Dataset Information

Clinical and cost implications of using immediate MRI in the management of patients with a suspected scaphoid fracture and negative radiographs results from the SMaRT trial.

ABSTRACT: AIMS: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 AND METHODS: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. RESULTS: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% vs 93.8%) and of any other fracture (98.5% vs 84.6%). CONCLUSION: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: Bone Joint J 2019;101-B:984-994.

SUBMITTER: Rua T

PROVIDER: S-EPMC6681676 | biostudies-literature | 2019 Aug

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Clinical and cost implications of using immediate MRI in the management of patients with a suspected scaphoid fracture and negative radiographs results from the SMaRT trial.

Rua T T Malhotra B B Vijayanathan S S Hunter L L Peacock J J Shearer J J Goh V V McCrone P P Gidwani S S

The bone & joint journal 20190801 8

<h4>Aims</h4>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.<h4>Patients and methods</h4>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, ...[more]

PMID: 31362557

Similar Datasets

Project description:IntroductionSome scaphoid fractures become visible on radiographs weeks after a trauma which makes normal radiographs directly after trauma unreliable. Untreated scaphoid fractures can lead to scaphoid non-union progressing to osteoarthritis. Therefore, the general treatment for patients with a clinically suspected scaphoid fracture and normal initial radiographs is immobilisation with below-elbow cast for 2 weeks. However, most of these patients are treated unnecessarily because eventually less than 10% of them are diagnosed with an occult scaphoid fracture. To reduce overtreatment and costs as a result of unnecessary cast treatment in patients with a clinically suspected scaphoid fracture and normal initial radiographs, we designed a study to compare below-elbow cast treatment with supportive bandage treatment. We hypothesise that the functional outcome after 3 months is not inferior in patients treated with supportive bandage compared to patients treated with below-elbow cast, but with lower costs in the supportive bandage group.Methods and analysisThe SUSPECT study is an open-labelled multicentre randomised controlled trial with non-inferiority design. A total of 180 adult patients with a clinically suspected scaphoid fracture and normal initial radiographs are randomised between two groups: 3 days of supportive bandage or 2 weeks of below-elbow cast. We aim to evaluate the functional outcome and cost-effectiveness of both treatments. The primary outcome is the functional outcome after 3 months, assessed with the Quick Disability of the Arm, Shoulder and Hand score. Secondary outcomes include functional outcome, recovery of function, pain, patient satisfaction, quality of life and cost-effectiveness measured by medical consumption, absence from work or decreased productivity.Ethics and disseminationThe Medical Ethics Committee of the Erasmus MC Medical Centre, Rotterdam, approved the study protocol (MEC-2017-504). We plan to present the results after completion of the study at (inter)national conferences and publish in general peer-reviewed journals.Trial registration numberNL6976.

Project description:ImportanceScaphoid fractures are the most common carpal fracture, but as many as 20% are not visible (ie, occult) in the initial injury radiograph; untreated scaphoid fractures can lead to degenerative wrist arthritis and debilitating pain, detrimentally affecting productivity and quality of life. Occult scaphoid fractures are among the primary causes of scaphoid nonunions, secondary to delayed diagnosis.ObjectiveTo develop and validate a deep convolutional neural network (DCNN) that can reliably detect both apparent and occult scaphoid fractures from radiographic images.Design, setting, and participantsThis diagnostic study used a radiographic data set compiled for all patients presenting to Chang Gung Memorial Hospital (Taipei, Taiwan) and Michigan Medicine (Ann Arbor) with possible scaphoid fractures between January 2001 and December 2019. This group was randomly split into training, validation, and test data sets. The images were passed through a detection model to crop around the scaphoid and were then used to train a DCNN model based on the EfficientNetB3 architecture to classify apparent and occult scaphoid fractures. Data analysis was conducted from January to October 2020.ExposuresA DCNN trained to discriminate radiographs with normal and fractured scaphoids.Main outcomes and measuresArea under the receiver operating characteristic curve (AUROC), sensitivity, and specificity. Fracture localization was assessed using gradient-weighted class activation mapping.ResultsOf the 11 838 included radiographs (4917 [41.5%] with scaphoid fracture; 6921 [58.5%] without scaphoid fracture), 8356 (70.6%) were used for training, 1177 (9.9%) for validation, and 2305 (19.5%) for testing. In the testing test, the first DCNN achieved an overall sensitivity and specificity of 87.1% (95% CI, 84.8%-89.2%) and 92.1% (95% CI, 90.6%-93.5%), respectively, with an AUROC of 0.955 in distinguishing scaphoid fractures from scaphoids without fracture. Gradient-weighted class activation mapping closely corresponded to visible fracture sites. The second DCNN achieved an overall sensitivity of 79.0% (95% CI, 70.6%-71.6%) and specificity of 71.6% (95% CI, 69.0%-74.1%) with an AUROC of 0.810 when examining negative cases from the first model. Two-stage examination identified 20 of 22 cases (90.9%) of occult fracture.Conclusions and relevanceIn this study, DCNN models were trained to identify scaphoid fractures. This suggests that such models may be able to assist with radiographic detection of occult scaphoid fractures that are not visible to human observers and to reliably detect fractures of other small bones.

Dataset Information

Clinical and cost implications of using immediate MRI in the management of patients with a suspected scaphoid fracture and negative radiographs results from the SMaRT trial.

Publications

Clinical and cost implications of using immediate MRI in the management of patients with a suspected scaphoid fracture and negative radiographs results from the SMaRT trial.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets