Abstract
Purpose
To identify evidence-based indications for PET/PET–CT scans in support of facilities planning and to describe a pilot project in which this information was applied for an investment decision in an Austrian region. The study updates a Health Technology Assessment (HTA) report (2015) on oncological indications, extending it to neurological indications and inflammatory disorders.
Methods
A systematic literature search to identify HTA reports, evidence-based guidelines, and systematic reviews/meta-analyses (SR/MA) was performed, supplemented by a manual search for professional society recommendations and explicit “not-to-do’s”. A needs-assessment was conducted in the context of the pilot study on investing in an additional PET–CT scanner in the Austrian region of Carinthia.
Results
Overall recommendations for indications as well as non-recommendations for the three areas (oncology, neurology, and inflammatory disorders) were compiled from the 2015 PET–HTA report and expanded for a final total of ten HTA, comprising 234 (positive and negative) recommendations from professional societies and databases, and supplemented by findings from 23 SR/MA. For the investment decision pilot study in Carinthia, 1762 PET scans were analyzed; 77.8% were assigned to the category “recommended evidence-based indications” (54.7%), “not recommended” (1.8%) or “contradictory recommendations” (21.3%). The remaining could not be assigned to any of the three categories.
Conclusions
The piloting of PET capacity planning using evidence-based information is a first of its kind in the published literature. On one hand, the high number of PET scans that could not be ascribed to any of the categories identified limits to the instructive power of the study to use evidence-based indication lists as the basis for a needs-assessment investment planning. On the other hand, this study reveals how there is a need to improve indication coding for enhanced capacity planning of medical services. Overall recommendations identified can serve as needs-based and evidence-based decision support for PET/PET–CT service provision.
Similar content being viewed by others
Explore related subjects
Discover the latest articles, news and stories from top researchers in related subjects.Avoid common mistakes on your manuscript.
Introduction
Europe is one of the largest markets for the fast-growing sector of medical devices (MDs) and diagnostic procedures, which encompass a broad and heterogeneous range of technologies. Due to the rising costs associated with introducing of new MDs and procedures into the healthcare system, payers have started to pay more attention to the effectiveness and financial implications of such new technologies. In this context, health technology assessment (HTA) has gained increasing recognition at the European level as a decision support tool [1].
No other medical technology has been evaluated as frequently by HTA institutions in European countries as “positron emission tomography (PET)”, or rather “positron emission tomography/computed tomography (PET/PET–CT)” [2, 3]. In its 2015 assessment report [4] on PET/PET–CT, the Ludwig Boltzmann Institute for Health Technology Assessment (LBI-HTA) aimed to capture the evidence base on oncological indications for a needs-based planning of PET/PET–CT facilities in Austria. It identified around 160 assessments on PET or PET–CT in a 10-year period (2004–2014), of which the first HTA were already published in 1995. This expresses uncertainty about the value of PET diagnostics in patient care. Notably, despite ongoing and controversial discussions about the patient-relevant benefits of PET/PET–CT, these technologies have rapidly been adopted both in Europe and abroad [2]. Additionally, the majority of those assessments is not accompanied by decisions regarding the reimbursement or planning of PET/PET–CT indications or devices. However, several approaches exist to deal with (to varying degrees) uncertain evidence or contradictory recommendations around reimbursement and capacity planning in Europe and globally [4]. In practice, capacity planning employs a mix of different methods and methodological approaches such as comparative approaches (e.g., benchmarking), analytical (e.g., health care needs-assessment) and/or reactive approaches (e.g., waiting lists). To provide volume forecasts for facility planning and workload vis-à-vis PET/PET–CT, the number of patients with (sub-)indications is important as is the estimated number of patients eligible for therapy monitoring and radiotherapy dose planning. In addition, some special features of PET/PET–CT (e.g., required radionuclides/tracers) have to be taken into account. Yet the planning of capacities based on evidence-based indications is rarely seen—neither in the literature nor in practice.
On the initiative of the German Society for Nuclear Medicine (DGN), the LBI-HTA and the Department of Health Care Management at the Berlin University of Technology collaborated to (1) update the LBI-HTA 2015 report to identify indications recommended by evidence [HTA, systematic reviews/meta-analyses (SR/MA), evidence-based guidelines (EBG)] for PET/PET–CT scans supporting facility planning in Germany and Austria and (2) describe a pilot study which applied those recommendations identified in the evidence review from step (1) to an investment decision in the Austrian region of Carinthia. The subsequent, updated, HTA report extended the scope of the 2015 report by including indications for neurology and inflammatory disorders in addition to oncological indications.
The following article summarizes both the results of the updated PET–HTA report, which has already been published (in German [5]), and the pilot study in Austria testing the practicalities of the recommendations.
Materials and methods
(1) Evidence-based indications and recommendations
Sources of information, search strategy, and study selection
A systematic literature search was carried out in July 2017 to identify HTA reports, SR/MA, and EBG to be included in the study. The databases MEDLINE, EMBASE, PubMed, and Cochrane Library were searched using a search strategy retrieved from a published report by the German Institute for Quality and Efficiency in Health Care (IQWiG), which was then updated and adapted [6]. A 5-year window (2012–2017) for EBG and SR/MA was chosen [7]. HTA for the newly included indications (neurology and inflammatory disorders) were limited to the last 10 years (2007–2017), while the most recent HTA [8–10] included in the PET–HTA report [4] were used for oncological indications, though oncological guidelines already included in the PET–HTA were updated if newer ones were available. Details about the searches are found in the Appendix A of the report [5] and a translated version is found in the Online Resource 1 of this article.
The literature was screened in a two-stage process (First: title/abstract; second: full text) by two researchers of the author group. Inclusion and exclusion criteria were determined based on the criteria from the PET–HTA report 2015 [4] for consistency. English- and German-language HTA, SR/MA, and EBG on the benefits of PET/PET–CT were included, if they discussed (1) patient-relevant benefits; (2) diagnostic accuracy/quality or change in patient management; (3) if they focused on one of the three indications/treatment areas (oncological and neurological indications, or inflammatory diseases); (4) were developed with an evidence-based methodology (e.g., a description of a literature search referenced more than two databases, inclusion/exclusion criteria and quality assessment, and double-check principle); and (5) were freely available. Differences in the assessment of literature were resolved through discussion and consensus building. A detailed overview of the criteria for inclusion and exclusion can be found in the Online Resource 2 of this article.
