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Rationale and Objectives: To compare follow-up imaging and surgical cost implications of the Society of Radiologists in Ultrasound (SRU) guidelines, 2017 and 2022 European (EUR) guidelines, 2020 Canadian Association of Radiologists (CAR) recommendations, and 2013 American College of Radiology (ACR) White Paper for managing incidentally detected gallbladder polyps., Materials and Methods: 253 consecutive patients with gallbladder polyps identified on ultrasound were independently reviewed by three radiologists for polyp size and morphology. Electronic medical records were reviewed for patient demographics, cholecystectomy (if performed) pathological findings, or any subsequent diagnosis of gallbladder cancer. For each patient, the following were calculated for each of the 5 guidelines studied: 1) number of recommended follow-up ultrasounds based on initial presentation, 2) number of surgical consultations recommended based on initial presentation, 3) number of surgical consultations recommended based on growth, and 4) associated imaging and surgical costs. Interrater agreement was calculated., Results: The SRU 2022 guidelines suggested significantly fewer follow-up ultrasounds and surgical consultations, leading to a cost reduction of 96.5 % and 96.7 % compared to European 2022 and 2017, respectively; 86.5 % compared to CAR; and 86.2 % compared to ACR guidelines. With SRU Recommendations, the majority of gallbladder polyps would be classified as extremely low risk (68.4 %), 30.8 % low risk, and 0.8 % indeterminate risk. In our cohort, a single case of gallbladder cancer was identified (26 mm) which would be recommended for surgical consult by all guidelines., Conclusion: The SRU 2022 guidelines can lead to significant savings for patients, health systems, and society, while reducing unnecessary medical interventions for managing incidentally detected gallbladder polyps., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: AK is on the editorial board of Academic Radiology If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2025 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Antimicrobial resistance comes with high morbidity and mortality burden, and ultimately high impact on healthcare and social costs. Efficient strategies are needed to limit antibiotic overuse. This paper investigates the cost-effectiveness of testing patients with lower respiratory tract infection with procalcitonin, either at the point-of-care only or combined with lung ultrasonography. These diagnostic tools help detect the presence of bacterial pneumonia, guiding prescription decisions. The clinical responses of these strategies were studied in the primary care setting. Evidence is needed on their cost-effectiveness. We used data from a cluster-randomized bi-centric clinical trial conducted in Switzerland and estimated patient-level costs using data on resource use to which we applied Swiss tariffs. Combining the incremental costs of the two strategies and the reduction in the 28-days antibiotic prescription rate (APR) compared to usual care, we calculated Incremental Cost-Effectiveness Ratios (ICER). We also used the Cost-Effectiveness Acceptability Curve as an analytical decision-making tool. The robustness of the findings is ensured by Probabilistic Sensitivity Analysis and scenario analysis. In the base case scenario, the ICER compared to usual care is $2.3 per percentage point (pp) reduction in APR for the procalcitonin group, and $4.4 for procalcitonin-ultrasound combined. Furthermore, we found that for a willingness to pay per patient of more than $2 per pp reduction in the APR, procalcitonin is the strategy with the highest probability to be cost-effective. Our findings suggest that testing patients with respiratory symptoms with procalcitonin to guide antibiotic prescription in the primary care setting represents good value for money., Competing Interests: Declarations. Conflict of interest: All the authors declare that they have no conflict of interest in this study., (© 2024. The Author(s).)

Objective:  This study aimed to implement a point-of-care ultrasound (POCUS) program into a large neonatal intensive care unit (NICU) to enhance care by improving (1) umbilical venous catheter (UVC) tip identification and (2) central placement., Study Design:  A POCUS program was established with core providers who received training from external and internal experts. A prospective study ( n  = 94) compared the accuracy of UVC identification between neonatology-performed ultrasound (NeoUS) and X-ray relative to a referent of radiology-interpreted ultrasound. Finally, an ultrasound-guided UVC insertion protocol was introduced to rescue noncentral traditionally placed catheters ( n  = 37)., Results:  Program implementation trained six providers for a total cost of approximately $10,500 USD. NeoUS was more accurate than X-ray at identifying UVC location (81.9 vs. 60.6%) with improved sensitivity and specificity (80.0 and 84.6 vs. 52.5 and 66.7%, respectively). POCUS guidance was able to rescue 89.2% of catheters that were originally noncentral., Conclusion:  POCUS implementation in a large NICU is feasible, affordable, and can improve quality of care., Key Points: · POCUS implementation is feasible and affordable.. · POCUS is more accurate than X-ray at monitoring UVCs.. · Central UVC placement can be increased with POCUS.., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Recent studies have validated the efficacy of point-of-care ultrasound (POCUS) as an alternative diagnostic imaging approach to computed tomography (CT) for patients with suspected acute diverticulitis. This study aimed to quantify the national impact of this approach in cost savings, ED length-of-stay (LOS), and radiation risk mitigation using a POCUS-first approach for acute diverticulitis in the emergency department (ED)., Methods: Using published data, we constructed a Monte Carlo simulation model to compare two POCUS-first strategies (nonselective and selective approaches) for evaluating patients with suspected acute diverticulitis in the ED. Primary outcomes were cost savings, reduction in ED LOS, and radiation risk mitigation., Results: In our simulation model, both nonselective and selective POCUS-first strategies showed substantial potential reductions in the annual number of CTs. Notably, the selective approach led to significantly fewer estimated POCUS examinations (433,847 ± 45,103 exams vs 720,048 ± 55,815 exams, p < 0.001) resulting in greater cost savings ($94,620,235 ± $10,090,807 vs $70,017,473 ± $11,583,911, p < 0.001) and greater reductions in ED LOS (508,569 ± 640,048 bed-hours vs 332,518 ± 774,485 bed-hours, p < 0.001). Reduction in radiation exposure was comparable between the two approaches (8,779,414 ± 2,389,982 mSv vs 8,846,058 ± 2,420,185 mSv, p = 0.536)., Conclusion: Both POCUS-first models can achieve substantial national annual cost savings, ED LOS reduction, and decreases in radiation exposure compared to the traditional CT-first approach. POCUS should be strongly considered as a first-line imaging modality for acute diverticulitis especially among low-risk patients., Competing Interests: Declaration of competing interest Andrew Goldsmith reports a relationship with Ultrasight LLC. that includes: employment. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Ultrasound imaging is widely valued for its safety, non-invasiveness, and real-time capabilities but is often limited by operator variability, affecting image quality and reproducibility. Robot-assisted ultrasound may provide a solution by delivering more consistent, precise, and faster scans, potentially reducing human error and healthcare costs. Effective force control is crucial in robotic ultrasound scanning to ensure consistent image quality and patient safety. However, existing robotic ultrasound systems rely heavily on expensive commercial force sensors or the integrated sensors of commercial robotic arms, limiting their accessibility. To address these challenges, we developed a cost-effective, lightweight, 3D-printed force sensor and a hybrid position-force control strategy tailored for robotic ultrasound scanning. The system integrates patient-to-robot registration, automated scanning path planning, and multi-sensor data fusion, allowing the robot to autonomously locate the patient, target the region of interest, and maintain optimal contact force during scanning. Validation was conducted using an ultrasound-compatible abdominal aortic aneurysm (AAA) phantom created from patient CT data and healthy volunteer testing. For the volunteer testing, during a 1-min scan, 65% of the forces were within the good image range. Both volunteers reported no discomfort or pain during the whole procedure. These results demonstrate the potential of the system to provide safe, precise, and autonomous robotic ultrasound imaging in real-world conditions.

Diagnostic imaging can provide essential evidence supporting the diagnosis of endocrine diseases in exotic companion animals. The specific modality chosen depends on species, specific disease process/organ affected, equipment availability, and often, cost to the owner. While radiography is widely available in veterinary practices, the sensitivity for visualization of endocrine organs is low. Therefore, ultrasonography, computed tomography, or MRI may be preferred. Other specialized imaging modalities are useful for specific disease processes, such as nuclear scintigraphy and PET. This article compiles current evidence for diagnostic imaging of the endocrine system in exotic animals, organized by imaging modality, species, and disease process., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: The purposes of this study were to assess the frequency of detection of clinically relevant findings by abdominal radiographs and abdominal ultrasound during restaging of solid, soft tissue tumours in dogs and to determine the cost per clinically relevant finding for both modalities., Materials and Methods: The medical records of 159 dogs which underwent a total of 223 restaging episodes following a diagnosis of a solid, soft tissue tumour within, or with potential for metastasis to, the abdomen were reviewed. Data collected from the sample dogs were reviewed for clinically relevant findings, including local recurrence, lymph node or intra-abdominal metastasis, and other changes that would influence prognosis or management. The clinically relevant findings were compared between abdominal radiographs and abdominal ultrasound. The cost per clinically relevant finding was calculated per modality based on current hospital costs., Results: Clinically relevant findings were observed in 158 restaging episodes. Ninety-two clinically relevant findings were detected with ultrasound alone, and 65 clinically relevant findings were detected with a combination of both modalities. Only one dog had a clinically relevant finding detected with radiographs alone. Findings were identified significantly more frequently with ultrasound than radiographs. Cost per clinically relevant finding was 495 USD (approx. 373 GBP/448 EUR) for abdominal radiographs and 323 USD (approx. 242 GBP/292 EUR) for abdominal ultrasound., Clinical Significance: Abdominal radiographs were of minimal use beyond abdominal ultrasound for restaging in this study, despite a higher cost per clinically relevant finding than abdominal ultrasound. This study does not support routine use of abdominal radiographs during routine restaging of solid, soft tissue tumours., (© 2024 British Small Animal Veterinary Association.)

