HAND & WRIST
Costs analysis and comparison of usefulness of acute MRI and 2 weeks of cast immobilization for clinically suspected scaphoid fractures
OrthoEvidence Journal (OE Journal) - ACE Report
OE Journal. 2016;4(14):15 Acta Orthop. 2015 Jun;86(3):303-9125 Norwegian patients, within a week of having acute wrist trauma requiring radiographic examination, were pseudo-randomized (based on the date of admission) to receive either early MRI treatment or standard treatment. The purpose of the study was to determine how early MRI compares with conventional management in treating suspected scaphoid fractures from a cost and efficacy perspective. Results indicated that the number of days absent from work and in a cast was significantly lower in the MRI group in patients without fractures, and no major difference was noted in the cost-minimization analysis.
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
はい = 1
不確実＝0.5
無関係 = 0
いいえ = 0
報告基準評価では、著者が出版物内で試験の方法論的特徴や試験特性を報告する際の透明性を評価します。評価は以下の5つのカテゴリーに分類されます。
1/4
Randomization
3/4
Outcome Measurements
4/4
Inclusion / Exclusion
4/4
Therapy Description
3/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
Fragility Indexは、重要な所見の解釈を助けるツールで、結果の強さの尺度を提供します。Fragility Indexは、その所見が有意でなくなるために、二項対立の結果に追加する必要がある連続した事象の数を表します。数値が小さいほど弱い所見を表し、数値が大きいほど強い所見を表します。
なぜ今この研究が必要なのですか？
Conventional treatment of occult scaphoid fractures involves wrist immobilization with radiographic reassessment 2 weeks later and studies have shown that 4/5 patients are immobilized unnecessarily. Acute MRI of the wrist has become a proficient method for ruling out injuries otherwise over treated and has been shown to reduce immobilization time in patients with suspected scaphoid fractures. However, no consensus was present at the time of this study about whether early MRI in suspected scaphoid fractures saves money as compared with conventional management. Thus the present study sought to determine the difference between the two treatments from an economic perspective in a Norwegian setting.
主な研究課題は何ですか？
How does early MRI compare with traditional radiographs and conventional management in the treatment of clinically suspected scaphoid fractures, from a cost and efficacy standpoint, in Norwegian patients?
重要な知見は？
- 7 scaphoid fractures were diagnosed in the MRI group and 4 in the control group with the number of other fractures also being higher in the MRI group than the control (n=22 vs. n=8)
- The numbers of consultations per patient were nearly identical between groups, and significant differences were found between the numbers of radiographs, the number of MRIs, and the numbers of elastic bandages used in the 2 groups
- The total number of days using a cast was lower for patients in the MRI group compared to the control group (MD= 4.6, p=0.05) and significantly lower in the MRI group in patients without fracture (MD= 13, p<0.005, 95% CI [11-15]) or without scaphoid fracture (MD= 6.5, p<0.005, 95% CI [3-10])
- In patients diagnosed with either scaphoid fractures (MD= 2.4, p=0.8) or other fractures (MD= 2.7, p=0.6), the number of days using a cast was similar
- Number of days of absence from work was not significantly different, yet for patients with no fractures, significantly fewer sick leave days were found for the MRI group (MD= 8 (3-13), p=0.002)
- No significant difference was present in the sum of all direct costs in the 2 groups (MRI group: 30,160 euros, Control group: 27, 997 euros) and the average direct medical cost of detecting/treating a patient with any occult wrist fracture was 1,160 euros in the MRI group and 2,545 euros in the control group
- Similar indirect costs were noted for the 2 groups (MRI group: 147,404 euros, Control group: 186,550 euros), yet in patients in paid work with no fracture indirect cost in the MRI group was less than half of the control
- Overall costs were marginally different between groups (MRI group: 177,564 euros, Control group: 214,548 euros)
最も覚えておくべきことは？
The number of days in a cast and absence from work was significantly lower in the MRI group in patients without fractures. No major difference was noted in the cost-minimization analysis in terms of overall costs.
それが私の患者ケアにどのように影響するか？
In a Norwegian setting, early MRI was useful in patients with clinically suspected scaphoid fracture and normal radiographs as it ruled out wrist fracture and decreased days in a cast and days on sick leave. However, the cost-minimization analysis found only marginal differences in overall costs between the groups. Further studies are warranted in other population subsets to determine the applicability of these results in the general population.
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