Methods: We examined prospective data from 206 patients with suspected PC who received care at the Charité University Hospital from 08/1999-11/2001 and underwent each of the following examinations: ultrasound (US), magnetic resonance imaging (MRI), computed tomography (CT), endoscopic ultrasound (EUS), fluorodeoxyglucose-positron-emission-tomography (PET), and endoscopic-retrograde-cholangio-pancreaticography (ERCP). Diagnostic costs were based on the German tariff for hospital services. We constructed a decision tree to predict diagnostic costs and diagnostic accuracy for both assessment of PC and resectability. We evaluated 44 strategies, based on single tests as well as combinations of two tests. For the base case analysis, we used point estimates of the conditional probabilities to perform a cohort simulation.
Results: The least costly and least effective strategy was ‘US alone' with 62% correctly identified patients (CIP) and mean costs of Euro 38 per patient. ‘CT alone' classified 10% more patients correctly, resulting in an incremental cost-effectiveness ratio (ICER) of Euro 1,925 per CIP. Strategy ‘MR alone', correctly classifying 5% more than ‘CT alone', had an ICER of Euro 3,479 per CIP. The most effective strategy ‘MR followed by ERCP for positive results' had also the largest ICER of Euro 14,467 per CIP.
Conclusions: Our study suggests that using MR as first test in the evaluation of patients with suspected PC results in the maximum number of CIPs. Whether adding ERCP after positive test results is good value for the money depends on the willingness-to-pay.