Evaluation of the health economic impact of initial diagnostic modality selection in patients suspected of having HCC in China and the USA

Figures & data

Table 1. Sensitivity and specificity of each diagnostic modality.

Country	MDCT sensitivity	MDCT specificity	ECCM-MRI sensitivity	ECCM-MRI specificity	CEUS sensitivity	CEUS specificity	EOB-MRI sensitivity	EOB-MRI specificity
US	69.0%^9	94.0%^9	75.0%^9	86.0%^9	85.0%^14	91.0%^14	87.0%^9	94.0%^9
China	73.4%^10	91.4%^10	79.7%^10	87.3%^10	85.0%^14	91.0%^14	92.3%^10	95.3%^10

Abbreviations. US, United States; MDCT, multidetector computed tomography; EOB-MRI, gadoxetic acid-magnetic resonance imaging; ECCM-MRI, extracellular contrast media-magnetic resonance imaging; CEUS, contrast-enhanced ultrasound.

Table 2. Percentage of follow-on confirmatory diagnostic procedures required, by imaging modality.

Country	MDCT	ECCM-MRI	CEUS	EOB-MRI
US	45.7%^a	33.2%^a	97.0%^a	25.3%^a
China	61.4%^6	51.6%^6	50.0%^a	31.8%^6

Abbreviations. US, United States; MDCT, multidetector computed tomography; EOB-MRI, gadoxetic acid-magnetic resonance imaging; ECCM-MRI, extracellular contrast media-magnetic resonance imaging; CEUS, contrast-enhanced ultrasound.

^a Derived from expert interviews.

Table 3. Waiting times for/between diagnostic procedures.

	Modality	Time (weeks)
		US	China
Time from initial consultation to first imaging procedure	MDCT	0.6	0.3
	ECCM-MRI	1.3	2.0
	CEUS	0.3	0.3
	EOB-MRI	1.3	2.0
Time to biopsy	Biopsy	1.4	1.0
	Initial imaging result
Time between imaging procedures (subsequent to initial modality)	Positive	2.6	13.5
	Negative	4.4	27.0

Abbreviations. US, United States; MDCT, multidetector computed tomography; EOB-MRI, gadoxetic acid-magnetic resonance imaging; ECCM-MRI, extracellular contrast media-magnetic resonance imaging; CEUS, contrast-enhanced ultrasound.

Figures were derived from expert interviews.

Table 4. Diagnosis costs.

Category	Modality	US (USD)	China (CNY)
Scan	MDCT	722.50^15	1,266.10^10
	ECCM-MRI	929.00^15	1,294.70^10
	CEUS	181.10^15	700.00^a
	EOB-MRI	929.00^15	1,294.70^10
Contrast agent	MDCT	178.40^16	200.00^a
	ECCM-MRI	58.50^16	200.00^a
	CEUS	382.80^16	1,000.00^b
	EOB-MRI	162.50^16	1,200.00^a
Biopsy		750.00^17	1,888.70^10

Abbreviations. US, United States; MDCT, multidetector computed tomography; EOB-MRI, gadoxetic acid-magnetic resonance imaging; ECCM-MRI, extracellular contrast media-magnetic resonance imaging; CEUS, contrast-enhanced ultrasound.

^aDerived from expert interviews.

^bAssumption based on literature.

Table 5. Treatment costs.

Treatment	US (USD)	China (CNY)
Surgical resection	3,646.00^15	57.997.20^10
Ablation	3,789.90^15	30,270.50^10
TACE/TARE	19,900.90^16	24,485.20^10
Liver transplant	49,425.80^15	248,867.90^10
SBRT	5,345.90^16	Not used
Systemic therapy	43,743.00^a	134,934.70^b
Best supportive care	12,790.00^a	Not used

Abbreviations. US, United States; TACE, transarterial chemoembolization; TARE, transarterial radioembolization; SBRT, stereotactic body radiotherapy.

Note: SBRT and best supportive care were not included as treatment options in the China model.

^a Assumption based on costs in the CMS database and IBM Micromedex^15,16.

^b Assumption based on literature.

Figure 1. US decision tree. Based on local clinical guidelines and validated in expert interviews. Staging is based on the BCLC staging system. Abbreviations. HCC, hepatocellular carcinoma; MDCT, multidetector computed tomography; EOB-MRI, gadoxetic acid-magnetic resonance imaging; ECCM-MRI, extracellular contrast media-magnetic resonance imaging; CEUS, contrast-enhanced ultrasound; TACE, transarterial chemoembolization; TARE, transarterial radioembolization; SBRT, stereotactic body radiotherapy.

Figure 2. China decision tree. Based on local clinical guidelines and validated in expert interviews. Abbreviations. HCC, hepatocellular carcinoma; MDCT, multidetector computed tomography; EOB-MRI, gadoxetic acid-magnetic resonance imaging; ECCM-MRI, extracellular contrast media-magnetic resonance imaging; CEUS, contrast-enhanced ultrasound; TACE, transarterial chemoembolization.

Figure 3. US Markov model diagram. Abbreviation. BCLC, Barcelona Clinic Liver Cancer.

Figure 4. China Markov model diagram.

