POSITRON EMISSION TOMOGRAPHY (PET) USE BY TERTIARY HEALTH CARE CENT RES AND ITS ACCESSIBILITY TO POPULATION: A POLICY PERSPECTIVE. a BRIEF Cost-Benefit analysis.

1. HEALTH ECONOMICS EMSRHS,CORVINUSUNIVERSITY 1
PRESENTED BY:
AUTHOR: DR. SHOEB AHMED ILYAS
CO-AUTHOR: DR. ANEZA JALIL &
DR. MUHAMMAD AZEEM KHAN
USE OF PET – HEALTH CARE
POLICY PERSPECTIVES

2. POSITRON EMISSION TOMOGRAPHY (PET)
 “Ace for cancer screening”
 “Precise detector of early-stage
cancer”
 PET Scans--- “Saving lives” or
“prescribing proper care” ?
 “Defensive Medicine" or ‘Medico-
Legal cases” Doctors Choice in Clinical
Practice.
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3. PET Scan-formally introduced to the
medical community in 1970.
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4. PET SCAN
 Positron EmissionTomography, PET scan, ---nuclear medicine
imaging modality, use small amounts of radioactive material
(tracer) to diagnose cancers, heart disease and neurological
abnormalities.
 MRI orCT ---structure.
 PET measures metabolism—function
 Superior in differentiating tumor from benign lesions, and
malignant from non-malignant masses.
 Alzheimer's disease, Parkinson's disease, epilepsy and other
neurological conditions.
 Assess brain function after brain injury. Treatment can be
specified to enhance recovery.
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5. PET Images Looks Like-
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6. Benefits and Risks of Using PET
Benefits:
 MostUseful and
Unique Information.
 Precise Information
than Surgery.
 Detects Diseases which
are not possible by CT
& MRI.
Risks:
 Radiation Exposure-
equal to CT Scan.
 Allergic Reactions to
Radiopharmaceuticals
….Very Rare
 Pregnant,
breastfeedingwomen
need to be careful
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7. Policy Perspectives in Use of PET
 Many exciting and potentially valuable
therapies in health care settings compete for
funding – simply introducing all of them is
impossible.
 HealthTechnology Assessment (HTA)
evidence in the use of PET imaging which can
improve the length or quality of patients' lives
at reasonable cost, or it can reduce the
overall expenditure without substantially
reducing the effectiveness of patient care is
not established.
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8. Policy Perspectives in Use of PET
 Resources-- limited, demonstrating the cost
effectiveness of new technologies is an important
step in their introduction.
 Especially challenging for diagnostic technologies,
as randomized controlled trials may not be
appropriate. Outcome?
 Most of the studies report diagnostic accuracy rather
than improved patient outcomes.
 Direct evidence that such improvement occurs, and
is sufficient to meet the criteria for cost
effectiveness, from well-designed trials would
constitute the most immediately persuasive case for
the introduction of PET imaging.
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9. Policy Perspectives in Use of PET
 No evidence to indicate PET screening
reduces cancer mortality.
 The problem of false-negative results cannot
be ignored.
 Evidence of False-Negatives -
Yasuda and Ide found that 168 of 526
malignant tumor cases yielded negative PET
results, but were diagnosed as cancerous by
other procedures such as CT, MRI or
ultrasonography
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10. Policy Perspectives in Use of PET
 FDG accumulates physiologically in normal
tissues, inflammatory lesions and cancer tissues
resulting in false-positives that cause anxiety for
the participants and wasteful expenses of
additional examinations are required to
differentiate cancerous tissue from normal
tissue. (Ide M, 2006)
 PET is suitable for the diagnosis of cancers of the
lung, breast, colon, pancreas, head and neck, as
well as malignant lymphoma. However, it is not
suitable for the diagnosis of cancers of stomach,
kidney, bladder, prostate, liver or biliary tract, or
leukemia. (HideoYasunaga, 2007)
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11. Policy Perspectives in Use of PET
 Shortage of both medical and technical staff
trained in PET and a lack of training
opportunities.This is an issue that needs to
be addressed urgently if PET is to expand at
an appropriate rate.
 PET machine cost $5 million.
 PET scan cost $850–$4,000, depending on
the type of scan.
 Cancer screening for whole-body by use of
FDG-PET is approximately $1000 on
average.(Mitsutake N et al, 2007)
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12. Policy Perspectives in Use of PET
 PET interpretation undertaken by nuclear
medicine physicians who have little
experience of CT- Deficiency ofTrained
Doctors.
 Many Hospitals with PET facility have poor
co-operation between radiologist and nuclear
medicine physician in interpretation of PET
results.
 Radiologists specialized in cross-sectional
imaging and nuclear medicine are less for
expansion of PET technology.
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13. Policy Perspectives in Use of PET
 Referral of a patient for a FDG-PET scan by
Multi-disciplinary team (MDT) justified and
authorized by theAdministration of Radioactive
SubstancesAdvisoryCommittee (ARSAC)
certificate holder or appropriate delegate, as the
‘gatekeeper’.
 In manyCountries PET capacity is still limited to
three scanners per 15 million inhabitants.
 In case of PET use, there should be a maximum
2-month (62-day) interval from urgent GP
referral for suspected cancer to first definitive
treatment, and a maximum 1-month (31-day)
interval from diagnosis (i.e. the decision to treat)
to first definitive treatment.
