A value-based care analysis of magnetic resonance imaging in patients with suspected rotator cuff tendinopathy and the implicated role of conservative management
These authors questioned the value of magnetic resonance imaging when it is used as the initial musculoskeletal imaging test before a trial of conservative therapy in patients with atraumatic shoulder pain, minimal to no strength deficits on examination, and suspected cuff tendinopathy.
They studied a group of 51 patients suspected to have cuff tendinopathy based on clinical findings. Every patient underwent MRI and was offered an initial trial of conservative management(education, activity modification, non-steroidal antiinflammatory drugs, and physical therapy). After a minimum of two months, patients were offered surgical intervention if they had persistent symptoms. Patients had an average follow-up of 28.3 ± 5.3 months after imaging to determine whether surgery was performed.
46 (90.2%) patients did not go on to surgical intervention, whereas 5 (9.8%) patients did at an average 68.3 days after imaging. Four (9%) of the patients having non-operative management had full thickness cuff tears. Four (80%) of the patients having surgery had full thickness cuff tears. These results suggest that over 90.2% of patients (46 of 51) had premature MRI, posing an unnecessary economic burden of $181,619 in advanced imaging charges.
Comment: Diagnostic tests are useful when they produce "actionable intelligence", that is when they change the course of treatment. The authors observe that most patients with atraumatic shoulder pain are well managed with non-operative approaches. If these patients are given a two month trial of exercises, activity modification and mild anti-inflammatory medications, most experience symptom improvement without surgery. If MRIs are reserved for those who do not respond, costs ranging from $612 to $4181 per patient can be avoided without compromising the quality of care.
Patients with atraumatic shoulder pain, minimal to no strength deficits on examination, and suspected cuff tendinopathy commonly present to surgeons for evaluation and management. A value-based approach to these patients would reserve MRI's for those who did not respond to non-operative management.
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