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Pathology of the triangular fibrocartilage complex is a prevalent cause of ulnar-sided wrist pain that presents a diagnostic challenge. We hypothesized that a history and physical examination (H&P) would be more cost-effective alone or with diagnostic injection than with magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA) in the diagnosis and treatment of a symptomatic triangular fibrocartilage complex abnormality.
Methods
A simple-chain decision analysis model was constructed to assess simulated subjects with ulnar-sided wrist pain and normal radiographs using several diagnostic algorithms: H&P alone, H&P + injection, H&P with delayed advanced imaging (MRI or MRA), and H&P + injection with delayed advanced imaging (MRI or MRA). Three years after diagnosis, effectiveness was calculated in Disabilities of the Arm, Shoulder, and Hand–adjusted life years. Costs were extracted from a commercial insurance database using US dollars. A probabilistic sensitivity analysis with 10,000 second-order trials with sampling of parameter distributions was performed. One-way and 2-way sensitivity analyses were performed.
Results
All strategies had similar mean effectiveness between 2.228 and 2.232 Disabilities of the Arm, Shoulder, and Hand–adjusted life years, with mean costs ranging from $5,584 (H&P alone) to $5,980 (H&P, injection, and MRA). History and physical examination alone or with injection were the most cost-effective strategies. History and physical examination alone was the most preferred diagnostic strategy, though H&P + injection and H&P with delayed MRA were preferred with adjustments in willingness-to-pay and parameter inputs. As willingness-to-pay increased considerably (>$65,000 per Disabilities of the Arm, Shoulder, and Hand–adjusted life year), inclusion of MRA became the most favorable strategy.
Conclusions
Advanced imaging adds costs and provides minimal increases in effectiveness in the diagnosis and treatment of a symptomatic triangular fibrocartilage complex abnormality. The most cost-effective strategy is H&P, with or without diagnostic injection. Magnetic resonance arthrogram may be favored in situations with a high willingness-to-pay or poor examination characteristics.
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Disclosures for this Article
Editors
Ryan Calfee, MD, MSc, has no relevant conflicts of interest to disclose.
Authors
All authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the bottom of the first page.
Planners
Ryan Calfee, MD, MSc, has no relevant conflicts of interest to disclose. The editorial and education staff involved with this journal-based CME activity has no relevant conflicts of interest to disclose.
Learning Objectives
Upon completion of this CME activity, the reader will understand:
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The most cost effective evaluation strategies for triangular fibrocartilage complex (TFCC) injury.
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The concept of cost effectiveness research.
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The value of foveal injection in the evaluation of ulnar wrist pain.
Deadline: Each examination purchased in 2021 must be completed by January 31, 2022, to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each JHS CME activity is up to one hour.
The differential diagnoses of ulnar-sided wrist pain can be broad, including injuries to bony, tendinous, ligamentous, joint, nerve, and vascular structures.
Triangular fibrocartilage complex (TFCC) pathology, defined as acute or chronic injury to the triangular fibrocartilage disc, palmar and dorsal radioulnar ligaments, meniscal homologue, ulnar collateral ligament, or subsheath of the extensor carpi ulnaris tendon, is the most common cause of ulnar-sided wrist pain.
Although 57% of patients may improve with nonsurgical management alone, durable improvements have been demonstrated with arthroscopic TFCC repair or debridement with or without ulnar shortening osteotomy and with ulnar shortening osteotomy alone.
The outcomes of arthroscopic repair versus debridement for chronic unstable triangular fibrocartilage complex tears in patients undergoing ulnar-shortening osteotomy.
Apart from a physical examination, some practitioners use additional diagnostic modalities, including selective injection, magnetic resonance imaging (MRI), magnetic resonance arthrogram (MRA), and diagnostic arthroscopy, to help refine the diagnosis. Advanced imaging in the form of MRI or MRA may be an option for diagnosing a TFCC abnormality. However, diagnostic imaging is the fastest rising cost driver in health care in the United States.
An x-ray can be used to establish ulnar variance, which is diagnostically useful since positive ulnar variance has been associated with symptomatic TFCC abnormalities and ulnar impaction syndrome.
Wrist arthroscopy has also been used as a diagnostic tool that can be simultaneously therapeutic.