In addition to the systematic search, a supplementary, comprehensive manual search for evidence-based recommendations on the use of PET/PET–CT was conducted. The selection of databases or websites [e.g., Cancer Care Ontario (CCO) and National Comprehensive Cancer Network (NCCN)] was based on the PET–HTA report 2015 [4] and complemented by relevant sources for the two new indications. The search could not be carried out in a systematic manner due to variation in search interfaces, but the search term PET was a common factor. Up-to-date recommendations of the following national and supranational societies of nuclear medicine were included: Austrian Society of Nuclear Medicine and Molecular Imaging (ÖGN), German Society for Nuclear Medicine (DGN), Swiss Society for Nuclear Medicine (SGNM), European Association of Nuclear Medicine (EANM), Society of Nuclear Medicine and Molecular Imaging (SNMMI), and Joint Collaboration of EANM and SNMMI. Databases (e.g., Choosing Wisely, NICE Do-not-Do database) that explicitly identify “inappropriate” (not-to-do) services were also included as a source of information. Screening of documents from websites or professional societies was carried out by one person, with the extraction performed using the double-check principle. During the process of updating the HTA report, information sources were again scanned between January and February 2018.
Data extraction
Extraction tables were compiled separately for the three indications, using the double-check principle. In a first summary table, study characteristics were extracted separately, because they differ among HTA (e.g., reported endpoints and number of included studies), SR/MA (e.g., reference standard), and EBG (e.g., funding/sponsoring and strength of the evidence). Evidence derived from HTA and SR/MA was thus presented in the further tables including the evidence base and verbatim conclusions. The recommendations from EBG and websites and databases of national and supranational societies were first extracted in tabular form and assessed along two dimensions: (1) appropriate use criteria and (2) inappropriate use criteria (e.g., suspension of decisions, recommendations based on insufficient evidence, and disinvestment recommendations), including also the corresponding strength of the evidence. Recommendations of a certain level/strength of evidence (see Box 1) were then considered and clustered according to type and content of recommendations for further analysis into their similarities and differences.
(2) Pilot study: evidence-based PET/PET–CT planning
A study was carried out to guide the investment decision for an additional PET–CT scanner in the region of Carinthia in Austria (561,000 inhabitants). First, a needs-assessment based on a data analysis of PET scans was conducted. Diagnoses were coded according to the International Statistical Classification of Diseases and Related Health Problems 10th revision (ICD-10, 2016 [14]). All PET scans performed from January to September 2017 were retrieved and clustered according to disease diagnosis (e.g., tumour type: C.00; malignant neoplasm of lip) and, if available, to subgroups of indications (e.g., C00.1 external lower lip). The information was then matched to identify recommendations for evidence-based indications or non-indications [see step (1)]. Indications with contradictory recommendations were—due to lack of detailed clinical information—ascribed to the category of dissenting or unclear evidence from HTA and/or guidelines. The categorization as well as the matching with evidence-based indications was performed by two researchers.
Results
(1) Evidence-based indications and recommendations
Results of the evidence selection process
The systematic search yielded 10,873 references (Fig. 1). After the removal of duplicates (2729 references) and the—ex post—introduction of a time limit (due to an enormous amount of materials), 4299 references were ultimately excluded and 3845 references remained for the two-step screening. Of these, 3412 references were excluded according to the inclusion and exclusion criteria, leaving 433 full texts, 43 of which were finally included (10 HTA reports, 20 SR/MA, and 13 EBG). An overview of the excluded references (n = 390) with reasons can be found in the Appendix D of the updated HTA report [5]. The screening of the collected alerts of the database searches (update: from July to December 2017) resulted in three more HTA, one EBG, and three SR/MA. As such, a total of 47 references were included.
The updated search results in guideline databases and websites and databases of relevant national and supranational societies regarding recommendations (see tables in report [5]) was compared with the results of the systematic research and the PET–HTA Report 2015, resulting in additional “appropriate use” recommendations from seven professional societies: DGN and the joint collaboration between EANM and SNMMI, RCP/RCR, ACR Appropriateness Criteria®, CAR Referral Guidelines, and two oncology expert networks for guideline development, CCO and NCCN. It also resulted in concrete “not-to-use” recommendations from four societies or databases: ACR, CAR, and the two disinvestment databases Choosing Wisely and NICE Do-not-Do database. Thus, a total of ten HTA, and 234 positive and negative recommendations from professional societies and databases were included, supplemented by the statements from 23 SR/MA.
Evidence on oncological indications
Study characteristics
The PET–HTA report (2015) included 35 HTA assessments on 20 oncological indications. In addition, the report update revealed two novel HTA on bronchial carcinoma from the US Agency for Healthcare Research and Quality (AHRQ) [15] and the HTA-Center for the Västra Götaland Region, Sweden [16] as well as one HTA each on mamma carcinoma, compiled also by AHRQ [15], on penile/testicular carcinoma and on bladder/renal cancer, the latter two compiled by the Scottish Health Technologies Group within Healthcare Improvement Scotland (SHTG/HIS [17–20]). For further oncological indications considered in the PET–HTA report 2015, no more recent HTA was found. Reported endpoints in the included studies used for the HTA reports refer to diagnostic accuracy (mainly tumour grading and change in management).
Recommendations as well as non-recommendations (n = 188) from professional societies (see Box 1 for abbreviations) were retrieved and extracted from AANS/CNS [21], ACCP [22], BSH [23], CCO [24–26], DGN [27], IMWG [28], and RCR/RCP [29]. Three common guidelines, one from SNMMI/EANM and others (ACNM, ACPM, ASCO, CANM, and SPR) [30], one from RANO/EANO [31], and one from EANM/SNMMI [32], were also considered. One guideline (Ryken et al. [33]) has been elaborated by several universities.
Three guidelines (CCO [24], RCR/RCP [29], SNMMI/EANM/others [30]) provided recommendations for tumours generally as well as for non-oncological indications. Another three guidelines dealt with tumours of the head (DGN [27], Ryken [33], RANO/EANO [31]); two focused on myeloma (BSH [23], IMWG [28]); and one guideline addressed prostate cancer (EANM/SNMMI [32]), anal canal carcinoma (CCO [25]), lung carcinoma (ACCP [22]), paraneoplastic syndrome (PNS) (CCO [26]), and pituitary adenoma (AANS/CNS [21]), respectively. The recommendations of ACR [34], CAR [35] and NCCN [36] as well as the explicit non-recommendations of choosing Wisely [37] and NICE Do-not-Do [38] were also considered.
