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Purpose To evaluate the cost-effectiveness of multiparametric diagnostic magnetic resonance (MR) imaging examination followed by MR imaging-guided biopsy strategies in the detection of prostate cancer in biopsy-naive men presenting with clinical suspicion of cancer for the first time. Materials and Methods A decision-analysis model was created for biopsy-naive men who had been recommended for prostate biopsy on the basis of abnormal digital rectal examination results or elevated prostate-specific antigen levels (age groups: 41-50 years, 51-60 years, and 61-70 years). The following three major strategies were evaluated: (a) standard transrectal ultrasonography (US)-guided biopsy; (b) diagnostic MR imaging followed by MR imaging-targeted biopsy, with no biopsy performed if MR imaging findings were negative; and (c) diagnostic MR imaging followed by MR imaging-targeted biopsy, with a standard biopsy performed when MR imaging findings were negative. The following three MR imaging-guided biopsy strategies were further evaluated in each MR imaging category: (a) biopsy with cognitive guidance, (b) biopsy with MR imaging/US fusion guidance, and (c) in-gantry MR imaging-guided biopsy. Model parameters were derived from the literature. The primary outcome measure was net health benefit (NHB), which was measured as quality-adjusted life-years (QALYs) gained or lost by investing resources in a new strategy compared with a standard strategy at a willingness-to-pay (WTP) threshold of $50 000 per QALY gained. Probabilistic sensitivity analysis was performed by using Monte Carlo simulations. Results Noncontrast MR imaging followed by cognitively guided MR biopsy (no standard biopsy if MR imaging findings were negative) was the most cost-effective approach, yielding an additional NHB of 0.198 QALY compared with the standard biopsy approach. Noncontrast MR imaging followed by in-gantry MR imaging-guided biopsy (no standard biopsy if MR imaging findings were negative) led to the highest NHB gain of 0.251 additional QALY compared with the standard biopsy strategy. All MR imaging strategies were cost-effective in 94.05% of Monte Carlo simulations. Analysis by age groups yielded similar results. Conclusion MR imaging-guided strategies for the detection of prostate cancer were cost-effective compared with the standard biopsy strategy in a decision-analysis model. RSNA, 2017 Online supplemental material is available for this article.

BACKGROUND:The strategic framework on multiple chronic conditions released by the US Department of Health and Human Services calls for identifying homogeneous subgroups of older adults to effectively target interventions aimed at improving their health. OBJECTIVE: We aimed to identify combinations of chronic conditions, functional limitations, and geriatric syndromes that predict poor health outcomes. DESIGN, SETTING AND PARTICIPANTS Data from the 2010-2012 Health and Retirement Study provided a representative sample of U.S. adults 50 years of age or older (n=16,640). MAIN MEASURES: Outcomes were: Self-reported fair/poor health, self-rated worse health at 2 years, and 2-year mortality. The main independent variables included self-reported chronic conditions, functional limitations, and geriatric syndromes. We conducted tree-based classification and regression analysis to identify the most salient combinations of variables to predict outcomes. KEY RESULTS: Twenty-nine percent and 23 % of respondents reported fair/poor health and self-rated worse health at 2 years, respectively, and 5 % died in 2 years. The top combinations of conditions identified through our tree analysis for the three different outcome measures (and percent respondents with the outcome) were: a) for fair/poor health status: difficulty walking several blocks, depressive symptoms, and severe pain (> 80 %); b) for selfrated worse health at 2 years: 68.5 years of age or older, difficulty walking several blocks and being in fair/poor health (60 %); and c) for 2-year mortality: 80.5 years of age or older, and presenting with limitations in both ADLs and IADLs (> 40 %). CONCLUSIONS: Rather than chronic conditions, functional limitations and/or geriatric syndromes were the most prominent conditions in predicting health outcomes. These findings imply that accounting for chronic conditions alone may be less informative than also accounting for the co-occurrence of functional limitations and geriatric syndromes, as the latter conditions appear to drive health outcomes in older individuals.

Transversus abdominis plane blocks improved immediate short-term opioid use and pain outcomes. Pain improvement was durable throughout the hospital stay. However, the blocks did not translate into less overall narcotic use, shorter length of stay, or lower readmission rates.

Objective To analyze trends in utilization of pre-surgical evaluations including video-EEG (VEEG) monitoring, intracranial EEG (IEEG) monitoring, and epilepsy surgery from 1998 to 2009 in the U.S. Methods Data from the Nationwide Inpatient Sample were used to identify admissions for pre-surgical evaluations and surgery. Surgical treatment of epilepsy was identified by the presence of primary ICD-9-CM procedure codes 01.52 (hemispherectomy), 01.53 (lobectomy), or 01.59 (other excision of the brain, including amygdalohippocampectomy). We calculated annual rates of pre-surgical evaluations and surgery based on published estimates of prevalence of epilepsy in the U.S. In addition, we examined variations by region and hospital characteristics, and conducted multivariable analysis to detect temporal trends, adjusting for changes in the population. Sensitivity analysis was also conducted using different algorithms to identify the study population and outcomes. Results We detected an increase in the rate of hospitalizations related to intractable epilepsy. Similarly, we noted a significant increase in hospitalizations for VEEG monitoring, but not in IEEG monitoring or in surgery. Multivariable analysis and sensitivity analysis confirmed these results. In addition, there was a significant increase in the proportion of pre-surgical evaluations and surgery performed in non-teaching hospitals. Conclusions Despite the increase in VEEG monitoring, the availability of guideline and evidences demonstrating benefits of epilepsy surgery was not associated with a greater employment of surgery over time. Nevertheless, access to pre-surgical evaluations and epilepsy surgery is no longer limited to large medical centers.

OBJECTIVE To examine the impact of individual and community characteristics on access to specialized epilepsy care. METHODS This retrospective cross-sectional study analyzed data from the California State Inpatient Sample, the State Ambulatory Surgery Database, and the State Emergency Department Database, that were linked with the 2009 Area Resource File and the location of the National Association of Epilepsy Center’s epilepsy centers. The receipt of video-EEG monitoring was measured and used to indicate access to specialized epilepsy care in subjects with persistent seizures, identified as those who had frequent seizure-related hospital admissions and/or ER visits. A hierarchical logistic regression model was employed to assess barriers to high quality care at both individual and contextual levels. RESULTS Among 115,632 persons with persistent seizures, individuals who routinely received care in an area where epilepsy centers were located were more likely to have access to specialized epilepsy care (OR: 1.81, 95% CI: 1.20, 2.72). Interestingly, the availability of epilepsy centers did not influence access to specialized epilepsy care in people who had private insurance. In contrast, uninsured individuals and those with public insurance programs including Medicaid and Medicare had significant gaps in access to specialized epilepsy care. Other individual characteristics such as age, race/ethnicity, and the presence of comorbid conditions were also associated with disparities in access to specialized care in PWE. CONCLUSION Both individual and community characteristics play substantial roles in access to high quality epilepsy care. Policy interventions that incorporate strategies to address disparities at both levels are necessary to improve access to specialized care for PWE.

Independent of patient- and hospital-level factors, blood product utilization continues to increase for all cardiac operations despite publication of blood conservation guidelines in 2007.