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Randomized Controlled Trial
. 2019 Aug;101-B(8):984-994.
doi: 10.1302/0301-620X.101B8.BJJ-2018-1590.R1.

Clinical and cost implications of using immediate MRI in the management of patients with a suspected scaphoid fracture and negative radiographs results from the SMaRT trial

T Rua  1   2 , B Malhotra  2 , S Vijayanathan  2 , L Hunter  3 , J Peacock  4 , J Shearer  1 , V Goh  2   5 , P McCrone  1 , S Gidwani  6
Affiliations
Randomized Controlled Trial

Clinical and cost implications of using immediate MRI in the management of patients with a suspected scaphoid fracture and negative radiographs results from the SMaRT trial

T Rua et al. Bone Joint J. 2019 Aug.

Abstract

Aims: The aim of the Scaphoid Magnetic Resonance Imaging in Trauma (SMaRT) trial was to evaluate the clinical and cost implications of using immediate MRI in the acute management of patients with a suspected fracture of the scaphoid with negative radiographs.

Patients and methods: Patients who presented to the emergency department (ED) with a suspected fracture of the scaphoid and negative radiographs were randomized to a control group, who did not undergo further imaging in the ED, or an intervention group, who had an MRI of the wrist as an additional test during the initial ED attendance. Most participants were male (52% control, 61% intervention), with a mean age of 36.2 years (18 to 73) in the control group and 38.2 years (20 to 71) in the intervention group. The primary outcome was total cost impact at three months post-recruitment. Secondary outcomes included total costs at six months, the assessment of clinical findings, diagnostic accuracy, and the participants' self-reported level of satisfaction. Differences in cost were estimated using generalized linear models with gamma errors.

Results: The mean cost up to three months post-recruitment per participant was £542.40 (sd £855.20, n = 65) for the control group and £368.40 (sd £338.60, n = 67) for the intervention group, leading to an estimated cost difference of £174 (95% confidence interval (CI) -£30 to £378; p = 0.094). The cost difference per participant increased to £266 (95% CI £3.30 to £528; p = 0.047) at six months. Overall, 6.2% of participants (4/65, control group) and 10.4% of participants (7/67, intervention group) had sustained a fracture of the scaphoid (p = 0.37). In addition, 7.7% of participants (5/65, control group) and 22.4% of participants (15/67, intervention group) had other fractures diagnosed (p = 0.019). The use of MRI was associated with higher diagnostic accuracy both in the diagnosis of a fracture of the scaphoid (100.0% vs 93.8%) and of any other fracture (98.5% vs 84.6%).

Conclusion: The use of immediate MRI in the management of participants with a suspected fracture of the scaphoid and negative radiographs led to cost savings while improving the pathway's diagnostic accuracy and patient satisfaction. Cite this article: Bone Joint J 2019;101-B:984-994.

Keywords: Cost analysis; Diagnostic accuracy; Immediate MRI; Suspected scaphoid fracture.

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Figures

Fig. 1
Fig. 1
A scaphoid series of a patient with negative radiographs who was randomized to the intervention (MRI) arm of the trial.
Fig. 2
Fig. 2
Diagnostic and intervention pathways for participants randomized to the control and intervention groups.
Fig. 3
Fig. 3
Imaging of a patient with fracture of the waist of the scaphoid showing the abbreviated MRI for: a) coronal T1; b) coronal proton density fat supressed (PDFS); and c) sagittal short T1 inversion recovery (STIR).
Fig. 4
Fig. 4
Participant flow chart for the Scaphoid Magnetic Resonance Imaging in Trauma (SMaRT) trial.
Fig. 5
Fig. 5
Distribution of clinical findings by randomization group.
Fig. 6
Fig. 6
Follow-up pathway for participants randomized to the control and intervention groups.
Fig. 7
Fig. 7
Histogram for the three-month cost distribution for the control and intervention groups.
See this image and copyright information in PMC

References

    1. Rua T, Parkin D, Goh V, McCrone P, Gidwani S. The economic evidence for advanced imaging in the diagnosis of suspected scaphoid fractures: systematic review of evidence. J Hand Surg Eur Vol 2018;43:642–651. - PubMed
    1. Yin ZG, Zhang JB, Kan SL, et al. Diagnosing suspected scaphoid fractures: a systematic review and meta-analysis. Clin Orthop Relat Res 2010;468:723–734. - PMC - PubMed
    1. Rua T, Vijayanathan S, Parkin D, et al. Rationale and design of the SMaRT trial: a randomised, prospective, parallel, non-blinded, one-centre trial to evaluate the use of magnetic resonance imaging in acute setting in patients presenting with suspected scaphoid fracture. Clin Trials 2018;15:120–129. - PubMed
    1. No authors listed Diagnostics Assessment Programme Manual. National Institute for Health and Clinical Excellence (NICE), 2011. National Health Service (NHS) https://www.nice.org.uk/Media/Default/About/what-we-do/NICE-guidance/NIC... (date last accessed 8 May 2019). - PubMed
    1. No authors listed NHS reference costs. Department of Health and Social Care, Gov.uk, 2016. https://www.gov.uk/government/collections/nhs-reference-costs (date last accessed 8 May 2019).

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