The number of radiological studies performed annually, including ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI), has been increasing dramatically. This trend is influenced by several factors, including an aging population with multiple comorbidities and a higher number of overall studies obtained per patient and/or per time period ( ). More than ever before, radiology is playing an integral role during both initial investigations and follow-up of patients with acute and chronic illnesses. For example, Beinfeld and Gazelle ( ) determined that medical technology has accounted for 19% of the growth in hospital costs between 1998 and 2000 and that imaging costs at one major tertiary care center increased by 50% between 1996 and 2002.
In this challenging practice environment, evidence-based medicine has been recognized as an essential tool for deciding on appropriate diagnostic, medical, and interventional care for patients. Additionally, greater emphasis is being placed on cost-effectiveness analysis (CEA) and health-related quality of life (HRQOL) outcomes to guide utilization of high-tech, often high-cost, diagnostic and therapeutic radiological resources. Equally important (perhaps more so in certain situations), these often less tangible values are increasingly being measured in addition to the physical outcomes. Much of the early development of HRQOL assessments focused specifically on patients with cancer ( ) and those with chronic renal failure on hemodialysis ( ). In these two groups of patients, newly introduced therapies were sometimes associated with modest improvements in survival but simultaneously with potentially significant morbidity. In the field of radiology, CEA and HRQOL measurements can be applied to most patient-related scenarios, including screening tests that use imaging, as well as diagnostic radiology studies and interventional procedures.
Understanding health-related quality of life
Quality of life (QOL) is a concept with many meanings and encompassing many themes. HRQOL may be defined as the value assigned to the duration of life, as it is modified by impairments of functional health states, caused by disease, injury, attempted treatment, or a policy ( ). It can be used to evaluate radiology-related studies in the same way in which it is used in other medical and surgical fields. There are several core domains of HRQOL that are typically included in a global assessment. These include health perceptions, social functions (such as usual social roles, sexual roles, and communication), psychological function (including mood and emotional components), physical abilities (such as mobility, physical activity, and ability for self-care), and impairments (which take into account sensory functions and symptoms) ( ).
HRQOL assessment may be combined with survival data in order to merge morbidity and mortality impacts into a single measure. In many industrialized countries, length of life has been steadily increasing over the past century. This is in part due to improvements in hygiene and nutrition as well as preventative medicine and more effective disease-specific medical intervention. Therefore, similar to other medical domains, when assessing a new diagnostic radiology modality, simply determining “years of life gained” may be insufficient as the sole outcome measure. Rather, it is often the improvement in QOL specifically caused by the heath care intervention that is a better gauge of its effectiveness. Thus, when deciding which outcomes are appropriate to measure, investigators should determine the potential differences between patient groups with respect to the effects of the study or intervention, the potential side effects or unintended consequences, as well as the outcomes of interest to consumers, patients, and society at large.
Issues in health-related quality of life related to radiology practice
With all of these screening, diagnostic, and minimally invasive radiological studies being performed, there is potential for significant impact on an individual’s QOL. One of the issues of CEA and HRQOL in radiology is the remoteness of the radiology test from the ultimate clinical outcome. This clinical outcome often relies on the clinician who is managing the patient’s care and the effectiveness of available, nonradiological, therapies. Nevertheless, radiology does contribute toward certain aspects of HRQOL. For instance, a patient may experience anxiety related to undergoing a new or perhaps unfamiliar type of radiological study. In addition, a patient might be subjected to significant discomfort related either directly or indirectly to the study, as a result of claustrophobia or back pain from lying for a prolonged period in an MRI machine, or perhaps from localized pain and systemic fevers related to an interventional procedure, such as uterine artery embolization. Additionally, financial and social impacts due to time away from work (opportunity costs) or from family activities may also affect patients’ HRQOL.
In situations where a patient may undergo one of several available types of diagnostic tests, the choice of which to perform has traditionally been decided by the ordering physician. However, with greater emphasis now being placed on patient autonomy, compounded with the increasing use of radiology, HRQOL factors and patient preference for attributes of a test (such as avoidance of pain, invasiveness, or inconvenience), unrelated to scientifically determined sensitivity and specificity of the test, are more commonly entertained. This is particularly relevant when a patient is presented with many different investigative imaging modalities to choose from, all of which may have a similar diagnostic accuracy. From a patient’s point of view, it may be worth waiting a period of time for a newer, less readily available and perhaps pain-free test that can give similar information, compared to a more readily available but invasive or uncomfortable standard method. These are issues that can be better evaluated by using HRQOL models and can be combined with CEA.
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Measuring health-related quality of life
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Determining patient utilities
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Quality-adjusted life-year and its costs
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Cost of life calculations
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Understanding cost-effectiveness
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Health-related quality of life and cost-effectiveness analysis influences in radiology
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Discounting
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Understanding test disutility
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Measuring test disutility
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Future directions
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