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14. Few Examples In Use of PET
 University of California LosAngeles who
demonstrated,retrospectively, that PET-
directed management for patients being
considered for cardiac transplantation could save
U.S. $34,707 per patient referred [DuongTH et al
1996]
 In an Australian decision tree model, based on
sensitivities and specificities for detecting
mediastinal spread by use of FDG-PET scanning
with selected Mediastinoscopy was judged to be
able to saveAU$ 2128 per patient and potentially
reduce inappropriate surgery [Yap kk et al 2005].
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15. Few Examples In Use of PET
 The HealthTechnology Board of Scotland has
accepted PET based on sensitivity and specificity
reports than other techniques in the
investigation of a number of common
malignancies.
 Compared withCT only, CT and FDG-PET for all
patients led to a relative reduction in surgery of
70% for patients with mediastinal lymph node
metastasis.
 PET for all with anatomical CT was shown to be
cost-effectivecompared withCT only, with life
expectancy increased by 0.10 years and expected
cost savings. [Alzahouri l et al 2005].
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16. Few Examples In Use of PET
 For radical radiotherapy, FDG-PET/CT provides
the opportunity to delineate the planning target
volume (PTV) excluding areas of collapse or
consolidation seen onCT and increase in PTV
may result from including sites of disease not
apparent on CT. (Mah K et al, 2002)
 FDG-PET scanning can be performed for the
investigation of solitary pulmonary nodules
where biopsy is not possible or has failed,
depending on nodule size, position and
computed tomography (CT) characterization
[NICE 2005].
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17. Financing PET
Different Payment Methods-
 Reimbursement from Health Insurance.
 Copayments.
 Money from Donations.
 Out of Pocket
 Full coverage to the Deserving people by
Government Sick Fund.
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18. Economic Evaluation Tools
 Economic Evaluation of Health
Care Programs
 Cost Benefit Analysis (CBA)
 Cost Effectiveness Analysis
(CEA)
 Cost Utility Analysis (CUA)
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19. Factors to be considered for PET
acquisition-
PRIMARY ACTIVITIES SECONDARYACTIVITIES
 Appointmentplanning
 Preparation of the patient
 Injection/incorporationof
18F-FDG tracer
 Data acquisition of 18F-
FDG-PET procedure
 Data reconstruction of the
18F-FDG-PET procedure
 Reading of the 18F-FDG-
PET procedure
 Patient-care-related
activities
 Transport of 18F-FDG
tracer
 Dispensing the patient
dose
 Discharge file
management
 Internal quality control
 External maintenance.
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20. Standard Cost for PET-Conti et al.
(1994)
 Equipment and maintenance :$1,223 &
440/year.
 Building: $1,440,000 (20 years).
 Satellite scanner equipment: $2,091,540 (6
years)
 Average EAC: 954,000/year,
 EAC/patient: very high, since there were very
few patients.
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21. Cost reducing options
 Traditional PET imaging uses cameras
specifically designed for imaging
positron-emitting radioisotopes.
 Gamma cameras modified for “PET-like”
imaging may lower cost and offer more
accessible alternatives to traditional PET.
Both these PET systems have whole body
scanning capability.
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22. CONCLUSION
 In any health-care system with limited
resources, priorities for investment must be set
on the basis of clear evidence of benefit to
patients and good value for the money spent.
 Scarcity of health care resources necessitates
appropriate selection of Diagnostic technology
and its control in the diffusion of health care
markets.
 Commitment to high quality patient care is
essential in all health care settings.
 Rational resource management is needed in
resource poor countries.
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23. REFERENCES-
 Alzahouri K, LejeuneC,Woronoff-Lemsi MC,
Arveux P, Guillemin F. Cost-effectivenessanalysis
of strategies introducing FDG-PET into the
mediastinal staging of non-small-cell lung cancer
from the French healthcare system perspective.
Clin Radiol 2005;60:479—92.
 Conti, P., Keppler, J.S., Halls, J.M., 1994. Positron
emission tomography: a financial and
operational analysis.American Journal of
Roentgenology 162 (6),1279–1286.
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24. REFERENCES-
 DuongTH, FonarowG, Laks H, et al(1996).Cost
effectivenessof positron emission tomography
(PET) in the management of ischemic
cardiomyopathy patients who are referred for
cardiac transplantation. JAmColl Cardiol
;27:144A.
 HideoYasunaga(2007) Who wants cancer
screening with PET? A contingent valuation
survey in Japan.
 Ide M (2006). Cancer screening with FDG-PET. Q
J Nucl Med Mol Imaging ;50:23–7.
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25. REFERENCES-
 Mah K, Caldwell CB, UngYC, Danjoux CE, Balogh
JM,Ganguli SN, et al (2002). The impact of
(18)FDG-PET on target and critical organs in CT-
based treatment planning of patients with poorly
defined non-small-cell lung carcinoma: a
prospective study. Int J Radiat Oncol Biol Phys
;52:339—50.
 Mitsutake N, Fujii R, Oku S, FuruiY,Yasunaga H
(2007). Business administration of PET facilities:
a nationwide survey of prices for PET screening
and a cost analysis of three facilities. Kaku Igaku
Jpn J Nucl Med;44:125–9 [in Japanese]
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26. REFERENCES-
 Yasuda S, Ide M (2005). PET and cancer
screening. Ann Nucl Med. 19:167–77.
 Yap KK,Yap KS, Byrne AJ, Berlangieri SU,
Poon A, Mitchell P, et al(2005). Positron
emission tomography with selected
mediastinoscopy compared to routine
mediastinoscopy offers cost and clinical
outcome benefits for pre-operative staging of
non-small-cell lung cancer. Eur J Nucl Med
Mol Imaging 2005;32:1033—40.
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