Moreover, 12 SR/MA for seven oncological sub-indications were included [39,40,41,42,43,44,45,46,47,48,49,50]; of those, two supplemented an HTA report [49, 50] and all considered diagnostic accuracy as an endpoint, especially for primary diagnosis and staging for pre-treatment/treatment planning. The systematic reviews consisted primarily of retrospective studies.
Quality assessment
The quality of the HTA was overall very good, with only a few questions not evaluated with “yes”. The assessment of the quality of the guidelines varied. In domain 1: “scope and purpose” and domain 4: “clarity of presentation”, the guidelines received high ratings and there were fewer variations among the guidelines. Domain 3 (“rigour of development”), which considers the accuracy of guideline development, ranged from 11% (DGN [27]) to 93% (ACCP [22]), showing the largest differences among the guidelines. In the overall rating, the ACCP guideline [22] was given a score of 5.67 (max. 7) and also ranked highest among two domains 3 and 4. The RCR/RCP guideline [29] attained last place with a mean score of 2.67.
The quality of the SR/MA in terms of overall qualitative assessment (no overall score) revealed that 10 out of 12 were “critically low”. Hence, the SR/MA is used only as supplementary information.
Overall recommendations
Table 2 provides an overview of the overall recommendations on oncological indications (see also Table 1 for the explanation of colors and categories).
There is a (relative) consensus that there is sufficient evidence for sub-indications in eight indications in favour of PET or PET–CT examinations (in Table 2 highlighted green). The first six were already determined in the 2015 report—(1) bronchial carcinoma (update: mainly pre-treatment, contradictory in re-staging and response control and in therapy monitoring), (2) colon carcinoma, (3) malignant lymphoma, (4) malignant melanoma (update: contradictory for diagnosis of recurrence), (5) mamma carcinoma (treatment response, for diagnosis of recurrence), and (6) head–neck tumours (in 2015 report: CUP, thyroid carcinoma; update: mainly for diagnosis of recurrence)—while two new treatment areas were added by the update: (7) myeloma and (8) neuroendocrine tumours.
There is a (relative) consensus that, in eight other indication areas, there was too little evidence in favour of PET examination (individual decisions possible) (in Table 2 highlighted red): (1) bladder carcinoma, (2) hepatic cancer, (3) cervical carcinoma, (4) gastric cancer, (5) ovarian and (6) uterus carcinoma, (7) prostate cancer, and (8) paraneoplastic neurological syndrome.
For a further set of eight indications, there is contradictory and equivocal evidence and recommendations were developed along with reservations (in Table 2 highlighted yellow or blue): (1) anal canal, (2) brain (especially glioma), (3) testicular, (4) renal, (5) penile carcinoma, (6) esophagus cancer (except re-staging), and (7) pancreatic carcinoma as well as (8) bone and soft-tissue tumour (+ gastrointestinal stromal tumour).
Evidence on neurological indications
Study characteristics
Two HTA reports were identified about neurological indications for the use of PET—one from the Australian Medical Services Advisory Committee (MSAC) [51] looking into Alzheimer’s dementia (AD) and one compiled by the Canadian Agency for Drugs and Technologies in Health (CADTH) on epilepsy [52]. Reported endpoints in the included studies of these HTA reports refer mainly to diagnostic accuracy; no study could be identified that investigates diagnostic effectiveness and safety.
Recommendations and non-recommendations (n = 28) from professional societies (see Box 1 for abbreviations) were retrieved and extracted from CCO [24, 53], EFNS [54], RCR/RCP [29], SNMMI/AA [55], and a common guideline from EANM/SNMMI [56]. RCR/RCP [29] provides recommendations for several non- and oncological indications. Two further guidelines ([54, 55]) consider Alzheimer’s dementia/dementia (ADD) or AD only, while another guideline (EANM/SNMMI [56]) presents general recommendations on brain-related disorders (refer to SNMMI/AA [55]) CCO [24, 53] (two guidelines) which considers epilepsy. In total, three SR/MA were included (for AD) [57,58,59]. All consider diagnostic accuracy in terms of primary diagnosis as the endpoint. Primarily, prospective studies were included in the SR/MA.
Quality assessment
The quality of the HTA was rated as very good, with only one question not judged as “yes”. The assessment of the quality of the guidelines showed that domains 1 (“scope and purpose”) and 4 (“clarity of presentation”) received very high ratings and are quite consistent. However, in terms of editorial independence, applicability, and accuracy of the guideline development, big differences were observed. In the overall assessment, SNMMI/AA [55] ranks first; RCR/RCP is in last place [29]. All the SR/MA rated “critically low” in the overall quality assessment (no comprehensive score). As such, the SR/MA are to be used as supplementary information for the overall recommendations.
Overall recommendations
For recommendations of neurological indications, evidence identified and presented only two sub-indications: Alzheimer’s dementia/dementia and epilepsy (see Table 3 for details).
There is a (relative) agreement that there is not sufficient evidence in favour of a PET/PET–CT for either of these two sub-indications (in Table 3 highlighted red), though professional societies uniformly/consistently name specific cases of AD or specific patient characteristics that speak for/against the use of PET, depending mainly on the respective tracer (amyloid vs. FDG). These recommendations, however, are only based on one source [55, Update: 60] and the authors themselves acknowledge the limitations, stating that, “At the time of this review, experience with clinical amyloid PET imaging [was] limited. Most published studies to date … [were] designed to validate this technology and understand disease mechanisms rather than to evaluate applications in clinical practice. As a result, published data are available primarily from highly selected populations with prototypical findings rather than from patients with comorbidities, complex histories, and atypical features often seen in clinical practice (e7)” [55].
Equivocal evidence (e.g., contradictory between HTA and EBG in Table 3, highlighted yellow or blue) was also found for the application of PET/PET–CT in patients having epilepsy (again, only in certain cases, in specialized epilepsy centres), though there is (some) consensus among the professional societies.
Evidence on inflammatory disorders
Study characteristics
In total, three HTA could be included about inflammatory disorder indications. One focused on infections in general from CADTH [61], dating back to 2008, and two other reports (each consists of a scoping report and an advice statement) from SHTG/HIS (2013) focus on pyrexia of unknown origin and sarcoidosis [62–65]. Reported endpoints in the studies within these HTA reports refer to diagnostic accuracy (mainly for primary diagnosis).
