Sunday, December 10, 2017

How much money should we spend on imaging rotator cuffs?

Cost-effectiveness of magnetic resonance imaging versus ultrasound for the detection of symptomatic full-thickness supraspinatus tendon tears

These authors sought to determine the value of magnetic resonance imaging (MRI) and ultrasound-based imaging strategies in the evaluation of a hypothetical population with a symptomatic full-thickness supraspinatus tendon tear using formal cost-effectiveness analysis. They used a decision analytic model from the health care system perspective for 60-year-old patients with symptoms secondary to a suspected supraspinatus tear to evaluate the incremental cost-effectiveness of 3 imaging strategies during a 2-year time horizon: MRI, ultrasound, and ultrasound followed by MRI.

Their results shown below show a 0.8% increased effectiveness for MRI which costs 16.5% more than ultrasound.

Comment:  What's really interesting in this paper is the first two sentences of the introduction. "Rotator cuff tears are a common source of shoulder pain, especially for older patients, and full-thickness tendon tears have been reported in up to 21% of the general population. Surgical treatment for rotator cuff disease has increased 238% during a span of 14 years (1995-2009), accounting for approximately 250,000 operations in the United States per year."

In 2012 the Unites States population of individuals over the age of 65 years was 41,506,000 (see this link). From these numbers it can be estimated that there are 8,716,200 individuals (21% times 41,506,000) with cuff tears, but less than 3% (250,000 divided by 8,716,200) of these receive surgery each year. One must ask, "how important is imaging in the decision to perform surgery, what percent of the population should have ultrasound or MRI to evaluate cuff integrity?" The reader can do the math of multiplying the cost of imaging by the number of folks at risk for having cuff tears.

The decision to attempt a cuff repair on a patient needs to be highly individualized. Shared patient-surgeon decision making needs to be based on findings that have been shown to be encouraging or discouraging about the prospect of the shoulder having a durably reparable cuff tear. It is of interest that many of these factors can be determined without ultrasound or MRI. We first published these guidelines in 1994 and have found them as useful today as back then. Note that the decision is based on considering the patient as well as the shoulder.

ENCOURAGING                                    DISCOURAGING

Age less than 55                                        Age over 65
Acute traumatic onset                                Insidious, atraumatic onset
No relation to work                                   Attribution of tear to work
Short duration of weakness                       Weakness over 6 weeks
No history of smoking                               Many smoking pack-years
No steroid injections                                  Repeated steroid injections
No major medications                                Steroids/antimetabolites
No concurrent disease                                Inflammatory joint disease
No infections                                              History of previous infection
No previous shoulder surgery                     Previous cuff surgery
Benign surgical history                               History of failed tissue repairs

Physical Examination 
Good nutrition                                             Poor nutrition/obesity
Mild weakness                                            Severe weakness
No spinatus atrophy                                    Severe spinatus atrophy
Stable shoulder                                           Anterior superior instability
Intact acromion                                           Previous acromioplasty
No stiffness                                                 Stiffness

Normal radiographs                                    Upwards head displacement
                                                                    Cuff tear arthropathy

MRI or Ultrasound 
Good tendon quality                                   Thin tendon
One tendon tear                                          Multiple tendon involvement
Small gap to close                                       Severe retraction

In our practice, we are depending less and less on rotator cuff imaging and more and more on the factors that can be discerned from a good history, physical examination, and plain radiographs.

The reader may also be interested in these posts:

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