Brealey Stephen D, Atwell Christine, Bryan Stirling, Coulton Simon, Cox Helen, Cross Ben, Fylan Fiona, Garratt Andrew, Gilbert Fiona J, Gillan Maureen G C, Hendry Maggie, Hood Kerenza, Houston Helen, King David, Morton Veronica, Orchard Jo, Robling Michael, Russell Ian T, Torgerson David, Wadsworth Valerie, Wilkinson Clare
Department of Health Sciences, York Trials Unit, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD, UK.
BMC Health Serv Res. 2006 Oct 13;6:133. doi: 10.1186/1472-6963-6-133.
Though new technologies like Magnetic Resonance Imaging (MRI) may be accurate, they often diffuse into practice before thorough assessment of their value in diagnosis and management, and of their effects on patient outcome and costs. MRI of the knee is a common investigation despite concern that it is not always appropriate. There is wide variation in general practitioners (GPs) access to, and use of MRI, and in the associated costs. The objective of this study was to resolve uncertainty whether GPs should refer patients with suspected internal derangement of the knee for MRI or to an orthopaedic specialist in secondary care.
METHODS/DESIGN: The design consisted of a pragmatic multi-centre randomised trial with two parallel groups and concomitant economic evaluation. Patients presenting in general practice with suspected internal derangement of the knee and for whom their GP was considering referral to an orthopaedic specialist in secondary care were eligible for inclusion. Within practices, GPs or practice nurses randomised eligible and consenting participants to the local radiology department for an MRI examination, or for consultation with an orthopaedic specialist. To ensure that the waiting time from GP consultation to orthopaedic appointment was similar for both trial arms, GPs made a provisional referral to orthopaedics when requesting the MRI examination. Thus we evaluated the more appropriate sequence of events independent of variations in waiting times. Follow up of participants was by postal questionnaires at six, twelve and 24 months after randomisation. This was to ensure that the evaluation covered all events up to and including arthroscopy.
The DAMASK trial should make a major contribution to the development of evidence-based partnerships between primary and secondary care professionals and inform the debate when MRI should enter the diagnostic pathway.
尽管磁共振成像（MRI）等新技术可能很准确，但它们在对其诊断和管理价值、对患者预后及成本的影响进行全面评估之前，往往就已应用于临床实践。尽管有人担心膝关节MRI检查并不总是合适的，但它仍是一种常见的检查方法。全科医生（GP）在获取和使用MRI方面以及相关成本方面存在很大差异。本研究的目的是解决关于全科医生是否应将疑似膝关节内部紊乱的患者转诊进行MRI检查或转诊至二级医疗保健机构的骨科专家的不确定性。
方法/设计：该设计包括一项实用的多中心随机试验，分为两个平行组，并进行同步的经济评估。在全科医疗中出现疑似膝关节内部紊乱且其全科医生考虑转诊至二级医疗保健机构的骨科专家的患者符合纳入标准。在各医疗机构内，全科医生或执业护士将符合条件并同意参与的参与者随机分配至当地放射科进行MRI检查，或分配至与骨科专家进行会诊。为确保两个试验组从全科医生会诊到骨科预约的等待时间相似，全科医生在要求进行MRI检查时会先临时转诊至骨科。因此，我们评估了更合适的事件顺序，而不受等待时间变化的影响。通过随机分组后6个月、12个月和24个月的邮政问卷对参与者进行随访。这是为了确保评估涵盖直至并包括关节镜检查的所有事件。
DAMASK试验应为初级和二级医疗保健专业人员之间基于证据的合作关系的发展做出重大贡献，并为MRI何时应进入诊断流程的辩论提供信息。