Recommendations and non-recommendations (n = 18) from professional societies (see Box 1 for abbreviations) were retrieved and extracted from ECCO/ESGAR [66], a common guideline of EANM/SNMMI [67] and RCR/RCP [29] who gave recommendations for several non-oncological indications. EANM/SNMMI [67] gave general recommendations on inflammatory disorders and ECCO/ESGAR [66] considers inflammatory bowel disease alone. Explicit non-recommendations by Choosing Wisely [37] or NICE Do-not-Do [38] were not identified.
In total, eight SR/MA were included for five indications [68,69,70,71,72,73,74,75]. All but two reviews [68, 69] include a meta-analysis and consider diagnostic accuracy as the primary endpoint.
Quality assessment
The quality of the three HTA was rated “very good”, with only a few questions that could not be judged “yes”. And the quality of the three guidelines revealed that domain 3 [on the rigour of the guideline development (including evidence clearly assigned to recommendations)] ranges widely, from 16% (RCR/RCP [29]) to 55% (ECCO/ESGAR [66]). Notably, all guidelines were rated 0% with regard to editorial independence (domain 6). The RCR/RCP [29] guideline scored poorest on in all areas compared to the other two. In the overall rating, ECCO/ESGAR [66] ranked first of the guidelines and all SR/MA were rated as “critically low”.
Overall recommendations
Table 4 shows the overall recommendations regarding the appropriate or inappropriate use of PET/PET–CT for inflammatory disorder indications. There is (relative) consensus around sufficient evidence in favour of PET or PET–CT for infections of the vertebral column/spondylodiscitis. For the following four sub-indications, however, there is contradictory or inconclusive evidence: periprosthetic joint infection, osteomyelitis, sarcoidosis, and fever of unknown origin.
(2) Pilot study: evidence-based PET/PET–CT planning
In a second step, the recommendations derived from the evidence were applied (matched) to the hospital data on PET scans in one hospital (Carinthia, Austria) to gain an understanding of the PET utilization and capacity needs. Between January and September 2017, 1762 PET scans were conducted at the Clinicum Klagenfurt/Carinthia (KABEG Management: Needs-assessment of PET–CT at the Clinicum Klagenfurt, June 2018, unpublished). Of those, 1370 (77.8%) could be assigned to the three categories (see Tables 1–4) as recommended by evidence-based indications (963, 54.7%), not recommended (311.8%) and contradictory recommendations (376, 21.3%). The other 392 (of 1762, 22.2%) could not be allocated to any of the three treatment areas due to missing information of the diagnostic code or lack of information from recommendations in HTA or clinical guidelines.
A systematic analysis of all 1762 PET scans was not possible for two reasons: first, all ambulatory patients who underwent a PET scan were coded with a non-specific diagnostic code (such as ‘other’ investigation), so that the underlying reasons for PET diagnosis could not be identified and, second, no diagnostic code was assigned to in-patients transferred for the PET scan from the other Carinthian hospitals. Of the 963 PET scans that were possible to match to evidence-based recommendations (see Table 5), four ICD-10 tumour categories alone accounted for 79%: C30–C39: malignant neoplasms, respiratory system, and intrathoracic organs (273, 28%), C43–C44: malignant neoplasms, skin, (224, 23%), C81–C96: malignant neoplasms, stated or presumed to be primary, of lymphoid, haematopoietic and related tissue (177, 18%), and D37–D48: neoplasms of uncertain or unknown behaviour (99, 10%).
The majority (22, 70%) of the 31 PET scans not recommended within evidence-based recommendations (see Table 5) were in the following three ICD-10 indications: C64–C68: Malignant neoplasms, urinary organs (10, 32%), C15–C26: malignant neoplasms digestive organs (6, 19%), and C50–C58: malignant neoplasms, breast and female genital organs, respectively (6, 19%).
Discussion
Summary of findings: (1) evidence-based indications and recommendations
Evidence assessments on PET/PET–CT have been increasingly published over the past two decades in many countries and languages. Taking a 2004–2014 perspective, the PET–HTA 2015 report identified 155 HTA reports to evaluate PET or PET–CT; even with a timeframe of 2008–2014, there were still 82 HTA available. Thirty-five of these were included and extracted for their statements on the use of PET/PET–CT for oncological indications. Five more recent HTA on oncological (sub-)indications were identified during the HTA report update. For the new indications—for neurological and inflammatory disorders—only five HTA could be considered. Recommendations of professional societies (e.g., guidelines) were also updated and explored for the three indications. A total of 234 recommendations were, therefore, included in the updated report. In addition, a total of 23 SR/MA provided supplementary information. Fifteen looked only at oncological indications. Cost-effectiveness of PETs was not an inclusion criterion and was, therefore, not explicitly considered; however, while almost no evidence exists, information was extracted from the reports when there was mention of cost-effectiveness.
In a comparison of HTA results, the tabulated recommendations of professional societies and SR/MA for oncological indications reveal that there is general agreement on “significant” indications (e.g., bronchial carcinoma, and head and neck tumours) for the use of PET/PET–CT. However, there are significant differences in the level of detail of sub-indications and in the approach for when a scan should not be performed. There is also significant variance in the reliance on the access of graded pre-diagnostics.
Between the current study and the 2015 PET–HTA report, several changes in the categorization of oncology indications and in level of contradictory among the evidence sources have occurred (below is an overview; see Tables 1, 2, 3, 4):
-
Mamma carcinoma (now recommended for certain sub-indications such as tumour response assessment for metastatic mamma carcinoma (mainly bone metastases), before: not recommended)
-
Cervix carcinoma (not recommended, before contradictory)
-
Testicular, renal, and penis carcinoma (contradictory, before not recommended)
-
New (not included in the PET–HTA report 2015): myeloma (recommended), neuroendocrine tumours not recommended), anal canal cancer (contradictory)
In the case of neurological indications and inflammatory disorders, there is comparatively more discrepancy in the recommendations of professional societies and between the HTA and professional societies. There is a notable, consistent emphasis on the weak and insufficient evidence base. The SR/MA included in our report demonstrate this: all were considered “critically low” in the quality assessment.
Summary of findings: (2) pilot study on evidence-based PET/PET–CT planning
Based on evidence-based recommended and not recommended indications formulated in step (1) of this study, a first-ever pilot of planning PET capacities was conducted and, as such, has no comparator.
