Yun Brian J, Myriam Hunink M G, Prabhakar Anand M, Heng Marilyn, Liu Shan W, Qudsi Rameez, Raja Ali S
Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
Harvard Medical School, Boston, MA.
Acad Emerg Med. 2016 Oct;23(10):1161-1169. doi: 10.1111/acem.13026. Epub 2016 Sep 27.
Hip fractures cause significant morbidity and mortality. Determining the optimal diagnostic strategy for the subset of patients with potential occult hip fracture remains challenging. We determined the most cost-effective strategy for the diagnosis of occult hip fractures from the choices of performing only computed tomography (CT), performing only magnetic resonance imaging (MRI), performing CT and if negative performing MRI (MRI-selective strategy) or discharging the patient without advanced imaging.
We developed a decision-analytic model to compare outcomes and costs of different diagnostic strategies for the diagnosis of an occult hip fracture from a societal perspective. Model inputs were derived from charge data, Medicare reimbursements, and the literature. Strategies with an incremental cost-effectiveness ratio (ICER) below $100,000 per quality-adjusted life-year (QALY) gained were considered cost-effective. We tested the robustness of our results using probabilistic sensitivity analysis.
Compared to a CT strategy, MRI provides an additional 0.05 QALY at an incremental cost of $1,227 and ICER of $25,438/QALY. For facilities without MRI capability, if the cost of transfer is below $1,228, transferring the patient to a MRI-capable facility is the most cost-effective strategy. Above this cost, employing a CT and if negative transfer to a MRI-capable facility strategy was more cost-effective. When the cost of a transfer reached more than $4,039, it became more cost-effective to only obtain a CT.
MRI is a cost-effective strategy for the diagnosis of an occult hip fracture. For facilities without MRI capability, the most cost-effective strategy depends on the cost of the interfacility transfer.
髋部骨折会导致显著的发病率和死亡率。确定对潜在隐匿性髋部骨折患者亚组的最佳诊断策略仍然具有挑战性。我们从仅进行计算机断层扫描（CT）、仅进行磁共振成像（MRI）、进行CT检查，若结果为阴性则进行MRI检查（MRI选择性策略）或不进行高级影像学检查就让患者出院这些选择中，确定了诊断隐匿性髋部骨折的最具成本效益的策略。
我们建立了一个决策分析模型，从社会角度比较不同诊断策略诊断隐匿性髋部骨折的结果和成本。模型输入数据来自收费数据、医疗保险报销情况及文献。增量成本效益比（ICER）低于每获得一个质量调整生命年（QALY）100,000美元的策略被认为具有成本效益。我们使用概率敏感性分析测试了结果的稳健性。
与CT策略相比，MRI可额外获得0.05个QALY，增量成本为1,227美元，ICER为25,438美元/QALY。对于没有MRI设备的机构，如果转运成本低于1,228美元，将患者转运至有MRI设备的机构是最具成本效益的策略。高于此成本时，采用CT检查，若结果为阴性则转运至有MRI设备的机构的策略更具成本效益。当转运成本超过4,039美元时，仅进行CT检查就更具成本效益。
MRI是诊断隐匿性髋部骨折的一种具有成本效益的策略。对于没有MRI设备的机构，最具成本效益的策略取决于机构间转运的成本。
