Children with headache suspected of having a brain tumor: A cost-effectiveness analysis of diagnostic strategies

Objective. To assess the clinical and economic consequences of 3 diagnostic strategies-magnetic resonance imaging (MRI), computed tomography followed by MRI for positive results (CT-MRI), and no neuroimaging with close clinic al follow-up-in the evaluation of children with headache suspected of havin g a brain tumor. Three risk groups based on clinical variables were evaluat ed. Materials and Methods. A decision-analytic Markov model and cost-effectiven ess analysis was performed incorporating the risk group prior probability, MRI and CT sensitivity and specificity, tumor survival, progression rates, and cost per strategy. Outcomes were based on quality-adjusted life year (Q ALY) gained and incremental cost per QALY gained. Results. For low-risk children with chronic nonmigraine headaches of >6 mon ths' duration as the sole symptom (prior probability of brain tumor 0.01%), no neuroimaging with close clinical follow-up was less costly and more eff ective than the 2 neuroimaging strategies. For the intermediate-risk childr en with migraine headache and normal neurologic examination (prior probabil ity of brain tumor 0.4%), CT-MRI was the most effective strategy but cost > $1 million per QALY gained compared with no neuroimaging. For high-risk chi ldren with headache of <6 months' duration and other clinical predictors of a brain tumor such as an abnormal neurologic examination (prior probabilit y of brain tumor 4%), the most effective strategy was MRI, with cost-effect iveness ratio of $113800 per QALY gained compared with no imaging. Conclusion. Our analysis suggests that MRI maximizes QALY gained at a reaso nable cost-effectiveness ratio in children with headache at high risk of ha ving a brain tumor. Conversely, the strategy of no imaging with close clini cal follow-up is cost saving in low-risk children. Although the CT-MRI stra tegy maximizes QALY gained in the intermediate-risk patients, its additiona l cost per QALY gained is high. In children with headache, appropriate sele ction of patients and diagnostic strategy may maximize quality-adjusted lif e expectancy and decrease costs of medical workup.