title: Does CT-based Rigidity Analysis Influence Clinical Decision-making in Simulations of Metastatic Bone Disease?
abstract: BACKGROUND
  There is a need to improve the prediction of fracture risk for patients with metastatic bone disease. CT-based rigidity analysis (CTRA) is a sensitive and specific method, yet its influence on clinical decision-making has never been quantified.
  
  
  OBJECTIVE
  What is the influence of CTRA on providers' perceived risk of fracture? (2) What is the influence of CTRA on providers' treatment recommendations in simulated clinical scenarios of metastatic bone disease of the femur? (3) Does CTRA improve interobserver agreement regarding treatment recommendations?
  
  
  METHODS
  We conducted a survey among 80 academic physicians (orthopaedic oncologists, musculoskeletal radiologists, and radiation oncologists) using simulated vignettes of femoral lesions presented as three separate scenarios: (1) no CTRA input (baseline); (2) CTRA input suggesting increased risk of fracture (CTRA+); and (3) CTRA input suggesting decreased risk of fracture (CTRA-). Participants were asked to rate the patient's risk of fracture on a scale of 0% to 100% and to provide a treatment recommendation. Overall response rate was 62.5% (50 of 80).
  
  
  RESULTS
  When CTRA suggested an increased risk of fracture, physicians perceived the fracture risk to be slightly greater (37% ± 3% versus 42% ± 3%, p < 0.001; mean difference [95% confidence interval {CI}] = 5% [4.7%-5.2%]) and were more prone to recommend surgical stabilization (46% ± 9% versus 54% ± 9%, p < 0.001; mean difference [95% CI] = 9% [7.9-10.1]). When CTRA suggested a decreased risk of fracture, physicians perceived the risk to be slightly decreased (37% ± 25% versus 35% ± 25%, p = 0.04; mean difference [95% CI] = 2% [2.74%-2.26%]) and were less prone to recommend surgical stabilization (46% ± 9% versus 42% ± 9%, p < 0.03; mean difference [95% CI] = 4% [3.9-5.1]). The effect size of the influence of CTRA on physicians' perception of fracture risk and treatment planning varied with lesion severity and specialty of the responders. CTRA did not increase interobserver agreement regarding treatment recommendations when compared with the baseline scenario (κ = 0.41 versus κ = 0.43, respectively).
  
  
  CONCLUSIONS
  Based on this survey study, CTRA had a small influence on perceived fracture risk and treatment recommendations and did not increase interobserver agreement. Further work is required to properly introduce this technique to physicians involved in the care of patients with metastatic lesions. Given the number of preclinical and clinical studies outlining the efficacy of this technique, better education through presentations at seminars/webinars and symposia will be the first step. This should be followed by clinical trials to establish CTRA-based clinical guidelines based on evidence-based medicine. Increased exposure of clinicians to CTRA, including its underlying methodology to study bone structural characteristics, may establish CTRA as a uniform guideline to assess fracture risk.
  
  
  METHODS
  Level III, economic and decision analyses.
authors.affiliation: Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, RN 115, Boston, MA, 02215, USA. anazaria@bidmc.harvard.edu.
authors.forename: Ara
authors.initials: A
authors.lastname: Nazarian
authors.affiliation: Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, RN 115, Boston, MA, 02215, USA.
authors.forename: Vahid
authors.initials: V
authors.lastname: Entezari
authors.affiliation: Center for Advanced Orthopaedic Studies, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, RN 115, Boston, MA, 02215, USA.
authors.forename: Juan C
authors.initials: JC
authors.lastname: Villa-Camacho
authors.affiliation: Departments of Anesthesiology and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: David
authors.initials: D
authors.lastname: Zurakowski
authors.affiliation: Orthopedics and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Jeffrey N
authors.initials: JN
authors.lastname: Katz
authors.affiliation: Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
authors.forename: Mary
authors.initials: M
authors.lastname: Hochman
authors.affiliation: Department of Radiation Oncology, Dana Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Elizabeth H
authors.initials: EH
authors.lastname: Baldini
authors.affiliation: Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Vartan
authors.initials: V
authors.lastname: Vartanians
authors.affiliation: Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
authors.forename: Max P
authors.initials: MP
authors.lastname: Rosen
authors.affiliation: Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
authors.forename: Mark C
authors.initials: MC
authors.lastname: Gebhardt
authors.affiliation: Department of Orthopaedic Surgery, Rhode Island Hospital, Warren Alpert Medical School, Brown University, Providence, RI, USA.
authors.forename: Richard M
authors.initials: RM
authors.lastname: Terek
authors.affiliation: Department of Orthopaedic Surgery, SUNY Upstate Medical University, Syracuse, NY, USA.
authors.forename: Timothy A
authors.initials: TA
authors.lastname: Damron
authors.affiliation: Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Yaszemski
authors.affiliation: Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Brian D
authors.initials: BD
authors.lastname: Snyder
mesh_terms: D001859:Bone Neoplasms / Q000000981:diagnostic imaging* / Q000556:secondary / Q000601:surgery; D000066491:Clinical Decision-Making; D005260:Female; D017144:Focus Groups; D005598:Fractures, Spontaneous / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery; D006801:Humans; D008297:Male; D010865:Pilot Projects; D010818:Practice Patterns, Physicians'; D011237:Predictive Value of Tests; D018570:Risk Assessment; D012307:Risk Factors; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed / Q000379:methods*