Objectives: This study aimed to evaluate the cost-effectiveness (CE) of 4 hepatocellular carcinoma (HCC) surveillance strategies in the United Kingdom, the GAAD algorithm, which combines Gender (biological sex) and Age with Elecsys® biomarker assays, alpha-fetoprotein (AFP) and protein induced by vitamin K absence-II (previously Des-γ-carboxy prothrombin); ultrasound (US); US + AFP and GAAD + US., Methods: A de novo microsimulation state-transition Markov model was developed in Microsoft Excel® from the perspective of the United Kingdom National Health Service to calculate life-years, quality-adjusted life-years (QALYs), costs, incremental CE ratios, and net monetary benefits. Parameters were sourced from peer-reviewed published literature, national guidelines, and public cost databases. Sensitivity and scenario analyses were performed to evaluate the impact of parameter and structural uncertainty on the results., Results: In a simulated cohort of 100 000 patients, discounted costs and QALYs per patient were £8663 and 6·066 for US, £9095 and 6·076 for US + AFP, £8719 and 6·078 for GAAD alone, and £9114 and 6·086 for GAAD + US. At a CE threshold of £20 000/QALY, GAAD was the most cost-effective strategy; however, although most costly, GAAD + US was the most clinically effective. Sensitivity and scenario analyses indicated that HCC incidence along with costs associated with diagnostic performance influence CE., Conclusion: Considering the cost of US and low incidence of HCC in the United Kingdom, this study suggests that GAAD alone or in combination with US are cost-effective surveillance strategies compared with US and US + AFP. Although GAAD + US showed the highest QALY increase, GAAD alone is considered preferable regarding CE; however, better performance estimates for GAAD + US are needed to confirm., Competing Interests: Author Disclosures Author disclosure forms can be accessed below in the Supplemental Material section., (Copyright © 2024. Published by Elsevier Inc.)

Objective: To evaluate the cost-effectiveness of risk-stratified hepatocellular carcinoma (HCC) screening in diabetic patients with metabolic dysfunction-associated steatotic liver disease (MASLD)., Design: A state-transition model from a healthcare payer perspective on a lifetime horizon., Setting: Japan., Population: A hypothetical cohort of 50-year-old diabetic patients with MASLD risk-stratified according to degree of obesity and progression to cirrhosis. Metabolic dysfunction-associated steatotic liver (MASL), metabolic dysfunction-associated steatohepatitis (MASH) and MASH cirrhosis are progressive manifestations of this specific type of liver disease., Intervention: Abdominal ultrasound (US), US with alpha-fetoprotein (AFP), US with AFP and lectin-reactive alpha-fetoprotein (AFP-L3), CT, extracellular contrast-media-enhanced MRI (ECCM-MRI), gadoxetic acid-enhanced MRI (EOB-MRI) and no screening., Main Outcome Measure: Costs, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), early-stage HCC cases, advanced-stage HCC cases and HCC-related deaths., Results: EOB-MRI is the most cost-effective screening method for non-obese diabetic patients with MASH cirrhosis and for obese diabetic patients with MASH and MASH cirrhosis. Cost-effectiveness was sensitive to HCC incidence in non-obese diabetic patients with MASH cirrhosis and obese diabetic patients with MASH, and the adherence rate of HCC screening in obese diabetic patients with MASH. When the semiannual HCC incidence was between 0.008 and 0.0138 in non-obese diabetic patients with MASH cirrhosis, US with AFP was more cost-effective than EOB-MRI. Cost-effectiveness acceptability curves showed that EOB-MRI was 50.7%, 96.0% and 99.9% cost-effective in obese diabetic patients with MASH and non-obese diabetic patients with MASH cirrhosis, and obese diabetic patients with MASH cirrhosis at a willingness-to-pay level of $50 000 per QALY gained. Compared with no screening in 100 000 non-obese diabetic patients with MASH cirrhosis and obese diabetic patients with MASH cirrhosis, EOB-MRI reduced total costs by US$69 million and by US$142 million, increased lifetime effectiveness by 12 546 QALYs and by 15 815 QALYs, detected 17 873 and 21 014 early-stage HCC cases, and averted 2068 and 2471 HCC-related deaths, respectively., Conclusions: Of all HCC screening methods for diabetic patients with MASH cirrhosis, EOB-MRI yields the greatest cost-saving with the highest QALYs, detects the greatest number of early-stage HCC cases and averts the greatest number of advanced-stage HCC cases and HCC-related deaths. The findings provide important insights for the precise implementation of risk-stratified HCC surveillance to reduce morbidity and mortality and improve the quality of life in diabetic patients with MASLD., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In consideration of patient out-of-pocket costs in low- and middle-income countries, this observational cohort study sought to quantify the travel expenses associated with receiving free cardiac services in India and create a point-of-care ultrasound (POCUS) referral model., Methods: In a tertiary hospital that offers free services in Bangalore, India, we interviewed outpatients awaiting cardiac evaluation regarding their out-of-pocket expenses. A subgroup underwent POCUS for signs of left atrial enlargement, inferior vena cava plethora, and extravascular lung water, and subsequent chart review for significant findings on echocardiography or need for immediate care. A model was tested in which a normal POCUS would negate the requirement for referral., Results: Patients (N = 219), of age (mean ± SD) 49.0 ± 12.9 y, traveled [median (IQR)] 1178 miles (248-1240), spent $104 ($26-$195), and lost 4.5 (0-10) days of work at a daily wage of $3.90 ($1.95-$6.50). The one-way travel cost equated to 27 days of daily pay. In the POCUS subgroup, symptoms were commonly chest pain (57%) and dyspnea (48%) and were less than moderate in severity (71%). Abnormal echo findings were present in 54% of patients, of whom 29% needed immediate care, and 71% were dismissed without follow-up. POCUS signs were related to an abnormal echo (p < 0.001), but not immediate care (p = 0.50). POCUS-based referral would have prevented 51% (35/68) of unnecessary referrals and missed 13% (9/68) of cases that required immediate care., Conclusions: Out-of-pocket costs, relative to income, can be significant for those seeking free cardiac care. POCUS performed locally could potentially reduce the costs of travel but would risk missing cases, depending on symptom type., (© 2024. The Author(s).)

Introduction: An optimal follow-up schedule for small (≤3-cm) hepatocellular carcinoma (HCC) after radiofrequency ablation (RFA) remains unclear in clinical guidelines. We aimed to assess the cost-effectiveness of follow-up strategies in patients with small HCC after RFA., Methods: In total, 11,243 patients were collected from global institutions to calculate recurrence rates. Subsequently, a Markov model covering a 10-year period was developed to compare 25 surveillance strategies involving different surveillance techniques (computed tomography [CT], magnetic resonance imaging or ultrasonography [US], and α-fetoprotein [AFP]) and intervals (3 or 6 months). The study endpoint was incremental cost-effectiveness ratio (ICER), which represented additional cost per incremental quality-adjusted life year. Sensitivity analysis was conducted by varying the values of input parameters to observe the ICER., Results: In a base case analysis, the dominant strategy was CT every 3 months during an initial 2 years, followed by semiannual CT, and then switch to biannual the combination of US screening and AFP testing after 5 years (m3&#95;CT-m6&#95;CT-m6&#95;USAFP), with an ICER of $68,570.92 compared with the "not followed" strategy. One-way sensitivity analysis showed the ICER consistently remained below the willingness-to-pay threshold of $100,000.00. In a probabilistic sensitivity analysis, m3&#95;CT-m6&#95;CT-m6&#95;USAFP was the most cost-effective approach in 95.6% of simulated scenarios at a willingness-to-pay threshold., Discussion: For small HCC after RFA, the recommended follow-up strategy is CT, with scans scheduled every 3 months for the first 2 years, every 6 months thereafter, and transition to biannual the combination of US screening and AFP testing after 5 years., (Copyright © 2024 by The American College of Gastroenterology.)

Point-of-care ultrasound (POCUS) has increasingly been used by neonatal providers in neonatal intensive care units in the United States. However, there is a lack of literature addressing the complexities of POCUS coding and billing practices in the United States. This article describes the coding terminology and billing process especially those relevant to neonatal POCUS. We elucidate considerations for neonatal POCUS billing framework and workflow integration. Directions on image storage and supporting documentation to facilitate efficient reimbursement, compliance with billing regulations, and appeal to insurance claim denial are discussed. KEY POINTS: · Code neonatal POCUS procedure precisely allows accurate reimbursement and reduced errors in billing.. · Document details to support medical necessity and reimbursement claims effectively.. · Adhere to regulations to avoid audits, denials, and ensure proper reimbursement.., Competing Interests: None declared., (Thieme. All rights reserved.)