A data-driven needs-assessment was initially conducted to provide a basis for an investment decision around the need for an additional PET–CT scanner in Carinthia, Austria. First, diagnoses were coded according to ICD-10 classifications. Then, the 1762 PET scans performed between January and September 2017 were matched to relevant recommendations for evidence-based indications/non-indications, resulting in 77.8% being assigned to either recommended (54.7%), not recommended (1.8%) or contradictory (21.3%) evidence-based indications. 22.2% could not be ascribed due to missing information of the diagnostic code or lack of information from recommendations in HTA or clinical guidelines. Based on the data analysis and an additional assessment of the utilization as well as occupancy rates, it was decided against the investment in a second PET scanner in Carinthia.
Limitations
The main strength of the presented work is the rigorous, systematic approach applied in all steps (e.g., double-check principle and quality assessment), complemented a comprehensive, targeted manual search. Nevertheless, the methodical process has some limitations. The systematic synthesis of available evidence, which mainly relies on already aggregated evidence, may result in a certain loss of detailed information. In addition, the primary outcome of interest in the data extraction was the conclusions as articulated by the respective authors, which are different in terms of formulation and meaning and, therefore, difficult to compare. As a result, a trend can be seen in the statements.
Moreover, the multitude of recommendations from professional organizations necessarily led to a capping of the number of sources, meaning that some were not included and important contextual insight may have been lost. For example, the S3 guidelines from the Association of Scientific Medical Societies e.V. (AWMF) in Germany and the guidelines from the Scottish Intercollegiate Guidelines Network (SIGN) were not included as they do not have a specific PET/PET–CT focus. However, they both provide important recommendations as they consider not only “study evidence”, but also detailed aspects of the diagnostic-therapeutic chain and differentiate more comprehensively among tumour entities. That some guidelines were a priori omitted may lead to a potential bias (of the overall picture). Similarly, the heterogeneous quality of the included guidelines may also result in a skewed overall picture of existent recommendations. The summary tables make this transparent by assigning respective recommendations to the corresponding guidelines, referencing, as well, the strength of evidence. Finally, in Tables 2, 3, and 4 of the overall recommendations, a differentiated consideration of tumour entities is lost. Nevertheless, they provide an overall picture that can be useful (see pilot).
Regarding the 22.2% of PET scans in Carinthia, Austria, that could not be assigned to a recommendation in the pilot study, one reason could be the very specific indications found in the evidence or a too detailed coding. In general, while the high number of PET scans that could not be ascribed to any category could be seen as limiting the explanatory/instructive power of the pilot to use evidence-based indication lists as basis for a needs-assessment and investment decisions, it also shows clearly that there is a need for improvement of coding indications within the context of planning of medical services. For the final investment decision, further information on timing and frequency of PET utilization and occupancy rate over full work days and weeks are needed.
Conclusion
Overall, this study has resulted in more detailed information and specifications around PET/PET–CT indications as compared to the 2015 PET–HTA report. This update together with the aggregate list of overall recommendations for indications as well as the explicit non-recommendations from the 2015 PET–HTA report can serve as needs-based and evidence-based decision support for PET/PET–CT service provision in hospitals as evidenced by the pilot study in Austria. A better coding of PET utilization is needed for planning. Furthermore, additional information such as timing, frequency of PET utilization, as well as occupancy rate over full work days and weeks, is also necessary to guide an investment decision.
References
Fuchs S, Olberg B, Panteli D, Busse R (2016) Health technology assessment of medical devices in Europe: processes, practices, and methods. Int J Technol Assess Health Care 32(4):246–255. https://doi.org/10.1017/S0266462316000349
Fuchs S, Olberg B, Perleth M, Busse R, Panteli D (2018) Testing a new taxonomic model for the assessment of medical devices: Is it plausible and applicable? Insights from HTA reports and interviews with HTA institutions in Europe. Health Policy. https://doi.org/10.1016/j.healthpol.2018.03.004
Hawlik K, Rummel P, Wild C (2018) Analysis of duplication and timing of health technology assessments on medical devices in Europe. Int J Technol Assess Health Care 34(1):18–26. https://doi.org/10.1017/S0266462317001064
Wild C, Patera N, Küllinger R, Narath M (2015) PET/PET–CT Evidenz zum Bedarf und Planung (bei onkologischen Indikationen). HTA Projektbericht Nr. 77. LBI-HTA, Wien
Fuchs S, Grössmann N, Eckhardt H, Busse R, Wild C (2018) PET/PET–CT Evidenz zum Bedarf und zur Planung in Deutschland und Österreich. HTA Projektbericht Nr. 77 Update. LBI-HTA, Wien und Working Papers in Health Policy and Management, Vol 12. TU Berlin, Berlin
Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (2013) Positronenemissionstomographie (PET) und PET/CT bei Ösophaguskarzinom. Abschlussbericht. IQWiG-Berichte – Nr. 172. IQWiG, Köln
Agency for Healthcare Research and Quality (2018) National guideline clearinghouse: fact sheet. AHRQ, Rockville
Agency for Healthcare Research and Quality (2014) Imaging tests for the staging of colorectal cancer. AHRQ, Rockville
Agency for Healthcare Research and Quality (2014) Imaging tests for the diagnosis and staging of pancreatic adenocarcinoma. AHRQ, Rockville
