Oh C H, Schweitzer M E, Spettell C M
Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA.
Skeletal Radiol. 1999 Dec;28(12):670-8. doi: 10.1007/s002560050572.
In a patient with internal derangement of the shoulder, the diagnostic method of choice is controversial. Conventional arthrography can diagnose most rotator cuff tears accurately; however, in many institutions MR arthrography is usually necessary to diagnose labral tears. We utilized decision tree methodology to compare the cost-effectiveness of conventional arthrography and conventional MRI with a hypothetical algorithm in which a patient underwent arthrography, performed with admixed gadolinium, which if negative, was followed by MRI.
The use of double-contrast arthrography alone, conventional MRI alone, and gadolinium-enhanced MRI used as an adjunct to conventional arthrography were modeled for the diagnosis of full-thickness rotator cuff tears (RCT), partial RCTs, labral tears, and the absence of cuff/labral tears using decision analysis methodology. English language medical publications were searched to determine the base probabilities for the accuracy of the diagnostic tests. The outcome utilities ranged from -1 to +1 to reflect the value of correct diagnostic evaluation. Charges for diagnostic tests and appropriate surgical treatments were based on 1997 Medicare reimbursement rates for professional fees and hospital charges in an outpatient setting. Sensitivity analyses were performed to evaluate the effects of uncertainty regarding the prevalence of each disease state and the accuracy of several diagnostic tests.
In the base-case analysis, the average effectiveness of double-contrast arthrography alone, MRI alone and arthrography selectively followed by MRI were 0.6610, 0.6715, and 0.7204, respectively. The average costs for each of these strategies were $1090, $2033, and $2339, respectively.
Arthrography performed with admixed diluted gadolinium, which if negative is immediately followed by MRI, was somewhat more expensive than conventional MRI. However, because of much greater effectiveness, cost-effectiveness was significantly higher for our proposed algorithm. Conventional arthrography without gadolinium, although less expensive, had severely limited effectiveness.
对于患有肩关节内部紊乱的患者，首选的诊断方法存在争议。传统关节造影术能够准确诊断大多数肩袖撕裂；然而，在许多机构中，通常需要磁共振关节造影来诊断盂唇撕裂。我们运用决策树方法，将传统关节造影术和传统磁共振成像（MRI）的成本效益与一种假设算法进行比较，该算法中患者先接受混合钆的关节造影术，若结果为阴性，则接着进行MRI检查。
采用决策分析方法，对单独使用双对比关节造影术、单独使用传统MRI以及将钆增强MRI用作传统关节造影术的辅助手段来诊断全层肩袖撕裂（RCT）、部分RCT、盂唇撕裂以及不存在肩袖/盂唇撕裂的情况进行建模。检索英文医学出版物以确定诊断测试准确性的基础概率。结果效用范围为 -1 至 +1，以反映正确诊断评估的价值。诊断测试和适当手术治疗的费用基于1997年医疗保险对门诊专业费用和医院收费的报销率。进行敏感性分析以评估每种疾病状态的患病率以及几种诊断测试准确性的不确定性所产生的影响。
在基础病例分析中，单独使用双对比关节造影术、单独使用MRI以及先进行关节造影术然后选择性地进行MRI的平均有效性分别为0.6610、0.6715和0.7204。这些策略各自的平均成本分别为1090美元、2033美元和2339美元。
使用混合稀释钆进行的关节造影术，若结果为阴性则立即进行MRI检查，其费用比传统MRI略高。然而，由于有效性显著更高，我们提出的算法的成本效益明显更高。不使用钆的传统关节造影术虽然成本较低，但其有效性严重受限。