Background and Objective: The high incidence of nodular thyroid pathology has led to growing concern about the economic impact that this pathology represents on the healthcare system. There are conclusive data about the cost-effectiveness of high-resolution units for nodular thyroid pathology; however, their implementation is not homogeneous in the Endocrinology and Nutrition services of our country. The objective of the present study was to evaluate the economic impact of the implementation of the high-resolution thyroid nodule unit (HRTNU) in our center., Patients and Methods: The present work is a prospective, observational and descriptive study carried out in 1314 patients (82% women, mean age 58 years ds = 11) evaluated at the HRTNU during the period of August 2022-August 2023. Demographic data (age and sex) were analyzed, referral center and consultation type, number of total consultations and neck ultrasound performed, number of fine needle aspiration (FNAB) performed, and cytology results were analyzed., Results: In the period from August 2022 to August 2023, a total of 1314 patients were evaluated (neck ultrasound and clinical consultation) and a total of 133 FNAB were performed, of which only 2.26% were non-diagnostic. Compared to the percentage of unsatisfactory FNAB from the previous year August 2021-July 2022 of 25%, a mean saving of 9931.43 euros was estimated. 84.47% of the patients evaluated for the first time by the HRTNU were discharged, estimating a mean saving of 133,200 euros., Conclusions: The implementation of a HRTNU at the Endocrinology and Nutrition departments, coordinated with primary and specialized care, is a cost-effectiveness alternative, as it reduces the number of medical consultations and is accompanied by a higher rate of diagnostic FNAB., (Copyright © 2024 SEEN and SED. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction: To investigate the actual cost of hematuria evaluation using nationally representative claims data, given that the workup for hematuria burdens the healthcare system with significant associated costs. We hypothesized that evaluation with contrast-enhanced computed tomography (CT) confers more cost to hematuria evaluation than renal ultrasound (US)., Methods: Using a national, privately insured database (MarketScan), we identified all individuals with an incident diagnosis of hematuria. We included patients who underwent cystoscopy and upper tract imaging within 3 months of diagnosis. We tabulated the costs of the imaging study as well as the total healthcare cost per patient. A multivariable model was developed to evaluate patient factors associated with total healthcare costs., Results: We identified 318,680 patients with hematuria who underwent evaluation. Median costs associated with upper tract imaging were $362 overall, $504 for CT with contrast, $163 for US, $680 for magnetic resonance imaging (MRI), $283 for CT without contrast, and $294 for retrograde pyelogram. Median cystoscopy cost was $283. Total healthcare costs per patient were highest when utilizing MRI and CT imaging. When adjusted for comorbidities, the use of any imaging other than ultrasound was associated with higher costs., Conclusions: In this nationally representative analysis, hematuria evaluation confers a significant cost burden, while the primary factor associated with higher costs of screening was imaging type. Based upon reduced cost of US-based strategies, further investigation should delineate its cost-effectiveness in the diagnosis of urological disease., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Ultrasound (US) is associated with severe visualization limitations (US Liver Imaging Reporting and Data System visualization score C) in one-third of patients with nonalcoholic fatty liver disease (NAFLD) cirrhosis undergoing hepatocellular carcinoma (HCC) screening. Data suggest abbreviated MRI (aMRI) may improve HCC screening efficacy. This study analyzed the cost-effectiveness of HCC screening strategies, including an US visualization score-based approach with aMRI, in patients with NAFLD cirrhosis., Methods: We constructed a Markov model simulating adults with compensated NAFLD cirrhosis in the United States undergoing HCC screening, comparing strategies of US plus visualization score, US alone, or no surveillance. We modeled aMRI in patients with visualization score C and negative US, while patients with scores A/B did US alone. We performed a sensitivity analysis comparing US plus visualization score with US plus alpha fetoprotein or no surveillance. The primary outcome was the incremental cost-effectiveness ratio (ICER), with a willingness-to-pay threshold of $100,000 per quality-adjusted life-year. Sensitivity analyses were performed for all variables., Results: US plus visualization score was the most cost-effective strategy, with an ICER of $59,005 relative to no surveillance. The ICER for US alone to US plus visualization score was $822,500. On sensitivity analysis, screening using US plus visualization score remained preferred across several parameters. Even with alpha fetoprotein added to US, the US plus visualization score strategy remained cost-effective, with an ICER of $62,799 compared with no surveillance., Discussion: HCC surveillance using US visualization score-based approach, using aMRI for visualization score C, seems to be the most cost-effective strategy in patients with NAFLD cirrhosis., (Copyright © 2024 by The American College of Gastroenterology.)

Study Question: What are the costs and effects of tubal patency testing by hysterosalpingo-foam sonography (HyFoSy) compared to hysterosalpingography (HSG) in infertile women during the fertility work-up?, Summary Answer: During the fertility work-up, clinical management based on the test results of HyFoSy leads to slightly lower, though not statistically significant, live birth rates, at lower costs, compared to management based on HSG results., What Is Known Already: Traditionally, tubal patency testing during the fertility work-up is performed by HSG. The FOAM trial, formally a non-inferiority study, showed that management decisions based on the results of HyFoSy resulted in a comparable live birth rate at 12 months compared to HSG (46% versus 47%; difference -1.2%, 95% CI: -3.4% to 1.5%; P = 0.27). Compared to HSG, HyFoSy is associated with significantly less pain, it lacks ionizing radiation and exposure to iodinated contrast medium. Moreover, HyFoSy can be performed by a gynaecologist during a one-stop fertility work-up. To our knowledge, the costs of both strategies have never been compared., Study Design, Size, Duration: We performed an economic evaluation alongside the FOAM trial, a randomized multicenter study conducted in the Netherlands. Participating infertile women underwent, both HyFoSy and HSG, in a randomized order. The results of both tests were compared and women with discordant test results were randomly allocated to management based on the results of one of the tests. The follow-up period was twelve months., Participants/materials, Setting, Methods: We studied 1160 infertile women (18-41 years) scheduled for tubal patency testing. The primary outcome was ongoing pregnancy leading to live birth. The economic evaluation compared costs and effects of management based on either test within 12 months. We calculated incremental cost-effectiveness ratios (ICERs): the difference in total costs and chance of live birth. Data were analyzed using the intention to treat principle., Main Results and the Role of Chance: Between May 2015 and January 2019, 1026 of the 1160 women underwent both tubal tests and had data available: 747 women with concordant results (48% live births), 136 with inconclusive results (40% live births), and 143 with discordant results (41% had a live birth after management based on HyFoSy results versus 49% with live birth after management based on HSG results). When comparing the two strategies-management based on HyfoSy results versus HSG results-the estimated chance of live birth was 46% after HyFoSy versus 47% after HSG (difference -1.2%; 95% CI: -3.4% to 1.5%). For the procedures itself, HyFoSy cost €136 and HSG €280. When costs of additional fertility treatments were incorporated, the mean total costs per couple were €3307 for the HyFoSy strategy and €3427 for the HSG strategy (mean difference €-119; 95% CI: €-125 to €-114). So, while HyFoSy led to lower costs per couple, live birth rates were also slightly lower. The ICER was €10 042, meaning that by using HyFoSy instead of HSG we would save €10 042 per each additional live birth lost., Limitations, Reasons for Caution: When interpreting the results of this study, it needs to be considered that there was a considerable uncertainty around the ICER, and that the direct fertility enhancing effect of both tubal patency tests was not incorporated as women underwent both tubal patency tests in this study., Wider Implication of the Findings: Compared to clinical management based on HSG results, management guided by HyFoSy leads to slightly lower live birth rates (though not statistically significant) at lower costs, less pain, without ionizing radiation and iodinated contrast exposure. Further research on the comparison of the direct fertility-enhancing effect of both tubal patency tests is needed., Study Funding/competing Interest(s): FOAM trial was an investigator-initiated study, funded by ZonMw, a Dutch organization for Health Research and Development (project number 837001504). IQ Medical Ventures provided the ExEm®-FOAM kits free of charge. The funders had no role in study design, collection, analysis, and interpretation of the data. K.D. reports travel-and speakers fees from Guerbet and her department received research grants from Guerbet outside the submitted work. H.R.V. received consulting-and travel fee from Ferring. A.M.v.P. reports received consulting fee from DEKRA and fee for an expert meeting from Ferring, both outside the submitted work. C.H.d.K. received travel fee from Merck. F.J.M.B. received a grant from Merck and speakers fee from Besins Healthcare. F.J.M.B. is a member of the advisory board of Merck and Ferring. J.v.D. reported speakers fee from Ferring. J.S. reports a research agreement with Takeda and consultancy for Sanofi on MR of motility outside the submitted work. M.v.W. received a travel grant from Oxford Press in the role of deputy editor for Human Reproduction and participates in a DSMB as independent methodologist in obstetrics studies in which she has no other role. B.W.M. received an investigator grant from NHMRC GNT1176437. B.W.M. reports consultancy for ObsEva, Merck, Guerbet, iGenomix, and Merck KGaA and travel support from Merck KGaA. V.M. received research grants from Guerbet, Merck, and Ferring and travel and speakers fees from Guerbet. The other authors do not report conflicts of interest., Trial Registration Number: International Clinical Trials Registry Platform No. NTR4746., (© The Author(s) 2024. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology.)

Background: Imaging is used to monitor disease activity in small bowel Crohn's disease (CD). Magnetic Resonance Enterography is often employed as a first modality in the United Kingdom for assessment and monitoring; however, waiting times, cost, patient burden and limited access are significant. It is as yet uncertain if small bowel intestinal ultrasound (IUS) may be a quicker, more acceptable, and cheaper alternative for monitoring patients with CD., Methods: A clinical service evaluation of imaging pathways was undertaken at a single NHS site in England, United Kingdom. Data were collected about patients who were referred and underwent an imaging analysis for their IBD. Only patients who underwent a therapy change were included in the analysis. Data were collected from care episodes between 01 January 2021-30 March 2022., Results: A combined total of 193 patient care episodes were reviewed, 107 from the IUS pathway and 86 from the MRE pathway. Estimated costs per patient in the IUS pathway was £78.86, and £375.35 per patient in the MRE pathway. The MRE pathway had an average time from referral to treatment initiation of 91 days (SD= ±61) with patients in the IUS pathway waiting an average of 46 days (SD= ±17)., Conclusions: Findings from this work indicate that IUS is a potential cost-saving option when compared to MRE when used in the management of CD. This is in addition to the cost difference of the radiological modalities. A large, multicentre, prospective study is needed to validate these initial findings.

Background:  The diagnosis of recurrent ipsilateral deep vein thrombosis (DVT) with compression ultrasonography (CUS) may be hindered by residual intravascular obstruction after previous DVT. A reference CUS, an additional ultrasound performed at anticoagulant discontinuation, may improve the diagnostic work-up of suspected recurrent ipsilateral DVT by providing baseline images for future comparison., Objectives:  To evaluate the cost-effectiveness of routinely performing reference CUS in DVT patients., Methods:  Patient-level data ( n  = 96) from a prospective management study (Theia study; NCT02262052) and claims data were used in a decision analytic model to compare 12 scenarios for diagnostic management of suspected recurrent ipsilateral DVT. Estimated health care costs and mortality due to misdiagnosis, recurrent venous thromboembolism, and bleeding during the first year of follow-up after presentation with suspected recurrence were compared., Results:  All six scenarios including reference CUS had higher estimated 1-year costs (€1,763-€1,913) than the six without reference CUS (€1,192-€1,474). Costs were higher because reference CUS results often remained unused, as 20% of patients (according to claims data) would return with suspected recurrent DVT. Estimated mortality was comparable in scenarios with (14.8-17.9 per 10,000 patients) and without reference CUS (14.0-18.5 per 10,000). None of the four potentially most desirable scenarios included reference CUS., Conclusion:  One-year health care costs of diagnostic strategies for suspected recurrent ipsilateral DVT including reference CUS are higher compared to strategies without reference CUS, without mortality benefit. These results can inform policy-makers regarding use of health care resources during follow-up after DVT. From a cost-effectiveness perspective, the findings do not support the routine application of reference CUS., Competing Interests: F.A.K. reports grants or contracts from Bayer, BMS, BSCI, MSD, Leo Pharma, Actelion, VarmX, The Netherlands Organisation for Health Research and Development, The Dutch Thrombosis Association, The Dutch Heart Foundation, and The Horizon Europe Program, all unrelated to this work and paid to his institution. All other authors report no conflict of interest., (Thieme. All rights reserved.)

