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Advanced Imaging Adds Little Value in the Diagnosis of Femoroacetabular Impingement Syndrome.

Publication ,  Journal Article
Cunningham, DJ; Paranjape, CS; Harris, JD; Nho, SJ; Olson, SA; Mather, RC
Published in: J Bone Joint Surg Am
December 20, 2017

BACKGROUND: Femoroacetabular impingement (FAI) syndrome is an increasingly recognized source of hip pain and disability in young active adults. In order to confirm the diagnosis, providers often supplement physical examination maneuvers and radiographs with intra-articular hip injection, magnetic resonance imaging (MRI), or magnetic resonance arthrography (MRA). Since diagnostic imaging represents the fastest rising cost segment in U.S. health care, there is a need for value-driven diagnostic algorithms. The purpose of this study was to identify cost-effective diagnostic strategies for symptomatic FAI, comparing history and physical examination (H&P) alone (utilizing only radiographic imaging) with supplementation with injection, MRI, or MRA. METHODS: A simple-chain decision model run as a cost-utility analysis was constructed to assess the diagnostic value of the MRI, MRA, and injection that are added to the H&P and radiographs in diagnosing symptomatic FAI. Strategies were compared using the incremental cost-utility ratio (ICUR) with a willingness to pay (WTP) of $100,000/QALY (quality-adjusted life year). Direct costs were measured using the Humana database (PearlDiver). Diagnostic test accuracy, treatment outcome probabilities, and utilities were extracted from the literature. RESULTS: H&P with and without supplemental diagnostic injection was the most cost-effective. Adjunct injection was preferred in situations with a WTP of >$60,000/QALY, low examination sensitivity, and high FAI prevalence. With low disease prevalence and low examination sensitivity, as may occur in a general practitioner's office, H&P with injection was the most cost-effective strategy, whereas in the reciprocal scenario, H&P with injection was only favored at exceptionally high WTP (∼$990,000). CONCLUSIONS: H&P and radiographs with supplemental diagnostic injection are preferred over advanced imaging, even with reasonable deviations from published values of disease prevalence, test sensitivity, and test specificity. Providers with low examination sensitivity in situations with low disease prevalence may benefit most from including injection in their diagnostic strategy. Providers with high examination sensitivity in situations with high disease prevalence may not benefit from including injection in their diagnostic strategy. Providers should not routinely rely on advanced imaging to diagnose FAI syndrome, although advanced imaging may have a role in challenging clinical scenarios. LEVEL OF EVIDENCE: Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

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Published In

J Bone Joint Surg Am

DOI

EISSN

1535-1386

Publication Date

December 20, 2017

Volume

99

Issue

24

Start / End Page

e133

Location

United States

Related Subject Headings

  • Young Adult
  • Severity of Illness Index
  • Sensitivity and Specificity
  • Physical Examination
  • Orthopedics
  • Male
  • Magnetic Resonance Imaging
  • Injections, Intra-Articular
  • Humans
  • Femoracetabular Impingement
 

Citation

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Cunningham, D. J., Paranjape, C. S., Harris, J. D., Nho, S. J., Olson, S. A., & Mather, R. C. (2017). Advanced Imaging Adds Little Value in the Diagnosis of Femoroacetabular Impingement Syndrome. J Bone Joint Surg Am, 99(24), e133. https://doi.org/10.2106/JBJS.16.00963
Cunningham, Daniel J., Chinmay S. Paranjape, Joshua D. Harris, Shane J. Nho, Steven A. Olson, and Richard C. Mather. “Advanced Imaging Adds Little Value in the Diagnosis of Femoroacetabular Impingement Syndrome.J Bone Joint Surg Am 99, no. 24 (December 20, 2017): e133. https://doi.org/10.2106/JBJS.16.00963.
Cunningham DJ, Paranjape CS, Harris JD, Nho SJ, Olson SA, Mather RC. Advanced Imaging Adds Little Value in the Diagnosis of Femoroacetabular Impingement Syndrome. J Bone Joint Surg Am. 2017 Dec 20;99(24):e133.
Cunningham, Daniel J., et al. “Advanced Imaging Adds Little Value in the Diagnosis of Femoroacetabular Impingement Syndrome.J Bone Joint Surg Am, vol. 99, no. 24, Dec. 2017, p. e133. Pubmed, doi:10.2106/JBJS.16.00963.
Cunningham DJ, Paranjape CS, Harris JD, Nho SJ, Olson SA, Mather RC. Advanced Imaging Adds Little Value in the Diagnosis of Femoroacetabular Impingement Syndrome. J Bone Joint Surg Am. 2017 Dec 20;99(24):e133.

Published In

J Bone Joint Surg Am

DOI

EISSN

1535-1386

Publication Date

December 20, 2017

Volume

99

Issue

24

Start / End Page

e133

Location

United States

Related Subject Headings

  • Young Adult
  • Severity of Illness Index
  • Sensitivity and Specificity
  • Physical Examination
  • Orthopedics
  • Male
  • Magnetic Resonance Imaging
  • Injections, Intra-Articular
  • Humans
  • Femoracetabular Impingement