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Patient history, physical exam alone preferred to using MRI to diagnose meniscus tears
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According to researchers from Duke University Medical Center, the preferred strategy was to rely solely on patients’ histories and physical examinations in cases of suspected degenerative meniscus tears; while use of MRI was preferred to confirm traumatic meniscus tears in cases with a positive patient history and physical examination.
“One of the take-home messages is advanced imaging does not always add value [and] the accuracy of physical exam and history for meniscus tear in the knee is quite good,” study author and assistant professor at Duke Orthopedics, Duke University Medical Center, Richard C. Mather III, MD, MBA, told Orthopedics Today.
Richard C. Mather III
Determining value added
Mather said the impetus for the study was based on previous research which showed the fastest rising segment of cost in our health system was diagnostic imaging and in particular advanced imaging. “This [study] is an opportunity to deliver as good as or better care at a lower cost. [As] the health care landscape is fragmented and changing, we are certainly moving to where patients are going to want to know more. This study gives us the ability to determine if advanced imaging adds incremental value. We can give our patients more detailed information to help them make their health care selections,” he said.
Mather and his colleagues constructed a simple-decision model run as a cost-utility analysis to assess the value added by MRI in various combinations with patient history and physical examination. The model examined traumatic and degenerative tears in primary care and orthopedic sports medicine clinic settings and researchers used the incremental cost-effectiveness ratio to compare strategies.
In both primary care and orthopedic sports medicine clinic settings, results showed that patient history and physical examination alone was the preferred diagnostic strategy for degenerative meniscus tears. MRI to confirm a positive patient history and physical examination for a suspected traumatic meniscus tear was the preferred cost effective diagnostic strategy with a willingness to pay of less than $50,000 per quality-adjusted life-year. However, MRI for all patients was inferior in all reasonable clinical scenarios.
According to study results, the prevalence of a meniscus tear in a clinician’s patient population was influential, with MRI to confirm traumatic tears in cases with a positive patient history and physical examination was the preferred diagnostic strategy when prevalence was less than 46.7%, and with patient history and physical examination preferred above that. Patient history and physical examination for degenerative tears was the preferred diagnostic strategy until the prevalence reached 74.2%, and then they preferred MRI to confirm a negative patient history and physical examination. For reference, the literature suggests the prevalence of meniscus tears in patients presenting with knee pain to be 9% in the primary care setting and 30% in orthopedic sports medicine settings.
Avoiding unnecessary surgeries
Interpreting and applying cost utility analyses can be challenging, so the authors also calculated the rate of incorrect treatment with each strategy. Compared with other strategies, MRI to confirm a positive physical examination led to more than a 10-fold lower rate of unnecessary surgeries in both primary care and orthopedic sports medicine clinic settings. MRI to confirm negative physical examination led to a 2.08 higher rate in primary care and a 2.26 higher rate in orthopedic clinics vs. patient history and physical examination alone.
“One of the interesting findings was that the number of unnecessary surgeries was higher with widespread use of MRI than it was with the use of history and physical exam alone, driven largely by the higher specificity of history and physical exam” Mather said. “A lot of people thought if we use history and physical exam it is going to be more inaccurate, when, in fact, using advanced imaging can lead [practitioners] to be more inaccurate. A well executed history and physical exam in as good as or better in some circumstances.”
He added “This study should be the starting point for identifying that this is an area for more efficiency and cost savings as we do not know how consistent and reproducible the diagnostic performance of history and physical exam is across a variety of clinicians” Mather said. “We want to go forward and confirm this through a more traditional, rigorous clinical study to demonstrate safety, efficacy and cost efficiency before we get behind it and recommend this to be a formal policy.” – by Casey Tingle
Reference:
Mather III RC, et al. Am J Sports Med. 2014;doi:10.1177/0363546514557937.
For more information:
Richard C. Mather III, MD, MBA, can be reached at Department of Orthopaedic Surgery, Duke University Medical Center, Box 2887, Durham, NC 27710; email: richard.mather@dm.duke.edu.
Disclosure: Mather reports no relevant financial disclosures.
Perspective
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Christopher S. Ahmad, MD
The study uniquely examines cost related to the use of MRI in the diagnosis of knee meniscal tears, which are extremely prevalent. This work is timely given our current need to manage health care costs of which MRI studies are a large factor. This research also has impact and potential to affect policy regarding use of MRI. I commend the authors for executing such an important study.
The findings are intuitive and conclude that degenerative meniscal tears can be managed with a positive history and physical alone, and that MRI is preferred to confirm acute meniscal tears. Cost models, such as those used in this study, require numerous assumptions (best guesses) and the data should be cautiously interpreted by policy makers and practitioners in that regard.
This study does raise several interesting issues. First, our patients and society have become accustomed to routine use of high-quality imaging and avoiding such imaging may result in patient skepticism and lack of confidence in the recommended treatments. A second issue relates to liability. Practitioners will certainly be slow to adopt a treatment protocol that avoids using an MRI if liability concern exists. Lastly, I very much believe that history and physical exam skills are becoming less emphasized and replaced by diagnostic tools such as MRI, which have become more sophisticated and readily available. Increased pressure on practitioners to be more productive and see more patients may also lead to increased MRI usage. From my perspective, this study strongly highlights the need for medical practitioners to acquire and maintain high level history and physical exam skills and to use them as we move into the future of cost-conscience health care.Click Here to Manage Email Alerts