Backgruound: There is debate about ultrasonography screening for thyroid cancer and its cost-effectiveness. This study aimed to evaluate the cost-effectiveness of early screening (ES) versus symptomatic detection (SD) for differentiated thyroid cancer (DTC) in Korea., Methods: A Markov decision analysis model was constructed to compare the cost-effectiveness of ES and SD. The model considered direct medical costs, health outcomes, and different diagnostic and treatment pathways. Input data were derived from literature and Korean population studies. Incremental cost-effectiveness ratio (ICER) was calculated. Willingness-to-pay (WTP) threshold was set at USD 100,000 or 20,000 per quality-adjusted life year (QALY) gained. Sensitivity analyses were conducted to address uncertainties of the model's variables., Results: In a base case scenario with 50 years of follow-up, ES was found to be cost-effective compared to SD, with an ICER of $2,852 per QALY. With WTP set at $100,000, in the case with follow-up less than 10 years, the SD was cost-effective. Sensitivity analysis showed that variables such as lobectomy probability, age, mortality, and utility scores significantly influenced the ICER. Despite variations in costs and other factors, all ICER values remained below the WTP threshold., Conclusion: Findings of this study indicate that ES is a cost-effective strategy for DTC screening in the Korean medical system. Early detection and subsequent lobectomy contribute to the cost-effectiveness of ES, while SD at an advanced stage makes ES more cost-effective. Expected follow-up duration should be considered to determine an optimal strategy for DTC screening.

Background: Primary hyperparathyroidism historically necessitated bilateral neck exploration to remove abnormal parathyroid tissue. Improved localization allows for focused parathyroidectomy with lower complication risks. Recently, positron emission tomography using radiolabeled 18F-fluorocholine demonstrated high accuracy in detecting these lesions, but its cost-effectiveness has not been studied in the United States., Methods: A decision tree modeled patients who underwent parathyroidectomy for primary hyperparathyroidism using single preoperative localization modalities: (1) positron emission tomography using radiolabeled 18F-fluorocholine, (2) 4-dimensional computed tomography, (3) ultrasound, and (4) sestamibi single photon emission computed tomography (SPECT). All patients underwent either focused parathyroidectomy versus bilateral neck exploration, with associated cost ($) and clinical outcomes measured in quality-adjusted life-years gained. Model parameters were informed by literature review and Medicare costs. Incremental cost-utility ratios were calculated in US dollars/quality-adjusted life-years gained, with a willingness-to-pay threshold set at $100,000/quality-adjusted life-year. One-way, 2-way, and threshold sensitivity analyses were performed., Results: Positron emission tomography using radiolabeled 18F-fluorocholine gained the most quality-adjusted life-years (23.9) and was the costliest ($2,096), with a total treatment cost of $11,245 or $470/quality-adjusted life-year gained. Sestamibi single photon emission computed tomography and ultrasound were dominated strategies. Compared with 4-dimentional computed tomography, the incremental cost-utility ratio for positron emission tomography using radiolabeled 18F-fluorocholine was $91,066/quality-adjusted life-year gained in our base case analysis, which was below the willingness-to-pay threshold. In 1-way sensitivity analysis, the incremental cost-utility ratio was sensitive to test accuracy, positron emission tomography using radiolabeled 18F-fluorocholine price, postoperative complication probabilities, proportion of bilateral neck exploration patients needing overnight hospitalization, and life expectancy., Conclusion: Our model elucidates scenarios in which positron emission tomography using radiolabeled 18F-fluorocholine can potentially be a cost-effective imaging option for primary hyperparathyroidism in the United States. Further investigation is needed to determine the maximal cost-effectiveness for positron emission tomography using radiolabeled 18F-fluorocholine in selected populations., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Eliciting a normal electromyography signal has been the usual method to confirm the functional integrity of the recurrent laryngeal nerve during intraoperative nerve monitoring. Given that oscillations of the vocal cord can be detected with trans-laryngeal ultrasound when the ipsilateral recurrent laryngeal nerve is stimulated with the endotracheal tube in situ, we aimed to compare the accuracy and cost of this novel method with the conventional electromyography method., Methods: Consecutive patients who underwent elective thyroid, parathyroid or neck dissection procedures were included. The NIM-Neuro 3.0 system was used. Endotracheal tube-based surface electrodes were utilized for electromyography signal recording. Standard anesthetic technique was adopted. Recurrent laryngeal nerve integrity was verified by both detection methods (laryngeal ultrasound and electromyography) independently. Vocal cord function was validated by flexible direct laryngoscopy postoperatively. For each method, concurrence with flexible direct laryngoscopy was defined as "true-positive" or "true-negative," based on the presence or absence of vocal cord paresis. Accuracy was calculated as the sum of all true positives and negatives divided by the total of nerves-at-risk. The cost of each method was calculated., Results: One hundred and four patients were eligible. Total number of nerves-at-risk was 155. Based on flexible direct laryngoscopy findings, the test sensitivity, specificity, positive predictive value, and negative predictive value of intraoperative laryngeal ultrasound were 75.0%, 99.3%, 85.7%, and 98.6%, respectively, while those of electromyography were 87.5%, 98.0%, 70.0%, and 99.3%, respectively. The prognostic accuracy in laryngeal ultrasound versus electromyography was comparable (98.1% vs 97.4%). The cost of the laryngeal ultrasound per operation was less than electromyography ($82 vs $454)., Conclusion: Laryngeal ultrasound has a similar detection accuracy to electromyography during intraoperative nerve monitoring. Apart from being a cheaper alternative, laryngeal ultrasound may be useful when there is unexplained loss of electromyography signals during surgery and may play a role in the intraoperative nerve monitoring troubleshooting algorithm., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To compare health-economic aspects of multiple imaging modalities used to monitor renal cysts, the present study evaluates costs and outcomes of patients with Bosniak IIF and III renal cysts detected and followed-up by either contrast-enhanced computed tomography (ceCT), contrast-enhanced magnetic resonance imaging (ceMRI), or contrast-enhanced ultrasonography (CEUS)., Patients and Methods: A simulation using Markov models was implemented and performed with 10 cycles of 1 year each. Proportionate cohorts were allocated to Markov models by a decision tree processing specific incidences of malignancy and levels of diagnostic performance. Costs of imaging and surgical treatment were investigated using internal data of a European university hospital. Multivariate probabilistic sensitivity analysis was performed to confirm results considering input value uncertainties. Patient outcomes were measured in quality-adjusted life years (QALY), and costs as averages per patient including costs of imaging and surgical treatment., Results: Compared to the 'gold standard' of ceCT, ceMRI was more effective but also more expensive, with a resulting incremental cost-effectiveness ratio (ICER) >€70 000 (Euro) per QALY gained. CEUS was dominant compared to ceCT in both Bosniak IIF and III renal cysts in terms of QALYs and costs. Probabilistic sensitivity analysis confirmed these results in the majority of iterations., Conclusion: Both ceMRI and CEUS can be used as alternatives to ceCT in the diagnosis and follow-up of intermediately complex cystic renal lesions without compromising effectiveness, while CEUS is clearly cost-effective. The economic results apply to a large university hospital and must be adapted for smaller hospitals., (© 2021 The Authors BJU International published by John Wiley & Sons Ltd on behalf of BJU International.)

