Krug, Bruno
[UCL]
(eng)
Diagnostic accuracy studies alone are not sufficient; the test's impact on patient outcome ought to be performed. Before introducing a test in clinical practice, its societal impact should be assessed as well.The cost-effectiveness of diagnostic tests is often assessed by means of economic models. Modelling is particularly well suited for diagnostic tests because of the complexity and the uncertainty of many clinical decisions. Its major strength lies on an explicit and systematic approach to decision making. But the results of such an analysis are also largely dependent on the assumptions underlying the model and on the inclusion of all relevant costs and outcomes. This search for valid input parameters has been pursued in the current thesis.
Implicit in economic analysis is the concept of assigning some monetary cost to the considered intervention. Accurate data on resource cost of 18F-FDG-PET are often scarce and contradictory. One possible way to calculate reliable cost data is Activity-Based Costing (ABC), a cost calculation method that allocates resource costs to products based on activity consumption. ABC goes beyond being just a more accurate accounting system. This approach can be used for operational decision making to improve the departmental workflow as well as to understand the financial impact of changes in consumption patterns or of the acquisition of new equipment (cost management), like acquiring a new hybrid scanner or establishing a PET-CT facility.
In the first chapter of the thesis, we will conduct two comprehensive descriptive cost analyses based on the ABC methodology of an 18F-FDG-PET study and of the commercial production of 18F-FDG patient dose. The determination of accurate costs estimates will better identify the critical cost components and evaluate the impact in changes in cost patterns.
The quality of a pharmaco-economic evaluation crucially depends on the value of the data based on the best available up-to-date evidence on the intervention and its comparator. As in other branches of science and medical care, the majority of PET review articles are narrative rather than systematic. The key difference between them is, for the latter, the explicit and systematic searching methodology and the critical appraisal of the studies. One of the goals of the thesis is to illustrate the advantage of a systematic review. We therefore designed, in the second chapter, a systematic review of 18F-FDG-PET in the staging Cutaneous Malignant Melanoma work-up.
Patients with metastatic melanoma have traditionally been managed with various systemic treatments; however, overall survival with this approach has been disappointing. Conventional teaching has been that resection was not indicated when the cancer is disseminated. Several series have however reported long-term survival after resection of distant metastases. In the absence of more active agents, surgery should be therefore reconsidered in the treatment paradigm at least for some highly selected patients.
Recently, Petersen et al published a large prospective study on the management of patients with suspected pulmonary metastasized melanoma, showing that complete metastasectomy is the only factor affecting the overall survival.
Improved survival is dependent on careful patient selection. Even if most guidelines consider 18F-FDG-PET-CT to detect occult extra-pulmonary disease prior to lung metastasectomy, the societal impact has never been assessed. In the third chapter we investigate, by means of a Markov model, the cost-effectiveness of 18F-FDG-PET for the surgical management of pulmonary metastases from Cutaneous Malignant Melanoma.
Bibliographic reference |
Krug, Bruno. Economic evaluation of positron emission tomography : activity-based costing and modelling techniques in malignant melanoma. Prom. : Vander Borght, Thierry ; Crott, Ralph |
Permanent URL |
http://hdl.handle.net/2078.1/28717 |