King's Health Economics, King's College London, London, UK.
Clinical Imaging and Medical Physics Directorate, Guy's and St Thomas' NHS Foundation Trust, London, UK.
Bone Joint J. 2019 Aug;101-B(8):984-994. doi: 10.1302/0301-620X.101B8.BJJ-2018-1590.R1.
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 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.
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% 93.8%) and of any other fracture (98.5% 84.6%).
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: 2019;101-B:984-994.
Scaphoid Magnetic Resonance Imaging in Trauma（SMaRT）试验的目的是评估在疑似腕舟骨骨折且 X 线片阴性的患者的急性管理中，立即进行 MRI 检查对临床和成本的影响。
在急诊就诊时疑似有舟骨骨折且 X 线片阴性的患者被随机分配到对照组，即不进行进一步的影像学检查，或干预组，即在此初始就诊时进行腕部 MRI 检查作为附加检查。大多数参与者为男性（对照组 52%，干预组 61%），对照组平均年龄为 36.2 岁（18-73 岁），干预组为 38.2 岁（20-71 岁）。主要结局是招募后三个月的总成本影响。次要结局包括六个月的总成本、临床发现的评估、诊断准确性以及参与者的自我报告满意度。使用具有伽马误差的广义线性模型估计成本差异。
对照组招募后三个月每名参与者的平均费用为 542.40 英镑（标准差 855.20，n = 65），干预组为 368.40 英镑（标准差 338.60，n = 67），估计费用差异为 174 英镑（95%置信区间（CI）-30 至 378；p = 0.094）。在六个月时，每位参与者的成本差异增加到 266 英镑（95% CI 3.30 至 528；p = 0.047）。总体而言，对照组有 6.2%（4/65）的参与者和干预组有 10.4%（7/67）的参与者（p = 0.37）发生舟骨骨折。此外，对照组有 7.7%（5/65）的参与者和干预组有 22.4%（15/67）的参与者（p = 0.019）诊断出其他骨折。MRI 的使用与更高的诊断准确性相关，无论是在诊断舟骨骨折（100.0%对 93.8%）还是任何其他骨折（98.5%对 84.6%）。
在疑似腕舟骨骨折且 X 线片阴性的患者的管理中，立即进行 MRI 检查可节省成本，同时提高了该方法的诊断准确性和患者满意度。