Objectives: The purpose of this study was to describe the design and impact of a point-of-care ultrasound (PoCUS) workflow integrated into the electronic medical record (EMR) on PoCUS utilization, documentation compliance, and resultant revenue potential., Methods: This was a single-center retrospective study at an academic center. The study period spanned from December 1, 2018 to June 30, 2019 (pre-implementation) to August 1, 2019 to February 29, 2020 (post-implementation). The implementation date was July 11, 2019 at which time a PoCUS workflow was integrated into the EMR in the emergency department without the purchase of middleware. Prior to this new workflow, a non-automated workflow was in place. PoCUS scan data were extracted from the EMR and archived examinations. The mean number of PoCUS examinations performed per month per 100 ED visits before and after implementation of the new workflow were compared using an unpaired t-test, stratified by all health care professionals, and attending physicians alone. The rate of documentation compliance before and after implementation of the new workflow were compared using a chi square contingency test. Potential revenue was calculated for each period by multiplying the number of eligible examinations by the respective 2020 Medicare conversion factor Relative Value Units., Results: Utilization of PoCUS from pre-implementation to post-implementation increased 28.7% from 5.01 to 6.45 mean examinations per month per 100 ED visits by all health care professionals (p = 0.063), and 75.1% from 2.01 to 3.52 by attending physicians (p = 0.0001). Examinations in compliance with workflow requirements increased from 153 (14.7%) to 1307 (94.0%). The rate of workflow compliance improved from 14.7% to 94.0% of examinations (p < 0.0001). Potential revenue increased from $546.01 to $22,014.47., Conclusions: The implementation of a middleware-free PoCUS workflow at our institution was associated with increased PoCUS utilization, documentation compliance, and potential revenue., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To characterize full cycle of care costs for managing an acute ureteral stone using time-driven activity-based costing., Methods: We defined all phases of care for patients presenting with an acute ureteral stone and built an overarching process map. Maps for sub-processes were constructed through interviews with providers and direct observation of clinical spaces. This facilitated calculation of cost per minute for all aspects of care delivery, which were multiplied by associated process times. These were added to consumable costs to determine cost for each specific step and later aggregated to determine total cost for each sub-process. We compared costs of eight common clinical pathways for acute stone management, defining total cycle of care cost as the sum of all sub-processes that comprised each pathway., Results: Cost per sub-process included $920 for emergency department (ED) care, $1665 for operative stent placement, $2368 for percutaneous nephrostomy tube placement, $106 for urology clinic consultation, $238 for preoperative center visit, $4057 for ureteroscopy with laser lithotripsy (URS), $2923 for extracorporeal shock wave lithotripsy, $169 for clinic stent removal, $197 for abdominal x-ray, and $166 for ultrasound. The lowest cost pathway ($1388) was for medical expulsive therapy, whereas the most expensive pathway ($8002) entailed a repeat ED visit prompting temporizing stent placement and interval URS., Conclusion: We found a high degree of cost variation between care pathways common to management of acute ureteral stone episodes. Reliable cost accounting data and an understanding of variability in clinical pathway costs can inform value-based care redesign as payors move away from pure fee-for-service reimbursement., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: The use of radiographic evaluation of carotid disease may vary, and current guidelines do not strongly recommend the use of cross-sectional imaging (CSI) prior to surgical intervention. We sought to describe the trends in preoperative carotid imaging and evaluate the associated clinical outcomes and Medicare payments for patients undergoing carotid endarterectomy (CEA) for asymptomatic carotid disease., Methods: We used a 20% Medicare sample from 2006 to 2014 identifying patients undergoing CEA for asymptomatic disease. We evaluated preoperative carotid ultrasound and CSI use: CT or MRI of the neck prior to CEA. We calculated average payments of each study from the carrier file and revenue center file. Imaging payments included both the professional component (PC) and the technical component (TC). Claims with a reimbursement of $0 and studies where payment for both the TC and PC could not be identified were excluded from the overall calculation to determine average payment per study. Inpatient reimbursements according to DRG 37-39 were calculated. We compared hospital length of stay (LOS), in hospital stroke, carotid re-exploration, and mortality according to CSI use., Results: A total of 58,993 CEAs were identified with pre-operative carotid imaging. The average age was 74.8 ± 7.5 years, and 56.0% were men. A total of 19,678 (33%) patients had ultrasound alone with an average of (2.4 ± 1.9) exams prior to CEA. A total of 39,315 patients underwent CSI prior to CEA with 2.5 ± 2.1 ultrasounds, 0.95 ± 0.86 neck CTs and 0.47 ± 0.7 MRIs per patient. The average payment for ultrasound was $140 ± 40, $282 ± 94 for CT and $410 ± 146 for MRI. The average inpatient reimbursements were $7,413 ± 4,215 for patients without CSI compared with $7,792 ± 3,921 for patients with CSI, P < 0.001. The average LOS during CEA admission was 2.5 ± 3.7days. Patients with CSI had a slightly lower percentage of patients being discharged by postoperative day 2 compared with ultrasound alone (88.9% vs. 91.5%, respectively, P < 0.001). The overall in-hospital stroke rate was 0.38% and carotid re-exploration rate was 1.0% and there was no statistical significant difference between groups. Median follow-up was 3.9 years, and mortality at 8 years was 50% and did not statistically differ between groups., Conclusions: Our analysis found preoperative imaging to include CSI in nearly two-thirds of patients prior to CEA for asymptomatic disease. As imaging and inpatient payments were higher with patients with CSI further work is needed to understand when CSI is appropriate prior to surgical intervention to appropriately allocate healthcare resources., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The frequency and cost of postoperative surveillance for older adults (>65 y) with T1N0M0 low-risk papillary thyroid cancer (PTC) have not been well studied., Methods: Using the SEER-Medicare (2006-2013) database, frequency and cost of surveillance concordant with American Thyroid Association (ATA) guidelines (defined as an office visit, ≥1 thyroglobulin measurement, and ultrasound 6- to 24-month postoperatively) were analyzed for the overall cohort of single-surgery T1N0M0 low-risk PTC, stratified by lobectomy versus total thyroidectomy., Results: Majority of 2097 patients in the study were white (86.7%) and female (77.5%). Median age and tumor size were 72 y (interquartile range 68-76) and 0.6 cm (interquartile range 0.3-1.1 cm), respectively; 72.9% of patients underwent total thyroidectomy. Approximately 77.5% of patients had a postoperative surveillance visit; however, only 15.9% of patients received ATA-concordant surveillance. Patients who underwent total thyroidectomy as compared with lobectomy were more likely to undergo surveillance testing, thyroglobulin (61.7% versus 24.8%) and ultrasound (37.5% versus 29.2%) (all P < 0.01), and receive ATA-concordant surveillance (18.5% versus 9.0%, P < 0.001). Total surveillance cost during the study period was $621,099. Diagnostic radioactive iodine, ablation, and advanced imaging (such as positron emission tomography scans) accounted for 55.5% of costs ($344,692), whereas ATA-concordant care accounted for 44.5% of costs. After multivariate adjustment, patients who underwent total thyroidectomy as compared with lobectomy were twice as likely to receive ATA-concordant surveillance (adjusted odds ratio 2.0, 95% confidence interval: 1.5-2.8, P < 0.001)., Conclusions: Majority of older adults with T1N0M0 low-risk PTC do not receive ATA-concordant surveillance; discordant care was costly. Total thyroidectomy was the strongest predictor of receiving ATA-concordant care., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To assess the appropriateness of abdominal aortic aneurysm (AAA) screening with ultrasound (US) and potential cost savings by adhering to guidelines and reviewing prior imaging., Methods: Screening aortic US performed in Nova Scotia from January 1 to April 30, 2019, were reviewed. Patient sex, age, risk factors, and study result (negative, <2.5 cm; ectatic, 2.5-2.9 cm; positive for AAA, ≥3 cm) were recorded. Previous imaging tests were reviewed for the presence/absence of aortic ectasia or aneurysm. Appropriateness was based on the Canadian Task Force on Preventive Health Care (CTFPHC) and the Canadian Society of Vascular Surgery (CSVS) guidelines. The number of potentially averted US, subsequent missed positive findings, and cost savings (over the 4-month period) were calculated according to: 1) each guideline; and 2) each guideline combined with review of imaging done 0 to 5 years and 0 to 10 years previously., Results: There were 17 (4.6%) of 369 ectatic aortas and 18 (4.9%) of 369 AAAs. The number of potentially averted examinations, missed ectatic aortas, missed AAAs, and cost savings were as follows, respectively: CTFPHC, 222 (60.2%) of 369, 8, 7, and CAD$20 501.70; CSVS, 117 (31.7%) of 369, 4, 2, and CAD$10 804.95. The model that would yield the greatest cost savings and fewest missed positive findings was the combination of CSVS guidelines with review of prior imaging within 5 years; this would avert 189 (51.2%) of 369 examinations, save CAD$17 454.15 over 4 months, and miss only 2 AAAs and 2 ectatic aortas., Conclusion: Over half of aortic US screening tests can be safely averted by adhering to CSVS guidelines and reviewing imaging performed within 5 years.

Objective: To evaluate the impact of the routine use of musculoskeletal ultrasound (MSUS) in rheumatology clinics by comparing one clinic with on-site MSUS (REU 1) and four clinics without this resource, which need to refer patients for the MSUS exams (REU 2-5)., Methods: The electronic medical records of all new patients at five rheumatology clinics during a 12-month period were reviewed. The impact of MSUS was analysed by comparing the percentage of direct discharges of patients from the different clinics, as an outcome of effectiveness, and the number and cost of radiology referrals for imaging exams (MSUS and MRI), as an outcome of cost-saving., Results: The medical records of 4923 patients were included in the study, distributed as follows: REU 1, 1464 (29.7%); REU 2, 1042 (21.2%); REU 3, 1089 (22.1%); REU 4, 579 (11.8%); and REU 5, 749 (15.2%). There were more direct discharges from REU 1 (34.4%) than from REU 2-5 (15.6%) (P<0.001). REU 1 made radiological referrals for X-rays, MRIs or MSUS exams in 773 (52.8%) patients, compared with 2626 (75.9%) patients in REU 2-5 (P<0.001). An estimation of costs for the clinical assessment of 1000 new patients revealed a cost-saving in REU 1 of €21 413 in MSUS and of €877 in MRI exams., Conclusion: The implementation of on-site MSUS in a new-patient rheumatology clinic is cost-effective, facilitating the direct discharge of patients and reducing the number and cost of radiological referrals for imaging exams., (© The Author(s) 2020. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Fetal growth restriction is a major risk factor for stillbirth. A routine late-pregnancy ultrasound scan could help detect this, allowing intervention to reduce the risk of stillbirth. Such a scan could also detect fetal presentation and predict macrosomia. A trial powered to detect stillbirth differences would be extremely large and expensive., Objectives: It is therefore critical to know whether this would be a good investment of public research funds. The aim of this study is to estimate the cost-effectiveness of various late-pregnancy screening and management strategies based on current information and predict the return on investment from further research., Methods: Synthesis of current evidence structured into a decision model reporting expected costs, quality-adjusted life-years, and net benefit over 20 years and value-of-information analysis reporting predicted return on investment from future clinical trials., Results: Given a willingness to pay of £20 000 per quality-adjusted life-year gained, the most cost-effective strategy is a routine presentation-only scan for all women. Universal ultrasound screening for fetal size is unlikely to be cost-effective. Research exploring the cost implications of induction of labor has the greatest predicted return on investment. A randomized, controlled trial with an endpoint of stillbirth is extremely unlikely to be a value for money investment., Conclusion: Given current value-for-money thresholds in the United Kingdom, the most cost-effective strategy is to offer all pregnant women a presentation-only scan in late pregnancy. A randomized, controlled trial of screening and intervention to reduce the risk of stillbirth following universal ultrasound to detect macrosomia or fetal growth restriction is unlikely to represent a value for money investment., (Copyright © 2020 ISPOR–The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Background: Despite previous studies demonstrating the benefit of office-based ultrasonography for musculoskeletal evaluation, many hand surgery clinics have yet to adopt this practice. The authors conducted a cost-benefit analysis of establishing an ultrasound machine in a hand clinic., Methods: The authors used the Medicare Physician Fee Schedule, Physician/Supplier Procedure Summary, and Physician Compare National Downloadable File databases to estimate provider reimbursement and annual frequency of office-based upper extremity-related ultrasound procedures. Ultrasound machine cost, maintenance fees, and consumable supply prices were gleaned from the literature. The primary outcomes were net cost-benefit difference and benefit-cost ratio at 1 year, 5 years, and 10 years after implementation. Sensitivity analyses were performed by varying factors that influence the net cost-benefit difference., Results: The estimated total initial expense to establish ultrasonography in the clinic was $53,985. The overall cost-benefit difference was -$49,530 per practice at the end of the first year (benefit-cost ratio, 0.3), -$1049 after 5 years (benefit-cost ratio, 1.0), and $52,022 after 10 years (benefit-cost ratio, 1.4). Benefits primarily accrued because of physician reimbursements. One-way sensitivity analysis revealed machine price, annual procedure volume, and reimbursement rate as the most influential parameters in determining the benefit-cost ratio. Ultrasonography was cost beneficial when the machine price was less than $46,000 or if the billing frequency exceeded six times per week. A societal perspective analysis demonstrated a large net benefit of $218,162 after 5 years., Conclusions: Implementation of office-based ultrasound imaging can result in a positive financial return on investment. Ultrasound machine cost and procedural volume were the most critical factors influencing benefit-cost ratio., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Critically ill parturients have an increased risk of developing pulmonary complications. Lung ultrasound (LUS) could be effective in addressing the cause of respiratory distress in resource-limited settings with high maternal mortality. We aimed to determine the frequency, timing of appearance, and type of pulmonary complications in critically ill parturients in an obstetric unit in Sierra Leone. In this prospective observational study, LUS examinations were performed on admission, after 24 and 48 hours, and in case of respiratory deterioration. Primary endpoint was the proportion of parturients with one or more pulmonary complications, stratified for the presence of respiratory distress. Secondary endpoints included timing and types of complications, and their association with "poor outcome," defined as a composite of transfer for escalation of care or death. Of 166 patients enrolled, 35 patients (21% [95% CI: 15-28]) had one or more pulmonary complications, the majority diagnosed on admission. Acute respiratory distress syndrome (period prevalence 4%) and hydrostatic pulmonary edema (4%) were only observed in patients with respiratory distress. Pneumonia (2%), atelectasis (10%), and pleural effusion (7%) were present, irrespective of respiratory distress. When ultrasound excluded pulmonary complications, respiratory distress was related to anemia or metabolic acidosis. Pulmonary complications were associated with an increased risk of poor outcome (odds ratio: 5.0; 95% CI: 1.7-14.6; P = 0.003). In critically ill parturients in a resource-limited obstetric unit, LUS contributed to address the cause of respiratory distress by identifying or excluding pulmonary complications. These were associated with a poor outcome.

