Scaphoid Fractures

Scaphoid Fractures

Scaphoid Fractures

From the UK: MRI is the most clinically and cost-effective first imaging strategy for suspected scaphoid fractures. Hospitals should work towards increasing access to MRI for this population.

UK National Institute for Health and Care Excellence – Guidelines for Scaphoid Fracture Diagnosis
The following is a selection from the UK National Institute for Health and Care Excellence (Guideline NG38 – Final Version, February 2016). The study was commissioned to assess the methods used to diagnose and treat non-complex fractures in UK healthcare institutions and to make recommendations regarding optimization of the process.

General overview
The GDG (Guideline Development Group) of the National Institute for Health and Care Excellence (NICE), identified MRI as the gold standard method for imaging of the scaphoid. Due to the significant clinical implications of a missed scaphoid fracture, the GDG chose to use MRI as the reference standard in this review, since MRI has 100% sensitivity for detecting scaphoid fractures. Neither X-rays nor CT appeared to have sufficient sensitivity to prohibit unacceptable levels of missed fractures and so MRI was regarded as the most accurate and only acceptable method.
The GDG, therefore, chose to recommend that immediate MRI be used as the first line investigation in all patients with a clinically suspected scaphoid fracture. The GDG also noted that MRI is able to diagnose soft tissue injuries and would therefore reduce the need for further imaging and reduce repeat hospital appointments.

Economic considerations
The strategy of immediate MRI scanning (according to data provided by full-body scanners as referenced by this study) had the highest net benefit in the full economic analysis, as it was shown to be: i) cost effective compared to all other strategies, such as CT and X-ray; and ii) the most clinically effective as it identifies all fractures, thus bringing about an improvement in quality of life compared to those with missed fractures in other strategies. Cost-consequence analyses have found that delayed X-rays were more costly than MRI (£29 more per patient). It was also found that the ICER (incremental cost-effectiveness ratio) for immediate MRI compared to immediate CT for diagnosing people with a suspected scaphoid fracture, was £3,754 per QALY[1].

The GDG study was based on current full-body MRI scanners, and concluded that MRI was the most cost-effective and efficient system. Aspect Imaging’s compact MRI, with its considerably cheaper purchasing and running costs will bring even higher savings than those outlined by the GDG study. In practical terms, the running cost of Aspect MRI is equivalent to the power consumption of a microwave oven.

Availability of MRI
Aspect Imaging Hand and Wrist MRI system can be installed practically anywhere, no RF shielded room is required. In addition, Aspect Compact MRI is highly cost-effective and affordable in comparison with current, full-body MRI systems.
Providing new, dedicated MRI scanners at hospitals them will improve access, reduce the delays to diagnosis and reduce the need for additional attendances for a broad group of patients. The reduction in delays to diagnosis could improve quality of life for some people and the reduced attendances could save some of the cost invested in the additional equipment and procedures. In addition, in contrast to CT or X-rays, MRI does not produce ionizing radiation. It should also be pointed out that extremity scanners are now becoming available at a lower purchase cost and with lower running costs.

The GDG also believed that the number of extremity injuries, scaphoid or other, that are currently imaged using a whole-body MRI scanner could be large enough to optimize the use of an extremity scanner to image these injuries in ED. This could potentially allow a whole-body scanner to be decommissioned by diverting this subgroup of patients to an extremity scanner, without reducing the capacity required for patients who require imaging using a whole-body scanner. This could therefore result in a service that has lower operating costs than current service provisions.


The GDG noted that this recommendation may require a significant change in service for some emergency departments, due to restricted access to MRI in some services. Nevertheless, an extremity MRI scanner could be used instead, which would reduce the reliance on the main hospital MRI machine, and also be more appropriate for children (as they could be easily occupied during the scan by watching a video or playing games etc., on a conveniently-placed tablet). Additionally, the system may also be used for the diagnosis of other extremity injuries.


The GDG also discussed how access to whole-body MRI may be more difficult due to the need to have access to trained healthcare professionals who may not always be available out of normal working hours. This issue could be addressed by rescheduling patient appointments for a dedicated MRI accordingly without undermining the cost-effectiveness of MRI as the first line imaging strategy.


Aspect Imaging’s dedicated MRI system is intuitive and easy to operate. The ease-of-use of our MRI would reduce the problem of requiring highly trained staff to operate the system, day or night.

Conclusion
The GDG concluded that as the evidence indicates that MRI is the most clinically and cost-effective first imaging strategy for suspected scaphoid fractures, hospitals should work towards increasing access to MRI for this population. The GDG further noted that greater access to MRI would have benefits for other patient populations also.
The GDG considered all of the above and decided that immediate MRI scanning was the most clinically and cost effective strategy based on the available evidence and the model results.
As such, the GDG strongly recommends that MRI be implemented for first-line imaging in people with suspected scaphoid fractures.
At Aspect Imaging, we have a dedicated solution that meets or exceeds all NICE requirements!

Link to the full study (PDF): https://www.nice.org.uk/guidance/ng38/evidence/full-guideline-2358460765

[1] QALY = Quality-Adjusted Life Year – a measure of disease burden, assessing both life quality and quantity. Used in economic evaluations to assess the value for money of medical interventions, one QALY equates to one year in perfect health.

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