Figure 5. False-positive rates for each modality in each country. Abbreviations. US, United States; MDCT, multidetector computed tomography; EOB-MRI, gadoxetic acid-magnetic resonance imaging; ECCM-MRI, extracellular contrast media-magnetic resonance imaging; CEUS, contrast-enhanced ultrasound.

Figure 6. False-negative rates for each modality in each country. Abbreviations. US, United States; MDCT, multidetector computed tomography; EOB-MRI, gadoxetic acid-magnetic resonance imaging; ECCM-MRI, extracellular contrast media-magnetic resonance imaging; CEUS, contrast-enhanced ultrasound.

Figure 7. Number of patients out of 1,000 receiving unnecessary treatment in current practice compared to an increase of 35% in the use of EOB-MRI. Abbreviations. US, United States; EOB-MRI, gadoxetic acid-magnetic resonance imaging.

Figure 8. Number of patients out of 1,000 receiving a false-negative diagnosis in current practice compared to an increase of 35% in the use of EOB-MRI. Abbreviations. US, United States; EOB-MRI, gadoxetic acid-magnetic resonance imaging.

Table 6. Current and alternative distributions of each modality.

Country	MDCT original proportion	MDCT alternative proportion	ECCM-original proportion	ECCM-alternative proportion	CEUS original proportion	CEUS alternative proportion	EOB-original proportion	EOB-alternative proportion
US	39%	23.8%	41%	25.1%	10%	6.1%	10%	45%
China	40%	22.9%	40%	22.9%	2%	1.1%	18%	53%

Abbreviations. US, United States; MDCT, multidetector computed tomography; EOB-MRI, gadoxetic acid-magnetic resonance imaging; ECCM-MRI, extracellular contrast media-magnetic resonance imaging; CEUS, contrast-enhanced ultrasound.

Figure 9. Percentage of follow-on confirmatory diagnostic procedures required, by imaging modality. Abbreviations. US, United States; MDCT, multidetector computed tomography; EOB-MRI, gadoxetic acid-magnetic resonance imaging; ECCM-MRI, extracellular contrast media-magnetic resonance imaging; CEUS, contrast-enhanced ultrasound.

Figure 10. Distribution of patients according to the number of examinations to achieve a final diagnosis. Abbreviation. US, United States.

Figure 11. Unnecessary treatment costs are associated with each initial imaging modality for 1,000 patients. *Unnecessary treatment refers to patients who receive treatment after a false-positive HCC diagnosis. Abbreviations. US, United States; USD, MDCT, multidetector computed tomography; EOB-MRI, gadoxetic acid-magnetic resonance imaging; ECCM-MRI, extracellular contrast media-magnetic resonance imaging; CEUS, contrast-enhanced ultrasound.

Figure 12. Unnecessary treatment costs for 1,000 patients for current practice compared to an increase of 35% in initial EOB-MRI usage. *Unnecessary treatment refers to patients who receive treatment after a false-positive HCC diagnosis. Abbreviations. US, United States; EOB-MRI, gadoxetic acid-magnetic resonance imaging.

Figure 13. Waiting time to diagnosis and treatment decision for each first-line diagnostic modality. Abbreviations. US, United States; MDCT, multidetector computed tomography; EOB-MRI, gadoxetic acid-magnetic resonance imaging; ECCM-MRI, extracellular contrast media-magnetic resonance imaging; CEUS, contrast-enhanced ultrasound.

Figure 14. Average time to final diagnosis and treatment decision for current practice compared to an increase of 35% in EOB-MRI usage. Abbreviations. US, United States; EOB-MRI, gadoxetic acid-magnetic resonance imaging.

Figure 15. One-way sensitivity analysis results. The numbers in the brackets after the variables show the upper and lower limits tested in the one-way sensitivity analysis. Abbreviations. US, United States; MDCT, multidetector computed tomography; EOB-MRI, gadoxetic acid-magnetic resonance imaging; ECCM-MRI, extracellular contrast media-magnetic resonance imaging; CEUS, contrast-enhanced ultrasound.

Figure 16. Per patient cost-offset results for different EOB-MRI usage levels compared to baseline values (10% in US; 18% in China) for the decision tree model timeframe (from initial imaging to treatment selection). Abbreviations. US, United States; EOB-MRI, gadoxetic acid-magnetic resonance imaging.

Table 7. Current practice and alternative scenario modality distributions for scenario analyses.

		Current practice	Alternative scenarios
MDCT	US	39.0%	39.0%	26.0%	19.5%	13.0%
	China	40.0%	43.9%	29.3%	22.0%	14.6%
ECCM-MRI	US	41.0%	41.0%	27.3%	20.5%	13.7%
	China	40.0%	43.9%	29.3%	22.0%	14.6%
CEUS	US	10.0%	10.0%	6.7%	5.0%	3.3%
	China	2.0%	2.2%	1.5%	1.1%	0.7%
EOB-MRI	US	10.0%	10.0%	40.0%	55.0%	70.0%
	China	18.0%	10.0%	40.0%	55.0%	70.0%

Abbreviations. US, United States; MDCT, multidetector computed tomography; EOB-MRI, gadoxetic acid-magnetic resonance imaging; ECCM-MRI, extracellular contrast media-magnetic resonance imaging; CEUS, contrast-enhanced ultrasound.

When EOB-MRI proportion is increased, the proportion of each other modality decreases correspondingly.

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