The purpose of this study was to critically evaluate the role of advanced imaging in the diagnosis and treatment of subacute to chronic ulnar-sided wrist pain in simulated subjects 55 years of age and younger with a focus on symptomatic TFCC abnormality. The study’s hypothesis was that history and physical examination (H&P) alone or with a diagnostic injection would be more cost-effective than these same strategies with MRI or MRA in the management of a symptomatic TFCC abnormality.
Materials and Methods
Cost-effectiveness model
This study is a cost-effectiveness analysis of 6 diagnostic strategies for simulated subjects with ulnar-sided wrist pain and normal radiographs. A simple-chain decision model was constructed and evaluated using TreeAge Pro 2020 (TreeAge Software), in accordance with the guidelines on the Second Panel on Cost-Effectiveness in Health and Medicine.
Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine.
Diagnostic strategies included H&P alone, H&P + diagnostic injection, H&P with MRI, H&P with MRA, H&P + diagnostic injection and MRI, and H&P + diagnostic injection and MRA. Table 1 shows key study definitions used throughout the manuscript. Table 2 displays model parameters. All model parameters were based on the best available evidence and were input as distributions for sampling, with the exception of the study’s time horizon (3 years), as appropriate. The 3-year time horizon was chosen since this was consistent with the duration of available clinical outcomes. Model parameter sources and critiques are included in Table E1 (available online on the Journal’s website at www.jhandsurg.org/). As shown in Table E2 (available online on the Journal’s website at www.jhandsurg.org/), this analysis was performed from the health payer perspective since it did not include informal health care sector and non–health care sector costs such as patient time costs and lost labor market earnings. However, in the setting of a unilateral injury to a non–weight bearing joint, it has been assumed that these indirect costs could be considered negligible.
Table 1Key Study Definitions
Terminology
Definition
True positive
•
Diagnostic modality correctly identifies that patient has specific pathology
•
Pathology correctly identified
True negative
•
Diagnostic modality correctly identifies that patient does not have specific pathology
•
Lack of pathology correctly identified
False positive
•
Diagnostic modality incorrectly identifies that patient has specific pathology
•
Pathology incorrectly identified in patient without pathology
False negative
•
Diagnostic modality incorrectly identifies that patient does not have specific pathology
•
Pathology missed in patient with pathology
Costs
•
Measure of the direct and indirect monetary expenses of an intervention
Effectiveness
•
Measure of benefits and/or harms of an intervention
•
Commonly expressed in quality-adjusted life years
Cost-effectiveness analysis
•
Analytic tool in which the costs and harms and benefits of an intervention and at least 1 alternative are calculated and presented as a ratio of the incremental cost and the incremental effect.
Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine.
Commonly used effectiveness outcome that measures a patient’s global health-related quality of life over the course of 1 year, with 0 representing death and 1 representing optimal health.
QuickDASH-adjusted life year
•
Effectiveness outcome that measures patient’s upper extremity–specific disability over the course of a year
•
Cannot be directly compared to quality-adjusted life year
ICER
•
Ratio of incremental costs (eg, additional resources incurred from use of 1 intervention over another) over incremental effectiveness (eg, additional benefit obtained from use of 1 intervention over another)
•
Calculated as
WTP
•
Cost that health payer would pay for additional unit of effectiveness
Figure 1 displays this study’s health state flow diagram for patients ≤55 years of age with subacute or chronic ulnar-sided wrist pain, normal radiographs (no clear cause of pain on plain x-rays such as fracture, dislocation, or region-specific degenerative change), and ulnar neutral or ulnar negative variance. Patients passed through a variety of health states for specific durations of time based on literature-determined probabilities described in Table 2. During this time, they underwent diagnostic and therapeutic interventions and experienced treatment success or failure. Success was defined as lack of a need for further diagnosis or treatment, regardless of the underlying etiology of ulnar-sided wrist pain. Generally, patients first underwent nonsurgical management with anti-inflammatories, physical therapy, and immobilization, followed by an opportunity for advanced imaging. If an initial workup was suggestive of a symptomatic TFCC abnormality and nonsurgical treatment failed, patients underwent surgery. If not, they underwent additional nonsurgical treatment. Patients failing a second round of nonsurgical treatment underwent surgery. Patients had treatment success and failure at rates consistent with the literature and in keeping with their underlying pathology. Operative complications were also modeled, including dorsal ulnar sensory nerve symptoms, arthroscopy portal complications, and deep infections, at rates consistent with the literature. Simulated subjects remained in their final state for the remainder of the 3-year time horizon. A detailed model is shown in Figure E1 (available online on the Journal’s website at www.jhandsurg.org/).
