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IS RADIOGRAPHER CHEST X-RAY REPORTING COST-EFFECTIVE? Mamta Bajre, Paul McCrone, Mark Pennington King’s Health Economics, King’s College London Institute of Psychiatry, Psychology and Neuroscience Background and aims • Supply of healthcare resources is limited • Demand for healthcare is high and potentially rising • Decisions need to be made about how to treat specific conditions and which conditions to prioritise • Expanding the role of allied health professionals is one solution to the challenge of increasing pressures on budgets • Some concerns over such expanded roles • Radiographer reporting of CXRs seen as a potential alternative to radiologist reporting • What are the cost implications of radiographer reporting of CXRs for suspected lung cancer? • How cost-effective is radiographer reporting? Methods • Study funded by Society of Radiographers and conducted by MSc student from City University • Evaluation options: Randomised trial Observational study Casenote review Simulation model • Advantages of models Results can be produced quickly Models can be adapted to aid generalisability Allows a focus on certain key parameters of interest • Disadvantages of models Models are by definition an abstraction from reality Data are not always available Key assumptions • Time taken to report chest X-rays is 2 minutes for both radiographers and radiologists • False negatives present at A&E at a later date at which point disease has advanced a stage (for patients at stage I to III) • Sensitivity and specificity of radiographer reporting of chest X-ray and radiologist reporting of both chest X-ray and CT-scan is independent of disease stage or other patient characteristics such as age. • Treatment costs in the year following diagnosis are maintained for the subsequent four years or until death • QOL in the year following diagnosis is maintained for the subsequent four years or until death • There is no QOL impact arising from false positive reporting • Findings for non-small cell lung cancer are generalisable to other lung cancers Model to assess cost-effectiveness Stage I Stage II CT confirmed lung cancer (TP) Stage III Stage IV True positive Stage I Stage II Lung cancer CT confirmed no lung cancer (FN) FN patients are lung cancer positive they come back to A&E Stage III Stage IV Stage I Stage II False negative Stage III Lung cancer patient coming Stage IV to A&E Radiologist reporting chest X-ray 1 True negative No lung cancer Patient sent for CT scan CT confirmed no lung cancer Image not clear and radiologist suspects cancer After initial clinical diagnosis GP refers for chest X-ray X-ray imaging is performed by radiographer 1 False positive Stage I Stage II CT confirmed lung cancer(TP) Stage III Model to assess cost-effectiveness Stage I Assumed to be 13% (Field et al, 2013) Stage II CT confirmed lung cancer (TP) Stage III Stage IV True positive Stage I Stage II Lung cancer CT confirmed no lung cancer (FN) FN patients are lung cancer positive they come back to A&E Stage III Stage IV Stage I Stage II False negative Stage III Lung cancer patient coming Stage IV to A&E Radiologist reporting chest X-ray 1 True negative No lung cancer Patient sent for CT scan CT confirmed no lung cancer Image not clear and radiologist suspects cancer After initial clinical diagnosis GP refers for chest X-ray X-ray imaging is performed by radiographer 1 False positive Stage I Stage II CT confirmed lung cancer(TP) Stage III Model to assess cost-effectiveness Stage I Assumed to be 13% (Field et al, 2013) Stage II CT confirmed lung cancer (TP) Stage III Stage IV True positive Stage I Stage II Lung cancer CT confirmed no lung cancer (FN) FN patients are lung cancer positive they come back to A&E Replaced with radiographer Stage III Stage IV Stage I Stage II False negative Stage III Lung cancer patient coming Stage IV to A&E Radiologist reporting chest X-ray 1 True negative No lung cancer Patient sent for CT scan CT confirmed no lung cancer Image not clear and radiologist suspects cancer After initial clinical diagnosis GP refers for chest X-ray X-ray imaging is performed by radiographer 1 False positive Stage I Stage II CT confirmed lung cancer(TP) Stage III Estimates of reporting accuracy Parameter % Sensitivity - Radiologist reporting CXR 69.7 Specificity - Radiologist reporting CXR 80.9 Sensitivity - Radiographer reporting CXR 78.1 Specificity - Radiographer reporting CXR 85.2 Sensitivity - Radiologist reporting CT Scan 94.4 Specificity - Radiologist reporting CT Scan 72.6 Sources: Woznitza (2016), Denise et al (2013) Cost of activities Activity £ Chest X-ray 27 Radiologist reporting chest X-ray 32 Radiographer reporting chest X-ray 29 A&E treatment 141 Sources: Oliver et al (2001), RSNA (2016), NHS Reference Costs 2014-15 Cancer prevalence 90 Percentage of cases 80 70 60 50 First presentation 40 Second presentation 30 20 10 0 Stage I Stage II Sources: CRUK (2013), assumptions Stage III Stage IV Cancer care costs 45000 40000 35000 Cost (£s) 30000 25000 Year 1 20000 Years 1-5 15000 10000 5000 0 Stage I Stage II Sources: CRUK (2014), assumptions Stage III Stage IV Quality-adjusted life years (QALYs) over 5 years 4 3.5 3 QALYs 2.5 2 1.5 1 0.5 0 Stage I Stage II 0.81 0.77 Sources: Niak et al (2015) Stage III 0.76 Stage IV 0.76 Results • At initial presentation there would be: 95.8 cancer cases identified through radiographer reporting 85.5 cancer cases identified through radiologist reporting • Total reporting costs: Radiographer £57,302 Radiologist £65,768 • Total costs including treatment: Radiographer £2,576,399 Radiologist £2,560,795 Difference = £15,604 • Total QALYs Radiographer 196.09 Radiologist 192.4 Difference = 3.69 Potential Cost-Effectiveness Results ? Incremental outcome Bad ? Good Incremental cost Incremental cost-effectiveness ratio Cost of treatment A – Cost of treatment B ICER = Effect of treatment A – Effect of treatment B £15,604 ICER = 3.69 QALYs = £4229 per QALY Conclusions • Radiographer reporting of CXRs appears to be a viable alternative to radiologist reporting • Costs will rise if accuracy is greater • Cost per QALY below NICE threshold (£20,000) • Caveats Simple model Data from limited sources Extra training costs not considered Earlier diagnosis not assessed More refined model and robust data required THANK YOU [email protected]