Agency for Healthcare Research and Quality (2014) Imaging techniques for the diagnosis and staging of hepatocellular carcinoma. AHRQ, Rockville
International Network of Agencies for Health Technology Assessment (2007) A checklist for health technology assessment reports. http://www.inahta.org/hta-tools-resources/briefs/#checklist. Accessed 12 Feb 2018
AGREE Next Steps Consortium (2014). The AGREE II Instrument. German Version. https://www.agreetrust.org/resource-centre/agree-ii/agree-ii-translations/. Accessed 13 Mar 2018
Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J et al (2017) AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 358:j4008. https://doi.org/10.1136/bmj.j4008
World Health Organization (2016) International statistical classification of diseases and related health problems (ICD-10). https://icd.who.int/browse10/2016/en. Accessed 10 Mar 2018
Agency for Healthcare Research and Quality (2014) AHRQ comparative effectiveness technical briefs. Imaging techniques for treatment evaluation for metastatic breast cancer. AHRQ, Rockville
Hallqvist A, Alverbratt C, Strandell A, Samuelsson O, Bjorkander E, Liljegren A et al (2017) Positron emission tomography and computed tomographic imaging (PET/CT) for dose planning purposes of thoracic radiation with curative intent in lung cancer patients: a systematic review and meta-analysis. Radiother Oncol 123(1):71–77. https://doi.org/10.1016/j.radonc.2017.02.011
Scottish Health Technologies Group/Healthcare Improvement Scotland (2017) Is FDG PET/CT clinically and cost effective in the staging and/or restaging of disease in patients with penile or testicular cancers? Evidence note 73. SHTG/HIS, Edinburgh, Glasgow
Scottish Health Technologies Group/Healthcare Improvement Scotland (2017) Is positron emission tomography/computed tomography (PET–CT) clinically and cost effective for staging and/or restaging in patients with suspected renal or bladder cancer following an abnormal result on contrast-enhanced computed tomography or magnetic resonance imaging? Evidence note 72. SHTG/HIS, Edinburgh/Glasgow
Scottish Health Technologies Group/Healthcare Improvement Scotland (2017) Is FDG PET–CT clinically and costeffective in the staging and/or restaging of disease in patients with penile or testicular cancers? Advice Statement 010/17. SHTG/HIS, Edinburgh, Glasgow
Scottish Health Technologies Group/Healthcare Improvement Scotland (2017) Is FDG PET–CT clinically and costeffective for staging and/or restaging in patients with suspected renal or bladder cancer following an abnormal result on contrast-enhanced CT or MRI? Advice Statement 009/17. SHTG/HIS, Edinburgh, Glasgow
Chen CC, Carter BS, Wang R, Patel KS, Hess C, Bodach ME et al (2016) Congress of neurological surgeons systematic review and evidence-based guideline on preoperative imaging assessment of patients with suspected nonfunctioning pituitary adenomas. Neurosurgery. 79(4):E524–E526. https://doi.org/10.1227/NEU.0000000000001391
Silvestri GA, Gonzalez AV, Jantz MA, Margolis ML, Gould MK, Tanoue LT et al (2013) Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American college of chest physicians evidence-based clinical practice guidelines. Chest 143(5 SUPPL):e211S–e250S. https://doi.org/10.1378/chest.12-2355
Chantry A, Kazmi M, Barrington S, Goh V, Mulholland N, Streetly M et al (2017) Guidelines for the use of imaging in the management of patients with myeloma. Br J Haematol 05:05. https://doi.org/10.1111/bjh.14827
Poon R (2017) Evidence from primary studies and systematic reviews and recommendations from clinical practice guidelines January to June 2017. Program in Evidence-Based Care Disease Site Group Reviewers, Ontario PET Steering Committee. Cancer Care Ontario, Toronto
Mahmud A, Poon R, Jonker D (2017) PET imaging in anal canal cancer. Program in evidence-based care recommendation report no.: PET-17. Cancer Care Ontario, Toronto
Harlos C, Poon R (2017) PET imaging in paraneoplastic neurological syndromes. Program in evidence-based care; evidence summary PET 18. Cancer Care Ontario, Toronto
Langen K, Bartenstein H, Boecker H, Brust P, Coenen H, Drzezga A et al (2013) DGN-Handlungsempfehlung (S1-Leitlinie). PET- und SPECT-Untersuchungen von Pateinten mit zerebralen Gliomen mittels radioaktiv markierter Aminosäuren. Stand 7/2013. DGN, Göttingen
Cavo M, Terpos E, Nanni C, Moreau P, Lentzsch S, Zweegman S et al (2017) Role of 18 F-FDG PET/CT in the diagnosis and management of multiple myeloma and other plasma cell disorders: a consensus statement by the International Myeloma Working Group. Lancet Oncol 18(4):e206–e217. https://doi.org/10.1016/S1470-2045%2817%2930189-4
Scarsbrook A, Barrington S (2016) Evidence-based indications for the use of PET–CT in the United Kingdom 2016. The Royal College of Radiologists, Royal College of Physicians of London, Royal College of Physicians and Surgeons of Glasgow, Royal College of Physicians of Edinburgh, British Nuclear Medicine Society, Administration of Radioactive Substances Advisory Committee, London
Jadvar H, Colletti PM, Delgado-Bolton R, Esposito G, Krause BJ, Iagaru AH et al (2017) Appropriate use criteria for (18)F-FDG PET/CT in restaging and treatment response assessment of malignant disease. J Nucl Med 58(12):2026–2037. https://doi.org/10.2967/jnumed.117.197988
Albert NL, Weller M, Suchorska B, Galldiks N, Soffietti R, Kim MM et al (2016) Response Assessment in Neuro-Oncology working group and European Association for Neuro-Oncology recommendations for the clinical use of PET imaging in gliomas. Neuro-Oncology 18(9):1199–1208. https://doi.org/10.1093/neuonc/now058
Fendler WP, Eiber M, Beheshti M, Bomanji J, Ceci F, Cho S et al (2017) 68 Ga-PSMA PET/CT: Joint EANM and SNMMI procedure guideline for prostate cancer imaging: version 1.0. Eur J Nucl Med Mol Imaging 44(6):1014–1024. https://doi.org/10.1007/s00259-017-3670-z
Ryken TC, Aygun N, Morris J, Schweizer M, Nair R, Spracklen C et al (2014) The role of imaging in the management of progressive glioblastoma: a systematic review and evidence-based clinical practice guideline. J Neurooncol 118(3):435–460. https://doi.org/10.1007/s11060-013-1330-0