Importantly, this model assumed that simulated subjects did not decline treatment, as could occur in clinical practice. Further, the performance of advanced imaging studies did not delay surgical consideration unless the results of the study were contrary to the simulated subject’s actual diagnosis, in which case, additional nonsurgical management was recommended. Final diagnosis and treatment decisions were based on the results of the final diagnostic test in the strategy. Nonsurgical treatments that were universally applied (anti-inflammatories, immobilization, and hand therapy) were assumed to have no negative impact on effectiveness. Similarly, the diagnostic local anesthetic injection and arthrogram for MRA were considered to be benign interventions without any negative impact on effectiveness. Simulated subjects without a symptomatic TFCC abnormality that underwent diagnostic and treatment arthroscopy were considered to have a probability of success with surgery (ie, their true pathology was discovered and treated on diagnostic arthroscopy). To penalize proceeding with surgical treatment in simulated subjects without a symptomatic TFCC abnormality, the range of probabilities of operative success was halved from the rate of operative success in simulated subjects with a symptomatic TFCC abnormality. Ulnar neutral or negative variance was also assumed.
Costs
Direct medical cost estimates and distributions were obtained from the PearlDiver Mariner database using specific Current Procedural Terminology (CPT) codes between 2010 and 2019 in US dollar values. To obtain relevant costs, all patients with a CPT or International Classification of Diseases diagnosis of symptomatic TFCC abnormality within the PearlDiver M30 database were first identified. Then, means and SDs for costs related to a clinic visit, x-ray, diagnostic injection, therapy, MRI, MRA, arthroscopic TFCC repair, infection operation, and antibiotic were tabulated in these patients (see Table E3, available online on the Journal’s website at www.jhandsurg.org/, for International Classification of Diseases and CPT codes). Costs of an arthroscopic TFCC repair and operation for infection were summed across the entire operative day’s episode of care to account for anesthetic costs and other costs related to surgery that would not be captured solely by the surgical CPT code. Therapy costs were summed across a 90-day time period starting with the patient’s initial diagnosis of a TFCC tear. Within the model, simulated subjects undergoing treatment for deep infection incurred additional costs of infection surgery, an antibiotic, and a clinic visit. Simulated subjects undergoing treatment for dorsal ulnar sensory nerve symptoms incurred additional costs of therapy and a clinic visit. Simulated subjects with arthroscopic portal complications incurred additional costs of an antibiotic and a clinic visit. Costs were summed and adjusted to 2020 US dollars using the consumer price index. Discounting of 3% per year was applied.
Benefits and harms
All simulated subjects entered the model with poor wrist effectiveness based on Disability of the Arm, Shoulder, and Hand (QuickDASH) scores and transitioned to improved wrist effectiveness based on their actual pathology and response to various treatments in each diagnostic scenario.
The outcomes of arthroscopic repair versus debridement for chronic unstable triangular fibrocartilage complex tears in patients undergoing ulnar-shortening osteotomy.
Generally, simulated subjects with treatment success with any modality (initial nonsurgical treatment, a second round of nonsurgical treatment, or surgery) were assumed to immediately benefit from these treatments at the conclusion of the treatment and transitioned to having improved wrist effectiveness for the remainder of the time horizon. Simulated subjects in the immediate postoperative period were assumed to have an additional 6 weeks of poor wrist effectiveness while recovering from surgery. Simulated subjects that sustained postsurgical complications continued to have poor wrist effectiveness for an additional 3 weeks with arthroscopic portal complications and 6 weeks with dorsal ulnar sensory nerve symptoms and deep infection.
Cumulative wrist effectiveness in QuickDASH was summed over the time horizon, based on the duration that simulated subjects remained in each wrist effectiveness state, to create QuickDASH life years. For ease of interpretation, QuickDASH scores (which range from 0 to 100, with lesser scores indicating lower disability and better outcomes) were subtracted from 100 and then divided by 100 to reflect the conventional direction of benefits in cost-effectiveness analyses and to mirror quality-adjusted life years. For example, simulated subjects with poor wrist effectiveness (mean QuickDASH score 35) throughout the 3-year time horizon would have an effectiveness of 0.65 (eg, ) per year for 3 years, providing a cumulative effectiveness of 1.95 QuickDASH-adjusted life years.
