title: Cost-effectiveness analysis of the diagnosis of meniscus tears.
abstract: BACKGROUND
  Diagnostic imaging represents the fastest growing segment of costs in the US health system. This study investigated the cost-effectiveness of alternative diagnostic approaches to meniscus tears of the knee, a highly prevalent disease that traditionally relies on MRI as part of the diagnostic strategy.
  
  
  OBJECTIVE
  To identify the most efficient strategy for the diagnosis of meniscus tears.
  
  
  METHODS
  Economic and decision analysis; Level of evidence, 1.
  
  
  METHODS
  A simple-decision model run as a cost-utility analysis was constructed to assess the value added by MRI in various combinations with patient history and physical examination (H&P). The model examined traumatic and degenerative tears in 2 distinct settings: primary care and orthopaedic sports medicine clinic. Strategies were compared using the incremental cost-effectiveness ratio (ICER).
  
  
  RESULTS
  In both practice settings, H&P alone was widely preferred for degenerative meniscus tears. Performing MRI to confirm a positive H&P was preferred for traumatic tears in both practice settings, with a willingness to pay of less than US$50,000 per quality-adjusted life-year. Performing an MRI for all patients was not preferred in any reasonable clinical scenario. The prevalence of a meniscus tear in a clinician's patient population was influential. For traumatic tears, MRI to confirm a positive H&P was preferred when prevalence was less than 46.7%, with H&P preferred above that. For degenerative tears, H&P was preferred until the prevalence reaches 74.2%, and then MRI to confirm a negative was the preferred strategy. In both settings, MRI to confirm positive physical examination led to more than a 10-fold lower rate of unnecessary surgeries than did any other strategy, while MRI to confirm negative physical examination led to a 2.08 and 2.26 higher rate than H&P alone in primary care and orthopaedic clinics, respectively.
  
  
  CONCLUSIONS
  For all practitioners, H&P is the preferred strategy for the suspected degenerative meniscus tear. An MRI to confirm a positive H&P is preferred for traumatic tears for all practitioners. Consideration should be given to implementing alternative diagnostic strategies as well as enhancing provider education in physical examination skills to improve the reliability of H&P as a diagnostic test.
  
  
  CONCLUSIONS
  Alternative diagnostic strategies that do not include the use of MRI may result in decreased health care costs without harm to the patient and could possibly reduce unnecessary procedures.
authors.affiliation: Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA richard.mather@dm.duke.edu.
authors.forename: Richard C
authors.initials: RC
authors.lastname: Mather
authors.affiliation: Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA.
authors.forename: William E
authors.initials: WE
authors.lastname: Garrett
authors.affiliation: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Cole
authors.affiliation: Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA.
authors.forename: Kristen
authors.initials: K
authors.lastname: Hussey
authors.affiliation: Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Bolognesi
authors.affiliation: Department of Orthopaedic Surgery, Bassett Health Care Network, Cooperstown, New York, USA.
authors.forename: Tally
authors.initials: T
authors.lastname: Lassiter
authors.affiliation: Department of Medicine and the Center for Applied Genomics & Precision Medicine, Duke University Medical Center, Durham, North Carolina, USA.
authors.forename: Lori A
authors.initials: LA
authors.lastname: Orlando
mesh_terms: D000328:Adult; D000368:Aged; D001182:Arthroscopy / Q000706:statistics & numerical data*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005188:False Negative Reactions; D005189:False Positive Reactions; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000191:economics*; D008297:Male; D008487:Medical History Taking; D008875:Middle Aged; D009985:Orthopedics / Q000191:economics* / Q000379:methods / Q000706:statistics & numerical data; D010808:Physical Examination; D010818:Practice Patterns, Physicians'; D015995:Prevalence; D011320:Primary Health Care / Q000191:economics* / Q000379:methods / Q000706:statistics & numerical data; D019057:Quality-Adjusted Life Years; D015203:Reproducibility of Results; D012421:Rupture / Q000175:diagnosis / Q000191:economics / Q000453:epidemiology; D012422:Rupture, Spontaneous / Q000175:diagnosis / Q000191:economics / Q000453:epidemiology; D012680:Sensitivity and Specificity; D000070600:Tibial Meniscus Injuries; D014481:United States; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*; D055815:Young Adult
keywords: MRI; cost; cost-effectiveness analysis; decision analysis; economic analysis; health policy; meniscus tears; physical examination