American College of Radiology (2018) ACR appropriateness criteria®. https://acsearch.acr.org/list. Accessed 20 Mar 2018
Canadian Association of Radiologists (2018) Referral guidelines. https://car.ca/patient-care/referral-guidelines/. Accessed 26 Mar 2018
National Comprehensive Cancer Network (2018) NCCN guidelines for treatment of cancer by site. https://www.nccn.org/professionals/physician_gls/f_guidelines.asp. Accessed 20 Mar 2018
American Board of Internal Medicine Foundation (2018) Choosing wisely. http://www.choosingwisely.org/. Accessed 07 Sept 2017
National Institute for Health and Care Excellence (2018) NICE Do-not-Do database. https://www.nice.org.uk/. Accessed 07 Sept 2017
Dunet V, Pomoni A, Hottinger A, Nicod-Lalonde M, Prior JO (2016) Performance of 18F-FET versus 18F-FDG-PET for the diagnosis and grading of brain tumors: systematic review and metaanalysis. Neuro-Oncol 18(3):426–34. https://doi.org/10.1093/neuonc/nov148
Evangelista L, Guttilla A, Zattoni F, Muzzio PC, Zattoni F (2013) Utility of choline positron emission tomography/computed tomography for lymph node involvement identification in intermediateto high-risk prostate cancer: a systematic literature review and meta-analysis. Eur Urol 63(6):1040–1048. https://doi.org/10.1016/j.eururo.2012.09.039
Dunet V, Rossier C, Buck A, Stupp R, Prior JO (2012) Performance of 18F-fluoro-ethyl-tyrosine (18F-FET) PET for the differential diagnosis of primary brain tumor: a systematic review and Metaanalysis. J Nucl Med 53(2):207–214. https://doi.org/10.2967/jnumed.111.096859
Evangelista L, Guttilla A, Saladini G, Zattoni F, Colletti PM, Rubello D (2013) Choline PET or PET/CT and biochemical relapse of prostate cancer: A systematic review and meta-analysis. Clin Nucl Med 38(5):305–314. https://doi.org/10.1097/RLU.0b013e3182867f3c
Maffione AM, Lopci E, Bluemel C, Giammarile F, Herrmann K, Rubello D (2015) Diagnostic accuracy and impact on management of (18)F-FDG PET and PET/CT in colorectal liver metastasis: a meta-analysis and systematic review. Eur J Nucl Med Mol Imaging 42(1):152–163. https://doi.org/10.1007/s00259-014-2930-4
Perera M, Papa N, Christidis D, Wetherell D, Hofman MS, Murphy DG et al (2016) Sensitivity, Specificity, and Predictors of Positive 68Ga-Prostate-specific Membrane Antigen Positron Emission Tomography in Advanced Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol 70(6):926–937. https://doi.org/10.1016/j.eururo.2016.06.021
Pyo J, Won Kim K, Jacene HA, Sakellis CG, Brown JR, Van den Abbeele AD (2013) End-therapy positron emission tomography for treatment response assessment in follicular lymphoma: a systematic review and meta-analysis. Clin Cancer Res 19(23):6566–6577. https://doi.org/10.1158/1078-0432.CCR-13-1511
Ren J, Yuan L, Wen G, Yang J (2016) The value of anti-1-amino-3-18Ffluorocyclobutane-1-carboxylic acid PET/CT in the diagnosis of recurrent prostate carcinoma: A meta-analysis. Acta Radiologica 57(4):487–493. https://doi.org/10.1177/0284185115581541
Sun Z, Yi YL, Liu Y, Xiong JP, He CZ (2015) Comparison of whole-body PET/PET-CT and conventional imaging procedures for distant metastasis staging in patients with breast cancer: A meta-analysis. Eur J Gynaecologic Oncol 36(6):672–676. https://doi.org/10.12892/ejgo2412.2015
Yang J, Kan Y, Ge BH, Yuan L, Li C, Zhao W (2014) Diagnostic role of Gallium-68 DOTATOC and Gallium-68 DOTATATE PET in patients with neuroendocrine tumors: A meta-analysis. Acta Radiologica 55(4):389–398. https://doi.org/10.1177/0284185113496679
Schroer-Gunther MA, Wolff RF, Westwood ME, Scheibler FJ, Schurmann C, Baumert BG et al (2012) F-18-fluoro-2-deoxyglucose positron emission tomography (PET) and PET/computed tomography imaging in primary staging of patients with malignant melanoma: a systematic review. Syst Rev 1(1):62. https://doi.org/10.1186/2046-4053-1-62
Schroer-Gunther M, Scheibler F, Wolff R, Westwood M, Baumert B, Lange S (2015) The role of PET and PET–CT scanning in assessing response to neoadjuvant therapy in esophageal carcinoma. Dtsch. 112(33–34):545–552. https://doi.org/10.3238/arztebl.2015.0545
Applegarth K, Campbell S, Mernagh P, Fodero L, Scuteri J (2015) F-18 Fluorodeoxyglucose (FDG) positron emission tomography (PET) for the diagnosis of Alzheimer’s disease. Medical Services Advisory Committee (MSAC) Application 1195, Commonwealth of Australia, Canberra
Canadian Agency for Drugs and Technologies in Health (2010) Positron emission tomography for epilepsy: clinical effectiveness and guidelines. Rapid response. CADTH, Ottawa
Burneo JG, Poon R, Kellett S, Houle S, Snead OC (2015) The utility of positron emission tomography (PET) in epilepsy. Program in evidence-based care PET recommendation report no.: 13. Cancer Care Ontario, Toronto
Filippi M, Agosta F, Barkhof F, Dubois B, Fox NC, Frisoni GB et al (2012) EFNS task force: the use of neuroimaging in the diagnosis of dementia. Eur J Neurol 19(12):1487–1501. https://doi.org/10.1111/j.1468-1331.2012.03859.x
Johnson KA, Minoshima S, Bohnen NI, Donohoe KJ, Foster NL, Herscovitch P et al (2013) Appropriate use criteria for amyloid PET: a report of the Amyloid Imaging Task Force, the Society of Nuclear Medicine and Molecular Imaging, and the Alzheimer’s Association. Alzheimer’s Dement 9(1):1–16. https://doi.org/10.1016/j.jalz.2013.01.002
Minoshima S, Drzezga AE, Barthel H, Bohnen N, Djekidel M, Lewis DH et al (2016) SNMMI Procedure Standard/EANM practice guideline for amyloid PET imaging of the brain 1.0. J Nucl Med 57(8):1316–1322. https://doi.org/10.2967/jnumed.116.174615
Smailagic N, Vacante M, Hyde C, Martin S, Ukoumunne O, Sachpekidis C (2015) 18F-FDG PET for the early diagnosis of Alzheimer’s disease dementia and other dementias in people with mild cognitive impairment (MCI). Cochrane Database of Systematic Reviews Issue 1. Art. No.: CD010632. https://doi.org/10.1002/14651858.CD010632.pub2