Model simulation and sensitivity analyses
Models were evaluated with a probabilistic sensitivity analysis using 10,000 second-order Monte Carlo simulations with resampling of the parameter distributions. Inferences were stable with this modeling strategy across multiple model runs. The primary study outcome was cost-effectiveness, defined as cumulative costs divided by cumulative effectiveness using QuickDASH scores over the study time horizon. Strategies were compared using incremental cost-effectiveness ratios, defined by the strategy-dependent differential costs divided by differential effectiveness.
Tornado diagrams based on differences in net monetary benefits were also constructed to evaluate the impact of each variable on model inference using ranges derived from the 95% confidence intervals of the parameter distributions. Variables having an impact on study inference (ie, changing preferred strategy at a set willingness-to-pay [WTP]) were considered to be sensitive variables. One-way sensitivity analyses were performed on all variables within the model that changed study inference. The probability of operative success in simulated subjects without a symptomatic TFCC abnormality was judged to be an important variable that is challenging to estimate. To examine the impact of this variable on other sensitive variables, 2-way sensitivity analyses were then performed to evaluate the impact of this variable, as well as the impact of sensitive variables, on study inference at a WTP of 50,000 per QuickDASH-adjusted life year. Lastly, as a crosswalk between QuickDASH-adjusted life years and quality-adjusted life years has not been determined, WTP across a broad range was evaluated using a cost-effectiveness acceptability curve to provide the reader with a sense of the comparative cost-effectiveness between strategies with various thresholds of WTP.
Model parameters and data quality critique
Table 2 displays the distributions and values of model parameters. Table E1 (available online on the Journal’s website at www.jhandsurg.org/) contains a complete listing of sources, rationales, and levels of evidence.
Results
Figure 2 displays the base case cost-effectiveness graph. Diagnostic strategies, including advanced imaging and injection, were absolutely dominated (were costlier and less effective) by other strategies. All strategies had similar effectiveness (2.228–2.232). Costs were lowest with H&P alone ($5,583.89) and with H&P with injection ($5627.50). Strategies that included advanced imaging cost $163 to $396 more than H&P alone. Table 3 shows the numerical results of this analysis.
Figure 2Base case cost-effectiveness for the 6 diagnostic strategies shown. A WTP of $50,000 per QuickDASH-adjusted life year is included for reference.
Figure E2 (available online on the Journal’s website at www.jhandsurg.org/) shows tornado diagrams displaying the impact of specific variables on changes in net monetary benefits at a WTP of $50,000 per QuickDASH-adjusted life year. Next, 1-way sensitivity analyses were conducted to determine threshold values for changes in the preferred diagnostic strategy for each variable, including those identified in the tornado diagrams. The full listing of threshold values is shown in Table 4.
Table 4Threshold Values for Model Parameters Derived From 1-Way Sensitivity Analyses Based on Net Monetary Benefits
Variable
Threshold Value
Preferred Below Threshold
Preferred Above Threshold
Costs
Cost of injection
$148.15
H&P + injection
H&P
Cost of MRA
$699.68
H&P with delayed MRA
H&P + injection
Cost of MRI
$430.83
H&P with delayed MRI
H&P + injection
Cost of initial operation
$9,775.17
H&P
H&P + injection
Cost of therapy
$900.30
H&P + injection
H&P
Effectiveness
Effectiveness of poor wrist in simulated subjects without symptomatic TFCC abnormality
0.535
H&P with delayed MRA
H&P + injection
Effectiveness of poor wrist in simulated subjects without symptomatic TFCC abnormality
0.674
H&P + injection
H&P
Effectiveness of poor wrist in simulated subjects with symptomatic TFCC abnormality
0.569
H&P
H&P + injection
Effectiveness of improved wrist in simulated subjects without symptomatic TFCC abnormality
0.836
H&P
H&P + injection
Effectiveness of improved wrist in simulated subjects without symptomatic TFCC abnormality
0.975
H&P + injection
H&P with delayed MRA
Effectiveness of improved wrist in simulated subjects with symptomatic TFCC abnormality
0.941
H&P + injection
H&P
Probabilities
Probability of success with second round of nonsurgical treatment in simulated subjects without symptomatic TFCC abnormality
0.249
H&P
H&P + injection
Probability of success with second round of nonsurgical treatment in simulated subjects without symptomatic TFCC abnormality
0.322
H&P + injection
H&P with delayed MRA
Probability of success with second round of nonsurgical treatment in simulated subjects with symptomatic TFCC abnormality
0.239
H&P
H&P + injection
Probability of nonsurgical success in simulated subjects without symptomatic TFCC abnormality
0.555
H&P + injection
H&P
Probability of nonsurgical success in simulated subjects with symptomatic TFCC abnormality
0.665
H&P + injection
H&P with delayed MRA
Probability of operative success in simulated subjects without symptomatic TFCC abnormality
0.466
H&P + injection
H&P
Probability of operative success in simulated subjects with symptomatic TFCC abnormality
History and physical examination alone was a cost-effective strategy across most of the analyses. With the exception of the analysis on the cost of an MRI, all other preference transitions were between H&P alone, H&P and injection, or H&P with a delayed MRA. History and physical examination+ injection with a delayed MRI or MRA were never the preferred strategies.