Study Objective: Point-of-care ultrasonography allows rapid diagnosis in the emergency department. A previous study found that a low prevalence of emergency medicine clinicians received point-of-care ultrasonography reimbursement in 2012 (0.7%). We determine nationwide point-of-care ultrasonography reimbursement patterns for 4 subsequent years., Methods: We performed a cross-sectional study using 2012 to 2016 data from the Centers for Medicare & Medicaid Fee-for-Service Provider Utilization and Payment Data Part B, defining point-of-care ultrasonographic examinations using Current Procedural Terminology codes. The emergency medicine workforce was defined by emergency medicine, family medicine, internal medicine, critical care, and advanced practice providers who received emergency medicine-specific reimbursements. We compared patterns of point-of-care ultrasonography reimbursement among emergency physicians in 2012 versus 2016 through a 2-sample test of proportions., Results: In 2012, 342 (0.7% of total) emergency medicine workforce clinicians were reimbursed for diagnostic point-of-care ultrasonography versus 801 (1.3%) in 2016. Emergency physicians represented an increasing proportion of the total workforce, increasing from 86.0% (95% confidence interval 82.3% to 89.6%) in 2012 (N=294) to 94.6% (95% confidence interval 93.1% to 96.2%) in 2016 (N=758). From 2012 to 2016, total point-of-care ultrasonography reimbursements increased from 13,697 to 31,717, with significant growth from echocardiograms (4,127 to 14,978), abdominal examinations (3,682 to 7,140), and thoracic examinations (801 to 5,278)., Conclusion: The proportion of emergency medicine workforce clinicians receiving diagnostic point-of-care ultrasonography reimbursements, as well as the number of point-of-care ultrasonographic studies, more than doubled from 2012 to 2016. Efforts are needed to understand barriers to adoption of point-of-care ultrasonography because only a small proportion of the emergency medicine clinician workforce was reimbursed in any year., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objectives: Peritonsillar abscess (PTA) is a very common infection, in particular in pediatric and adolescent population. A distinction between peritonsillar cellulitis and abscess should be made to determine the appropriate treatment. Nonetheless, the difference cannot always be made on physical examination alone and often requires imaging by computed tomography (CT). Radiation exposure as well as the cost and waiting time question the use of CT in this pathology. We present our experience in the use of Transcutaneous Cervical Ultrasonography for the diagnosis and management of peritonsillar abscess in the adult population., Study Design: Clinical-prospective., Methods: Adult patients were evaluated for suspicion of PTA. Clinical findings were documented and all patients underwent a Transcutaneous Cervical Ultrasonography performed by a second otorhinolaryngology specialist well versed in Ultrasonography without knowing the clinical history, details of the physical examination, or the suspected side. Ultrasonography findings were later compared with the clinical examination and outcome of the medical or surgical management., Results: Eight adult patients (range 18-53 year-old) were enrolled in the study. Six of them, had, ultrasonography findings compatible with a peritonsillar liquid collection underwent surgical drainage that confirmed and drained an abscess. On two patients, the ultrasonography images described an aspect of peritonsillar cellulitis that was managed conservatively and showed a favorable remission. No complications during stay or side effects or intolerance to the ultrasound were recorded., Conclusion: Transcutaneous Cervical ultrasonography is a fast, useful tool, better tolerated than the intra-oral ultrasonography in diagnosing PTA. It avoids all irradiation exposure is much cheaper and the waiting time is shorter. Worth noting, is the richness of information pertaining the anatomy, vessels and abscess location and extension, for the surgeon performing the exam just prior to surgery. The efficiency and training of otorhinolaryngology specialists with this technique shows numerous promising benefits and deserves to be further developed., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Liver ultrasound scan (US) use in diagnosing Non-Alcoholic Fatty Liver Disease (NAFLD) causes costs and waiting lists overloads. We aimed to compare various Machine learning algorithms with a Meta learner approach to find the best of these as a predictor of NAFLD., Methods: The study included 2970 subjects, 2920 constituting the training set and 50, randomly selected, used in the test phase, performing cross-validation. The best predictors were combined to create three models: 1) FLI plus GLUCOSE plus SEX plus AGE, 2) AVI plus GLUCOSE plus GGT plus SEX plus AGE, 3) BRI plus GLUCOSE plus GGT plus SEX plus AGE. Eight machine learning algorithms were trained with the predictors of each of the three models created. For these algorithms, the percent accuracy, variance and percent weight were compared., Results: The SVM algorithm performed better with all models. Model 1 had 68% accuracy, with 1% variance and an algorithm weight of 27.35; Model 2 had 68% accuracy, with 1% variance and an algorithm weight of 33.62 and Model 3 had 77% accuracy, with 1% variance and an algorithm weight of 34.70. Model 2 was the most performing, composed of AVI plus GLUCOSE plus GGT plus SEX plus AGE, despite a lower percentage of accuracy., Conclusion: A Machine Learning approach can support NAFLD diagnosis and reduce health costs. The SVM algorithm is easy to apply and the necessary parameters are easily retrieved in databases., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Common bile duct stones are present in 10% of patients with symptomatic gallstones. One-third of UK patients undergoing cholecystectomy will have preoperative ductal imaging, commonly with magnetic resonance cholangiopancreatography. Intraoperative laparoscopic ultrasound is a valid alternative but is not widely used. The primary aim of this study was to assess cost effectiveness of laparoscopic ultrasound compared with magnetic resonance cholangiopancreatography., Materials and Methods: A prospective database of all patients undergoing laparoscopic cholecystectomy between 2015 and 2018 at a district general hospital was assessed. Inclusion criteria were all patients, emergency and elective, with symptomatic gallstones and suspicion of common bile duct stones (derangement of liver function tests with or without dilated common bile duct on preoperative ultrasound, or history of pancreatitis). Patients with known common bile duct stones (magnetic resonance cholangiopancreatography or failed endoscopic retrograde cholangiogram) were excluded. Ninety-day morbidity data were also collected., Results: A total of 420 (334 elective and 86 emergency) patients were suspected to have common bile duct stones and were included in the study. The cost of a laparoscopic ultrasound was £183 per use. The cost of using the magnetic resonance cholangiopancreatography unit was £365 per use. Ten postoperative magnetic resonance cholangiopancreatographies were performed for inconclusive intraoperative imaging. The estimated cost saving was £74,650. Some 128 patients had common bile duct stones detected intraoperatively and treated. There was a false positive rate of 4.7%, and the false negative rate at 90 days was 0.7%. laparoscopic ultrasound use saved 129 bed days for emergency patients and 240 magnetic resonance cholangiopancreatography hours of magnetic resonance imaging., Conclusion: The use of laparoscopic ultrasound during laparoscopic cholecystectomy for the detection of common bile duct stone is safe, accurate and cost effective. Equipment and maintenance costs are quickly offset and hospital bed days can be saved with its use.

Introduction: The value of hepatocellular carcinoma (HCC) surveillance is defined by the balance of benefits, i.e., early tumor detection, and potential harms, related to false positive and indeterminate results. Although physical harms can be observed in 15%-20% of patients with cirrhosis undergoing HCC surveillance, previous cost-effectiveness analyses have not incorporated costs of harms. We aimed to evaluate the cost-effectiveness of HCC surveillance including both benefits and harms., Design: We constructed a Markov model to compare surveillance strategies of ultrasound (US) alone, US and alpha fetoprotein (AFP), and no surveillance in 1 million simulated patients with compensated cirrhosis. Harms included imaging and biopsy in patients undergoing surveillance for HCC. Model inputs were based on literature review, and costs were derived from the Medicare fee schedule, with all costs inflated to 2018 dollars. The primary outcome was the incremental cost-effectiveness ratio per incremental quality-adjusted life-year., Results: In the base case analysis, US with AFP was the dominant strategy over both US alone and no surveillance. In a probabilistic sensitivity analysis, US with AFP was the most cost-effective strategy in 80.1% of simulations at a willingness-to-pay threshold of $100,000 per quality-adjusted life-year. In our threshold analyses, an HCC incidence >0.4% per year and surveillance adherence >19.5% biannually were necessary for US with AFP to be cost-effective compared with no surveillance., Discussion: Accounting for both surveillance-related benefits and harms, US and AFP is more cost-effective for HCC surveillance than US alone or no surveillance in patients with compensated cirrhosis.

