IMAGING/ORIGINAL RESEARCH
Cost-effectiveness of Magnetic Resonance Imaging in Cervical Spine Clearance of Neurologically Intact Patients With Blunt Trauma Xiao Wu, BS†; Ajay Malhotra, MD, MMM*†; Bertie Geng, BS; Renu Liu, MD; Khalid Abbed, MD; Howard P. Forman, MD, MBA; Pina Sanelli, MD, MPH *Corresponding Author. E-mail: [email protected], Twitter: @CEA_Yale.
Study objective: Use of magnetic resonance imaging (MRI) for cervical clearance after a negative cervical computed tomography (CT) scan result in alert patients with blunt trauma who are neurologically intact is not infrequent, despite poor evidence in regard to its utility. The objective of this study is to evaluate the utility and cost-effectiveness of using MRI versus no follow-up in this patient population. Methods: A modeling-based decision analysis was performed during the lifetime of a 40-year-old individual from a societal perspective. The 2 strategies compared were no follow-up and MRI. A Markov model with a 3% discount rate was used with parameters from the literature. Base cases and probabilistic and sensitivity analyses were performed to assess the cost-effectiveness of the strategies. Results: The cost of MRI follow-up was $11,477, with a health benefit of 24.03 quality-adjusted life-years; the cost of no follow-up was $6,432, with a health benefit of 24.08 quality-adjusted life-years. No follow-up was the dominant strategy, with a lower cost and a higher utility. Probabilistic sensitivity analysis showed no follow-up to be the better strategy in all 10,000 iterations. No follow-up was the better strategy irrespective of the negative predictive value of initial CT result, and it remained the better strategy when the incidence of missed unstable injury resulting in permanent neurologic deficits was less than 64.2% and the incidence of patients immobilized with a hard collar who still received cord injury was greater than 19.7%. Multiple 3-way sensitivity analyses were performed. Conclusion: MRI is not cost-effective for further evaluation of unstable injury in neurologically intact patients with blunt trauma after a negative cervical spine CT result. [Ann Emerg Med. 2017;-:1-10.] Please see page XX for the Editor’s Capsule Summary of this article. 0196-0644/$-see front matter Copyright © 2017 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2017.07.006
INTRODUCTION Cervical spine injuries occur in up to 4% of patients with blunt trauma, and clearance of the cervical spine remains one of the critical steps in the evaluation. Unstable injury can result in permanent neurologic sequelae if not immobilized in a timely fashion.1-4 For awake, alert patients who are neurologically intact with no midline cervical spine tenderness, the National Emergency X-Radiography Utilization Study (NEXUS) decisionmaking rules have been instrumental in clinically clearing the collar.5 For patients who fail the NEXUS criteria, computed tomography (CT) is used as the next step in radiographic clearance. A high-quality cervical CT scan (
Cost-effectiveness of Magnetic Resonance Imaging in Cervical Spine Clearance of Neurologically Intact Patients With Blunt Trauma Xiao Wu, BS†; Ajay Malhotra, MD, MMM*†; Bertie Geng, BS; Renu Liu, MD; Khalid Abbed, MD; Howard P. Forman, MD, MBA; Pina Sanelli, MD, MPH *Corresponding Author. E-mail: [email protected], Twitter: @CEA_Yale.
Study objective: Use of magnetic resonance imaging (MRI) for cervical clearance after a negative cervical computed tomography (CT) scan result in alert patients with blunt trauma who are neurologically intact is not infrequent, despite poor evidence in regard to its utility. The objective of this study is to evaluate the utility and cost-effectiveness of using MRI versus no follow-up in this patient population. Methods: A modeling-based decision analysis was performed during the lifetime of a 40-year-old individual from a societal perspective. The 2 strategies compared were no follow-up and MRI. A Markov model with a 3% discount rate was used with parameters from the literature. Base cases and probabilistic and sensitivity analyses were performed to assess the cost-effectiveness of the strategies. Results: The cost of MRI follow-up was $11,477, with a health benefit of 24.03 quality-adjusted life-years; the cost of no follow-up was $6,432, with a health benefit of 24.08 quality-adjusted life-years. No follow-up was the dominant strategy, with a lower cost and a higher utility. Probabilistic sensitivity analysis showed no follow-up to be the better strategy in all 10,000 iterations. No follow-up was the better strategy irrespective of the negative predictive value of initial CT result, and it remained the better strategy when the incidence of missed unstable injury resulting in permanent neurologic deficits was less than 64.2% and the incidence of patients immobilized with a hard collar who still received cord injury was greater than 19.7%. Multiple 3-way sensitivity analyses were performed. Conclusion: MRI is not cost-effective for further evaluation of unstable injury in neurologically intact patients with blunt trauma after a negative cervical spine CT result. [Ann Emerg Med. 2017;-:1-10.] Please see page XX for the Editor’s Capsule Summary of this article. 0196-0644/$-see front matter Copyright © 2017 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2017.07.006
INTRODUCTION Cervical spine injuries occur in up to 4% of patients with blunt trauma, and clearance of the cervical spine remains one of the critical steps in the evaluation. Unstable injury can result in permanent neurologic sequelae if not immobilized in a timely fashion.1-4 For awake, alert patients who are neurologically intact with no midline cervical spine tenderness, the National Emergency X-Radiography Utilization Study (NEXUS) decisionmaking rules have been instrumental in clinically clearing the collar.5 For patients who fail the NEXUS criteria, computed tomography (CT) is used as the next step in radiographic clearance. A high-quality cervical CT scan (