The results of the 2-way sensitivity analyses are shown in Table 4. These were largely the same as results for the 1-way sensitivity analyses, except for the transition between H&P with delayed MRA and H&P + injection on the probability of operative success in simulated subjects without a symptomatic TFCC abnormality (Fig. 3).
Figure 3Two-way sensitivity analysis on probability of operative success in simulated subjects without symptomatic TFCC abnormality and on probability of symptomatic TFCC abnormality.
Figure 4 shows the cost-effectiveness acceptability curve across a range of WTP values per QuickDASH-adjusted life year. History and physical examination alone was the preferred strategy until a WTP of approximately $65,000 per QuickDASH-adjusted life year, after which H&P with delayed MRA was preferred. History and physical examination + injection was never more favorable than H&P alone or H&P with delayed MRA in this analysis. History and physical examination + injection became less favorable than H&P with delayed MRA at approximately $50,000 per QuickDASH-adjusted life year.
Figure 4Cost-effectiveness acceptability curve for the 6 diagnostic strategies shown.
Lastly, the impact of diagnostic modality on false positive surgery rates (ie, proceeding to surgery without a symptomatic TFCC abnormality) and false negative surgery delay rates (ie, failing to proceed to surgery in the setting of a symptomatic TFCC abnormality) were examined in the base case using expected values (Table 5). History and physical examination alone resulted in a false positive surgery rate of 0.084 and a false negative surgery delay rate of 0.028. In contrast, strategies including advanced imaging resulted in false positive surgery rates of 0.012–0.044 and false negative surgery delay rates of 0.029–0.045. The number needed to treat (ie, number of patients to undergo additional diagnostic modalities; Table 1) to avoid a single false positive surgery was calculated at 13.8 patients when comparing the strategy of H&P with delayed MRA or H&P + injection with delayed MRA (lowest rates of false positive surgery) to H&P alone (highest rate of false positive surgery). Compared to the strategies with the highest rates of false negative surgery delay (H&P + injection, H&P with delayed MRI, or H&P + injection with delayed MRI), the number needed to treat to avoid a false negative surgery delay was 61.5 patients in H&P with delayed MRA or H&P + injection with delayed MRA and 57.7 with H&P alone.
Table 5False Negative Surgery Delay Rates, False Positive Surgery Rates, and NNT for Each Diagnostic Strategy Using Expected Values From Parameter Distributions in the Base Case
This study examined the cost-effectiveness of various diagnostic strategies for patients aged 55 years and younger presenting with ulnar-sided wrist pain and normal radiographs, with a focus on symptomatic TFCC abnormalities. The findings support that H&P alone is the preferred diagnostic strategy in the context of our treatment algorithm. Advanced imaging added costs and had little benefit in this patient population at reasonable levels of WTP.
Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis.
Therefore, surgical treatment remains a reasonable approach even in patients who have failed nonsurgical management with a negative MRI/MRA.
This study’s finding that advanced imaging is not cost-effective in the diagnosis of ulnar-sided wrist pain with normal radiographs should not be misconstrued to indicate that advanced imaging is never an appropriate part of the diagnosis or treatment of ulnar-sided wrist pain. Surgeons should use clinical judgment to determine whether advanced imaging would be beneficial for their individual patient, although the findings of our study suggest that this should be a rare occurrence.