Objective: The aim of the study was to assess cost-effectiveness of abdominal ultrasound, magnetic resonance imaging, endoscopic ultrasound, computed tomography, positron emission tomography, and no screening for pancreatic cancer screening in familial high-risk individuals (HRIs)., Methods: We developed decision trees with Markov models for a hypothetical cohort of familial HRIs at the age of 50 year using a healthcare sector perspective and a lifetime horizon. Main outcomes were costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios., Results: In a base-case analysis, abdominal ultrasound was the most cost-effective (US $11,035, 17.4875 QALYs). Magnetic resonance imaging yielded the best benefits. Cost-effectiveness was sensitive to the incidence of pancreatic cancer. Endoscopic ultrasound was more cost-effective than abdominal ultrasound when the incidence of pancreatic cancer was greater than 0.008 and under 0.016. Magnetic resonance imaging was more cost-effective than endoscopic ultrasound when the incidence of pancreatic cancer was greater than 0.016. Probabilistic sensitivity analysis using Monte-Carlo simulation for 10,000 trials demonstrated that abdominal ultrasound was cost-effective 76% of the time at a willingness-to-pay threshold of US $50,000/QALY gained., Conclusions: Abdominal ultrasound is the most cost-effective and recommended for pancreatic cancer screening in familial HRIs in Japan. Evaluating the risk of pancreatic cancer among familial HRIs as a target for screening is significant.

Ultrasound is the most widely used medical imaging modality worldwide. It is abundant, extremely safe, portable, and inexpensive. In this review, we consider some of the current development trends for ultrasound imaging, which build upon its current strength and the popularity it experiences among medical imaging professional users.Ultrasound has rapidly expanded beyond traditional radiology departments and cardiology practices. Computing power and data processing capabilities of commonly available electronics put ultrasound systems in a lab coat pocket or on a user's mobile phone. Taking advantage of new contributions and discoveries in ultrasound physics, signal processing algorithms, and electronics, the performance of ultrasound systems and transducers have progressed in terms of them becoming smaller, with higher imaging performance, and having lower cost. Ultrasound operates in real time, now at ultrafast speeds; kilohertz frame rates are already achieved by many systems.Ultrasound has progressed beyond anatomical imaging and monitoring blood flow in large vessels. With clinical approval of ultrasound contrast agents (gas-filled microbubbles) that are administered in the bloodstream, tissue perfusion studies are now routine. Through the use of modern ultrasound pulse sequences, individual microbubbles, with subpicogram mass, can be detected and observed in real time, many centimeters deep in the body. Ultrasound imaging has broken the wavelength barrier; by tracking positions of microbubbles within the vasculature, superresolution imaging has been made possible. Ultrasound can now trace the smallest vessels and capillaries, and obtain blood velocity data in those vessels.Molecular ultrasound imaging has now moved closer to clinic; the use of microbubbles with a specific affinity to endothelial biomarkers allows selective accumulation and retention of ultrasound contrast in the areas of ischemic injury, inflammation, or neoangiogenesis. This will aid in noninvasive molecular imaging and may provide additional help with real-time guidance of biopsy, surgery, and ablation procedures.The ultrasound field can be tightly focused inside the body, many centimeters deep, with millimeter precision, and ablate lesions by energy deposition, with thermal or mechanical bioeffects. Some of such treatments are already in clinical use, with more indications progressing through the clinical trial stage. In conjunction with intravascular microbubbles, focused ultrasound can be used for tissue-specific drug delivery; localized triggered release of sequestered drugs from particles in the bloodstream may take time to get to clinic. A combination of intravascular microbubbles with circulating drug and low-power ultrasound allows transient opening of vascular endothelial barriers, including blood-brain barrier; this approach has reached clinical trial stage. Therefore, the drugs that normally would not be getting to the target tissue in the brain will now have an opportunity to produce therapeutic efficacy.Overall, medical ultrasound is developing at a brisk rate, even in an environment where other imaging modalities are also advancing rapidly and may be considered more lucrative. With all the current advances that we discuss, and many more to come, ultrasound may help solve many problems that modern medicine is facing.

Objective: To determine if use of the hematuria risk index can reduce testing and cost, while maintaining equivalent lesion detection in patients with asymptomatic microscopic hematuria., Materials and Methods: Retrospective cohort study of 1049 patients at single institution. Hematuria risk index score was calculated based on clinical factors including age, sex, smoking history, and degree of hematuria for each patient along with evaluation studies performed and total number of tumors discovered. Cost benefit analysis was performed based on published Medicare averages., Results: Tumor detection rate in overall, low-risk, and moderate-risk groups were 1.2%, 0%, and 2.96% at a total cost of $408,376. When low-risk group is not screened cost decreases to $166,252 with no lesions missed. The cost to discover one lesion/cancer in the overall group was $34,031.3, the cost to find one high-grade clinically significant lesion/cancer was $136,125.3 for the overall group. When the low-risk group was removed, the cost to find a high-grade clinically significant lesion/cancer decreased to $55,417.3 without missing any significant lesions. Ultrasound may be utilized instead of computed tomography with minimal loss of lesion detection in select moderate risk patients., Conclusion: None of the low-risk hematuria risk patients were diagnosed with any lesions, as such these patients may not need an evaluation. Furthermore, by utilizing a risk-stratified approach to the assessment of asymptomatic microscopic hematuria health care costs can be significantly decreased with limited negative consequences in terms of lesion detection., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: We investigated the yield of ultrasound surveillance for small abdominal aortic aneurysms (AAAs) in patients older than 80 years compared with a younger population for detecting AAA growth reaching the threshold size for repair. Secondary objectives included analysis of the incidence of AAA repair and the cost-benefit of surveillance., Methods: A retrospective cohort study was performed of all patients undergoing AAA surveillance in Ottawa between 2007 and 2015. Patients were dichotomized by enrollment age (<80 years vs ≥80 years) and stratified by enrollment AAA size. Cohorts were cross-referenced with the Ottawa surgical database, leveraging the common health region to ensure complete data capture. The threshold size for repair was sex specific (female, 5.0 cm; male, 5.5 cm). Factors influencing AAA growth rate were assessed with a general linear multiple mixed model. Analyses with Cox proportional hazards models with competing risk for mortality assessed aorta-related events, and cost-benefit was analyzed by referencing Ontario billing codes., Results: A total of 1231 patients underwent serial ultrasound surveillance, of whom 500 were older than 80 years at some point during the study period. The mean AAA growth rate was 1.63 mm/y (95% confidence interval [CI], 1.54-1.71). Old age and small enrollment aneurysm size were significantly protective against AAA growth. Overall, 357 (29%) patients reached the AAA size threshold for repair, and 272 (22%) underwent AAA repair. Patients older than 80 years were less likely to reach the AAA threshold size for repair compared with their younger counterparts (adjusted hazard ratio, 0.77; 95% CI, 0.61-0.97). Of the 357 patients whose AAA reached the threshold size for repair, octogenarians were substantially less likely to undergo elective AAA repair (adjusted hazard ratio, 0.34; 95% CI, 0.24-0.47). Repair of ruptured AAA was rare (0.8%), and age differences were insignificant. For every octogenarian with an enrollment AAA size between 3.0 and 3.9 cm who ultimately received elective AAA repair, 51 patients were enrolled in surveillance without elective repair. This corresponded to an estimated $33,139 in ultrasound fees., Conclusions: Surveillance of most patients with small AAA is appropriate. However, patients older than 80 years were significantly less likely than their younger counterparts to experience aortic growth reaching the threshold size for repair. Furthermore, in the unlikely event of AAA growth, patients older than 80 years were substantially less likely to undergo repair. These results suggest that in the context of patient-specific health and wishes, surveillance of AAAs <4 cm in octogenarians is costly and unlikely to be beneficial., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Using ultrasound for the diagnostic workup of thyroid lesions is a widely accepted technique. An inexpensive phantom model of thyroid lesions would be an invaluable tool for engaging medical students in learning the diagnostic algorithm for thyroid lesions and how to perform fine needle aspiration (FNA). The aim of this study was to devise an inexpensive and reproducible training phantom model for thyroid lesion detection, image interpretation and in vitro FNA using ultrasound guidance. A simple phantom model imitating benign cystic lesions, intermediately suspicious lesions and highly suspicious lesions was developed using a chicken breast, red seedless grapes, pimento olives and blackberries. The phantom was constructed for a total cost of $4.09 per unit and constructed in approximately 3 min. Nine models were constructed in total, demonstrating that the model design is replicable. This thyroid FNA phantom is an inexpensive, easy-to-produce model that allows medical students to practice measuring lesions and performing FNAs using ultrasonography. Future studies could be explored to assess this model's role in medical student education., Competing Interests: Conflict of interest disclosure The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article., (Copyright © 2020 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Background: Current reimbursement policy surrounding telemedicine has been cited as a barrier for the adaptation of this care model. The objective of this study is to analyze the reimbursement figures for outpatient telemedicine consultation in vascular surgery., Methods: Patients first underwent synchronous telemedicine visits after receiving point-of-care ultrasound at one of 3 satellite locations of Henry Ford Health System in Michigan. Visit types included new, return, and postoperative patients. Reimbursement information related to payor, adjustment, denial, paid and outstanding balances were recorded for each telemedicine visit. Then, using an enterprise data warehouse, a retrospective analysis was performed for the aforementioned telemedicine visits. The data were analyzed to determine the outcome of total billed charges, number of denied claims, reimbursement per payor, reimbursement per patient, and out-of-pocket costs to the patients., Results: Among 184 virtual clinical encounters, the payors included Aetna US Healthcare, Blue Advantage, Blue Cross Blue Shield, Cofinity Plan, Health Alliance Plan, HAP Medicare Advantage, Humana Medicare Advantage, Medicaid, Medicare, Molina Medicaid HMO, United Healthcare, Blue Care Network, Aetna Better Health of Michigan, Priority Health, and self-pay. Among the 15 payors, reimbursement ranged from 0% to 67% of the total charges billed. Among the 184 virtual visits, a grand total of $22,145 was collected or an average of $120.35 per virtual encounter. The breakdown of charges billed was 40% adjusted, 41% paid by insurance, 10% paid by patient, and 13% denied. There were 27 total denials (15%). Denial of payment included telehealth and nontelehealth reasons, citing noncovered charges, payment included for other prior services, new patient quality not met, and not covered by payor. The average out-of-pocket cost to patients was $12.59 per visit., Conclusions: These reimbursement data validate the economic potential within this new platform of healthcare delivery. As our experience with the business model grows, we expect to see an increase in reimbursement from private payors and acceptance from patients. Within a tertiary care system, telemedicine for chronic vascular disease has proven to be a viable means to reach a broader population base, and without significant cost to the patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Accurate localisation of the abnormal hyperfunctioning gland with preoperative imaging has a critical role in parathyroid surgery to obtain a successful outcome. This study aimed to evaluate the diagnostic performance of second-line imaging and their contribution to the treatment success in primary hyperparathyroidism when the first-line methods were negative or discordant., Methods: Among the patients who underwent parathyroidectomy due to primary hyperparathyroidism, 33 who underwent four-dimensional computed tomography and/or four-dimensional magnetic resonance imaging because of negative or discordant first-line imaging results were included. Persistent and recurrent cases were excluded., Results: The majority of the patients were female (84.8%) and the mean age was 59.2 years. Seventeen patients had four-dimensional computed tomography and 25 had four-dimensional magnetic resonance imaging, respectively. Four-dimensional computed tomography and four-dimensional magnetic resonance imaging localised the culprit gland successfully in 52.9% and 84%, respectively. Twenty-five patients in whom single adenoma was detected underwent focused parathyroidectomy. The culprit gland was solitary in 32 cases and one patient had double adenoma. Normocalcaemia was achieved in all cases. Among the 29 patients who completed their postoperative sixth month success rate was 100%., Conclusion: Four-dimensional magnetic resonance imaging had high accuracy with fast dynamic imaging in detecting parathyroid adenomas. When the first-line imaging methods were negative or inconclusive, four-dimensional magnetic resonance imaging should be considered primarily since it is cost effective in Turkey and emits no radiation.

