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Diagnostic Imaging Strategies for Occult Hip Fractures: A Decision and Cost-Effectiveness Analysis
Brian J Yun1,2, M G Myriam Hunink3,4, Anand M Prabhakar5,6,7
1Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA. byun@partners.org.
Insights
Magnetic resonance imaging (MRI) is a cost-effective diagnostic strategy for occult hip fractures. For facilities without MRI, the optimal approach balances transfer costs against imaging expenses to ensure the most economical patient care.
Area of Science:
- Orthopedic Surgery
- Radiology
- Health Economics
Background:
- Hip fractures lead to substantial patient morbidity and mortality.
- Diagnosing occult hip fractures presents a significant clinical challenge.
- Identifying the most effective diagnostic pathway is crucial for patient outcomes.
Purpose of the Study:
- To determine the most cost-effective diagnostic strategy for occult hip fractures.
- To compare strategies including computed tomography (CT), magnetic resonance imaging (MRI), and selective imaging protocols.
- To evaluate diagnostic pathways from a societal perspective.
Main Methods:
- A decision-analytic model was developed to assess costs and outcomes.
- Model inputs were sourced from charge data, Medicare reimbursements, and existing literature.
- Cost-effectiveness was defined by an incremental cost-effectiveness ratio (ICER) below $100,000 per quality-adjusted life-year (QALY) gained.
Main Results:
- Magnetic resonance imaging (MRI) yielded an additional 0.05 QALY at an incremental cost of $1,227 (ICER: $25,438/QALY) compared to CT.
- For facilities lacking MRI, patient transfer to an MRI-capable facility is cost-effective if transfer costs are below $1,228.
- Alternative strategies involving CT followed by transfer or only CT become more cost-effective as transfer costs increase.
Conclusions:
- Magnetic resonance imaging (MRI) represents a cost-effective diagnostic approach for occult hip fractures.
- The optimal strategy for facilities without MRI capability is contingent upon interfacility transfer costs.
Objective:
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.
Methods:
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.
Results:
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.
Conclusion:
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.