One notable limitation is that there were no reports of injection diagnostic test characteristics, so these were estimated conservatively. Further, the model assumed that patients with and without a symptomatic TFCC abnormality have the same overall benefits with surgical and nonsurgical management. However, to penalize an incorrect diagnosis, the rate of success for operative treatment was halved in simulated subjects without a symptomatic TFCC abnormality undergoing surgery. These assumptions were tested in a sensitivity analysis, which indicated a minimal change in the model preference across a range of surgical and nonsurgical success rates. As the purpose of this study was to focus on the cost-effectiveness of diagnostic algorithms rather than treatments, we did not compare different treatments (ie, open vs arthroscopic treatments). Further, despite the fact that most studies evaluating TFCC treatment report outcomes in QuickDASH, there are no studies correlating QuickDASH scores with traditional measures of quality of life; therefore, QuickDASH scores were used as a surrogate for quality of life. This complicates the interpretation of the tornado diagrams and 1-way sensitivity analyses, since the interpretation is based on maximizing net monetary benefits, which requires a set WTP. However, a QuickDASH-specific WTP is not available. Because QuickDASH measures are specific to the upper extremity and do not account for global quality of life, we speculate that a QuickDASH-specific WTP would be considerably lower than a WTP based on global quality-of-life metrics (ie, the WTP threshold would likely be less than $50,000/quality-adjusted life year). Based on the cost-effectiveness acceptability curve, advanced imaging would be even less favored with a lower WTP, but we acknowledge that this is speculative. Because of these limitations, we also included false negative surgery delay rates and false positive surgery rates, along with numbers needed to treat, which can be compared between studies since they do not rely on the quality of life. Also, the technical characteristics of MRI and MRA performance, such as field strength, spatial resolution, injection technique (for MRA), and obtaining triplanar imaging with appropriate cartilage-sensitive sequences, may alter the diagnostic accuracy of MRI and MRA, and were not considered. Of note, studies evaluating the diagnostic characteristics of MRI and MRA may overstate their benefits, since imaging studies performed in these studies were likely performed in ideal conditions and in high-prevalence samples. Further, since this study was performed from the health payer perspective, we did not include some indirect costs such as those incurred from time away from work or activities since we judged that the impact of those costs would be minimal in the setting of a unilateral upper-extremity injury. Because of these assumptions, this model may not extrapolate well to patients with an exceptional disability or indirect cost related to their symptomatic TFCC abnormality. Injections (diagnostic injections and arthrograms) were considered to be benign interventions, although a small proportion of patients may experience a side effect such as a local anesthetic or contrast-related complication. Importantly, additional cost and disability related to diagnostic injection or arthrogram would further favor H&P alone, supporting the study’s main inference. Lastly, the study relies on a diagnostic and treatment algorithm currently in use in our clinical practice that was developed over years of experience. These results may not generalize to alternative diagnostic and treatment algorithms.
In conclusion, this model of simulated subjects presenting with ulnar-sided wrist pain with normal radiographs incorporated reasonable, literature-based parameter estimates to demonstrate: (1) the cost-effectiveness of H&P alone or H&P + diagnostic injection as the basis of diagnosis and treatment; and (2) the minimal additional benefit and the additional costs of advanced imaging. Specific clinical scenarios may warrant consideration of advanced imaging. In an era of increasing scrutiny on health care expenditures, reduction of unnecessary diagnostic tests may become increasingly important.
Appendix
Figure E1Complete simple-chain decision analysis model for 1 diagnostic strategy.
Figure E2Tornado diagrams displaying the impacts of specific variables on changes in net monetary benefits at a WTP of $50,000 per QuickDASH-adjusted life year. Figures are grouped by costs, effectiveness, probabilities, time estimates, and diagnostic testing characteristics. The vertical black lines represent transition values between strategies found to maximize net monetary benefits at the set WTP. EV, expected value.
Triangular distribution centered on mean rate of operative success bounded by lower and upper limits of reported rates. Rate halved to account for alternate pathology determined in operating room
Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis.
Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis.
Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis.
Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis.
ICD-9, International Classification of Diseases, 9th edition; ICD-10, ICD International Classification of Diseases, 10th edition; NDC, National Drug Code.
The outcomes of arthroscopic repair versus debridement for chronic unstable triangular fibrocartilage complex tears in patients undergoing ulnar-shortening osteotomy.
Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine.
Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis.
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