final sample; 27 studies were published in imaging-specialized journals. Fifty-two studies (54%) evaluated the performance of a single imaging modality, while 44 studies (46%) compared two or more different imaging modalities. The most common areas of interest were cardiovascular (45%) and neuroradiology (17%). Forty-two technologies (27%) concerned ultrasound, while 34 (22%) concerned magnetic resonance. Seventy-nine (51%) technologies used ionizing radiation. Test accuracy was reported or calculated for 90% (n = 133 and n = 5, respectively) and assumed perfect (reference test or gold-standard test without alternative testing strategy to capture false-negatives and false-positives) for 8% (n = 12) of technologies. Only 22 studies (23%) assessing 40 imaging technologies (26%) considered inconclusive or indeterminate results. The risk of testing was reported for 32 imaging technologies (21%). Fifteen studies (16%) considered the value of diagnostic imaging unrelated to treatment. Four studies incorporated it as quality-of-life adjustments, while 10 studies mentioned it only in their discussions or as a limitation.
  
  
  CONCLUSIONS
  The intrinsic value of imaging (the value of imaging unrelated to treatment) has not been appropriately defined or incorporated in the existing cost-utility literature, which could be due to a lack of evidence on the issue. Thus, more research is needed on metrics for a more comprehensive evaluation of diagnostic imaging. Similarly, the incorporation of variations in imaging tests accuracy, inconclusive results and associated risks has lacked uniformity in the cost-utility literature. Acknowledgment of these characteristics in future cost-utility publications will enhance their value and provide results that more closely resemble routine clinical practice.
authors.affiliation: Department of Radiology, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA. hotero@tuftsmedicalcenter.org
authors.forename: Hansel J
authors.initials: HJ
authors.lastname: Otero
authors.forename: Chi H
authors.initials: CH
authors.lastname: Fang
authors.forename: Meera
authors.initials: M
authors.lastname: Sekar
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Ward
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Neumann
mesh_terms: D003362:Cost-Benefit Analysis; D003952:Diagnostic Imaging / Q000191:economics* / Q000706:statistics & numerical data*; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D010506:Periodicals as Topic; D015203:Reproducibility of Results; D018570:Risk Assessment; D012307:Risk Factors; D012680:Sensitivity and Specificity; D014481:United States