Background: More and more family physicians (FPs) are using point-of-care ultrasonography (POCUS) in Europe. Still, there is no general consensus about the specific knowledge and skills that a FP should acquire in order to effectively perform POCUS. The objective of this study was to identify indications for the use of POCUS among FPs, explore the barriers of its use and provide an expert opinion of FPs on knowledge and skills required to effectively implement POCUS in family practice., Methods: A modified two-round Delphi study was carried out among FPs using POCUS in Slovenia., Results: 21 FPs were invited to participate in the study. A total of 13 FPs (62%) responded the round-one questionnaire and 10 (48%) completed the round-two questionnaire. Results show a large variability of indications for the use of POCUS in family practice, the most common being acute abdominal conditions, lung ultrasonography and eyeballing echocardiography. In contrast, the results show little variability in barriers for the use of POCUS, the most common being lack of time, inaccessibility of specific training programmes and financial issues. There is a strong consensus on the knowledge and skills needed to perform POCUS. Panellists agreed on a learning medical knowledge, technical skills and expressed a need for individual consultations and tutorship options., Conclusion: This study proves that although POCUS is used in family practice for a wide variety of indications with a significant number of barriers, there is a strong consensus on what a FP needs to know to effectively perform POCUS.

Diabetes and atherosclerosis are the predominant causes of stroke and cardiovascular disease (CVD) both in low- and high-income countries. This is due to the lack of appropriate medical care or high medical costs. Low-cost 10-year preventive screening can be used for deciding an effective therapy to reduce the effects of atherosclerosis in diabetes patients. American College of Cardiology (ACC)/American Heart Association (AHA) recommended the use of 10-year risk calculators, before advising therapy. Conventional risk calculators are suboptimal in certain groups of patients because their stratification depends on (a) current blood biomarkers and (b) clinical phenotypes, such as age, hypertension, ethnicity, and sex. The focus of this review is on risk assessment using innovative composite risk scores that use conventional blood biomarkers combined with vascular image-based phenotypes. AtheroEdge™ tool is beneficial for low-moderate to high-moderate and low-risk to high-risk patients for the current and 10-year risk assessment that outperforms conventional risk calculators. The preventive screening tool that combines the image-based phenotypes with conventional risk factors can improve the 10-year cardiovascular/stroke risk assessment.

Purpose: This rapid scoping review addresses the commentary titled the ACR TI-RADS™: An Advance in the Management of Thyroid Nodules or Pandora's Box of Surveillance? suggesting that the 2017 American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS™-2017) adds to a plethora of existing guidelines, incorporates an inconsistent lexicon, and potentially contradicts recommendations., Materials and Methods: The author performed a rapid scoping review using a combination of English keywords to identify and review peer reviewed articles contained in electronic databases (e-databases) comparing 2 or more guidelines for managing adult thyroid nodules (GMTNs) with (UGMTNs) and without (non-UGMTNs) ultrasound. E-databases included Medline (PubMed), EBSCO, Google, and Google Scholar published (2010-2019)., Results: The search returned 28 articles, where the author identified 12 different guidelines. Most articles evaluated diagnostic performance (N = 26), not quality (N = 2) measures. The most commonly reviewed UGMTNs were in descending order ATA-2015, ACR TI-RADS™-2017, South Korean, and EU TI-RADS. No article reviewed all GMTNs or identified a generally accepted UGMTNs or non-UGMTNs. Primary origin continents were: North America (U.S.A), Asia (Japan, South Korea, Thailand), Europe (France, Italy, U.K.), and South America (Chile)., Conclusion: A plethora of UGMTNs may exist. No guideline enjoys general acceptance and evaluations of performance and quality vary., (© 2020 Wiley Periodicals, Inc.)

Background: Inaccurate diagnosis of appendicitis leads to increased costs and morbidity. Ultrasound costs less than computed tomography (CT) or MRI but has lower sensitivity and may not visualize the appendix., Methods: We conducted a cost-effectiveness analysis using a decision-analytic model of 10 imaging strategies for suspected appendicitis in a hypothetical cohort of patients: no imaging with discharge or surgery; CT only; MRI only; or staged approach with CT or MRI after 1) negative ultrasound result or ultrasound without appendix visualization, 2) ultrasound without appendix visualization, or 3) ultrasound without appendix visualization but with secondary signs of inflammation. Inputs were derived from published literature and secondary data (quality-of-life and cost data). Sensitivity analyses varied risk of appendicitis and proportion of visualized ultrasound. Outcomes were effectiveness (quality-adjusted life-years [QALYs]), total direct medical costs, and cost-effectiveness (cost per QALY gained)., Results: The most cost-effective strategy for patients at moderate risk for appendicitis is initial ultrasound, followed by CT if the appendix is not visualized but secondary signs are present (cost of $4815.03; effectiveness of 0.99694 QALYs). Other strategies were well above standard willingness-to-pay thresholds or were more costly and less effective. Cost-effectiveness was sensitive to patients' risk of appendicitis but not the proportion of visualized appendices., Conclusions: Tailored approaches to imaging based on patients' risk of appendicitis are the most cost-effective. Imaging is not cost-effective in patients with a probability <16% or >95%. For moderate-risk patients, ultrasound without secondary signs of inflammation is sufficient even without appendix visualization., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

The incidence of hepatocellular carcinoma (HCC) is increasing worldwide, with significant morbidity and associated costs. Treatment allocation depends on the stage of diagnosis; however, resource utilization can be significant across all stages. We aimed to summarize the available data on the cost effectiveness of surveillance of and treatments for HCC in the context of current treatment guidelines. We performed a focused review of studies investigating the economic burden and cost effectiveness of HCC surveillance treatment modalities published between January 2000 and January 2019. The overall economic burden of HCC is increasing in the USA and in several countries worldwide due to its rising incidence and the proliferation of therapies. Liver transplantation is a cost-effective strategy for early-stage HCC treatment in selected patients. In settings where liver transplantation is not available or in patients awaiting transplant, ablative or locoregional therapies are cost effective with increases in quality-adjusted life-years. First-line therapy with sorafenib for advanced stage HCC is cost effective in the treatment of compensated cirrhosis. The cost effectiveness of recently approved systemic therapies for advanced HCC require further investigation. Existing studies have shown that guideline-recommended surveillance techniques and several available therapies for the treatment of HCC are cost effective; however, there are limitations in the literature, including reliance on suboptimal modeling with incomplete/simplified model structure or inadequate inputs. With increasing therapeutic options in patients with HCC, understanding their relative value is critical in designing HCC treatment algorithms.

Objective: To estimate the cost-effectiveness of routine, screening renal bladder ultrasound (RBUS) for children age 2-24 months after a first febrile urinary tract infection (UTI), as recommended by the American Academy of Pediatrics., Study Design: We developed a decision analytic model that simulates a population of children after a first febrile UTI. The model incorporates the diagnostic utility of RBUS to detect vesicoureteral reflux and genitourinary anomalies. We adopted a health-system perspective, 5-year horizon, and included 1-way and 2-way sensitivity analyses. Costs were inflated to 2018 US dollars, and our model incorporated a 3% discounting rate. We compared routine RBUS after first, febrile UTI compared with routine RBUS after second UTI (ie, control arm). Our main outcomes were recurrent UTI rate and incremental cost per quality-adjusted life-year (QALY)., Results: Among children 2-24 months after a first febrile UTI, RBUS had an overall accuracy (true positives + true negatives) of 64.4%. The recurrent UTI rate in the intervention arm was 19.9% compared with 21.0% in the control arm. Thus, 91 patients would need to be screened with RBUS to prevent 1 recurrent UTI. RBUS increases QALYs by +0.0002 per patient screened, corresponding to an incremental cost-effectiveness ratio of $803 000/QALY gained. In the RBUS arm, 20.6% of children would receive unnecessary voiding cystourethrograms compared with 12.2% of children in the control group., Conclusions: Screening RBUS after a first, febrile UTI in children age 2-24 months does not meet cost-effectiveness guidelines. Our findings support deferred screening until a second UTI., (Copyright © 2019 Elsevier Inc. All rights reserved.)