Zhang S, Smailagic N, Hyde C, Noel-Storr AH, Takwoingi Y, McShane R et al (2014) 11C-PIB-PET for the early diagnosis of Alzheimer’s disease dementia and other dementias in people with mild cognitive impairment (MCI). Cochrane Database of Systematic Reviews Issue 7. Art. No.: CD010386. https://doi.org/10.1002/14651858.CD010386.pub2
Morris E, Chalkidou A, Hammers A, Peacock J, Summers J, Keevil S (2016) Diagnostic accuracy of (18)F amyloid PET tracers for the diagnosis of Alzheimer’s disease: a systematic review and metaanalysis. Eur J Nucl Med Mol Imaging 43(2):374–385. https://doi.org/10.1007/s00259-015-3228-x
Johnson KA, Minoshima S, Bohnen NI, Donohoe KJ, Foster NL, Herscovitch P et al (2013) Update on appropriate use criteria for amyloid PET imaging: dementia experts, mild cognitive impairment, and education. Amyloid Imaging Task Force of the Alzheimer’s Association and Society for Nuclear Medicine and Molecular Imaging. Alzheimer’s Dement 9(4):106–109. https://doi.org/10.1016/j.jalz.2013.06.001
Canadian Agency for Drugs and Technologies in Health (2008) FDG-PET to assess infections: a review of the evidence. CADTH, Ottawa
Scottish Health Technologies Group/Healthcare Improvement Scotland (2013) What is the sensitivity and specificity of PET/CT compared with other diagnostic imaging modalities in determining the cause of pyrexia of unknown origin (PUO)? What is the clinical and cost effectiveness of PET/CT as a first-line investigation in patients with PUO? SHTG/HIS, Edinburgh/Glasgow
Scottish Health Technologies Group/Healthcare Improvement Scotland (2013) Does the addition of positron emission tomography/computed tomography (PET/CT) to the routine investigation and assessment of patients with sarcoidosis yield clinical and economic benefits? SHTG/HIS, Edinburgh/Glasgow
Scottish Health Technologies Group/Healthcare Improvement Scotland (2013) Does the addition of PET/CT to the routine investigation and assessment of patients with sarcoidosis yield clinical and economic benefits? Advice Statement 002/13. SHTG/HIS, Edinburgh/Glasgow
Scottish Health Technologies Group/Healthcare Improvement Scotland (2013) What is the sensitivity and specificity of positron emission tomography/computed tomography (PET/CT) compared to other diagnostic imaging modalities in determining the cause of pyrexia of unknown origin (PUO)? What is the clinical and cost effectiveness of PET/CT as a first-line imaging investigation in patients with PUO? Advice Statement 011/13. SHTG/HIS, Edinburgh/Glasgow
Panes J, Bouhnik Y, Reinisch W, Stoker J, Taylor SA, Baumgart DC et al (2013) Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines. J Crohn’s Colitis 7(7):556–585. https://doi.org/10.1016/j.crohns.2013.02.020
Jamar F, Buscombe J, Chiti A, Christian PE, Delbeke D, Donohoe KJ et al (2013) EANM/SNMMI guideline for 18F-FDG use in inflammation and infection. J Nucl Med 54(4):647–658. https://doi.org/10.2967/jnumed.112.112524
Quartuccio N, Caobelli F, Evangelista L, Alongi P, Kirienko M, De Biasi V et al (2015) The role of PET/CT in the evaluation of patients affected by limbic encephalitis: a systematic review of the literature. J Neuroimmunol 284:44–48. https://doi.org/10.1016/j.jneuroim.2015.05.002
Gomes A, Glaudemans AW, Touw DJ, van Melle JP, Willems TP, Maass AH et al (2017) Diagnostic value of imaging in infective endocarditis: a systematic review. Lancet Infect Dis 17(1):e1–e14. https://doi.org/10.1016/S1473-3099(16)30141-4
Mahmood M, Kendi AT, Farid S, Ajmal S, Johnson GB, Baddour LM et al (2017) Role of (18)F-FDG PET/CT in the diagnosis of cardiovascular implantable electronic device infections: A metaanalysis. J Nucl Cardiol 14(10):017–1063. https://doi.org/10.1007/s12350-017-1063-0
Juneau D, Golfam M, Hazra S, Erthal F, Zuckier LS, Bernick J et al (2018) Molecular Imaging for the diagnosis of infective endocarditis: A systematic literature review and meta-analysis. Int J Cardiol 253:183–188. https://doi.org/10.1016/j.ijcard.2017.10.116
Prodromou ML, Ziakas PD, Poulou LS, Karsaliakos P, Thanos L, Mylonakis E (2014) FDG PET is a robust tool for the diagnosis of spondylodiscitis: A meta-analysis of diagnostic data. Clin Nucl Med 39(4):330–335. https://doi.org/10.1097/RLU.0000000000000336
Treglia G, Sadeghi R, Annunziata S, Zakavi SR, Caldarella C, Muoio B, et al (2013) Diagnostic performance of Fluorine-18-Fluorodeoxyglucose positron emission tomography for the diagnosis of osteomyelitis related to diabetic foot: A systematic review and a meta-analysis. Foot 23(4):140–148. https://doi.org/10.1016/j.foot.2013.07.002
Yan J, Zhang C, Niu Y, Yuan R, Zeng X, Ge X, et al (2016) The role of 18F-FDG PET/CT in infectious endo-carditis: A systematic review and meta- Analysis. Int J Clin Pharmacol Ther 54(5):337–342. https://doi.org/10.2106/JBJS.15.00898
Verberne SJ, Raijmakers PG, Temmerman OP (2016) The Accuracy of Imaging Techniques in the Assessment of Periprosthetic Hip Infection: A Systematic Review and Meta-Analysis. J Bone Joint Surg Am 98(19):1638–1645. https://doi.org/10.2106/JBJS.15.00898
Acknowledgements
The support of Helene Eckhardt, Fabian Dressenhöfer, Christian Nam Kai Tran, and Anna Irshad in compiling the HTA report is hereby gratefully acknowledged. We would also like to thank Katherine Polin for the language check.
Funding
This study was funded by the German Society for Nuclear Medicine (DGN) who did not have any influence on the content of the report.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
All authors declare that they have no conflict of interest.
Ethical approval
This article does not contain any studies with human participants or animals performed by any of the authors.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
OpenAccess This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
About this article
Cite this article
Fuchs, S., Grössmann, N., Ferch, M. et al. Evidence-based indications for the planning of PET or PET/CT capacities are needed. Clin Transl Imaging 7, 65–81 (2019). https://doi.org/10.1007/s40336-019-00314-7
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40336-019-00314-7