OBJECTIVES

Given the limited accuracy of radiographs on presentation to the Emergency Department (ED), the management of suspected scaphoid fractures remains clinically challenging and pose a substantial economic burden to healthcare systems. This trial evaluated the cost and cost-effectiveness implications of using immediate Magnetic Resonance Imaging (MRI) as an add-on test during the ED attendance for patients with negative findings on the initial radiographs.

METHODS

A pragmatic, randomized, single-center trial compared the use of immediate MRI in the ED against standard care with radiographs only. Participants’ use of health care services and costs were estimated from primary care and secondary care databases and questionnaires at baseline, 3 and 6 months post-recruitment. Costs were compared using generalized linear models and combined with diagnosis accuracy and quality-adjusted life years (QALYs, based on the EQ-5D-5L) to estimate cost-effectiveness at three and six months. Cost-effectiveness acceptability curves were used to estimate the probability of cost-effectiveness.

RESULTS

A total of 136 participants were randomized (mean age 37 years; 57% male; 79% full-time employed). Mean (SD) cost up to three months post-recruitment per participant was £542.4 (£855.2) for the control group and £368.4 (£338.6) for the intervention, leading to an estimated cost difference of £174 (95% CI -£30 to £378, p=0.094). The cost difference per participant at six months increased to £266 (95% CI £3.3 to £528, p=0.047). The MRI intervention dominated standard care costing less and achieving more QALY gains, presenting a probability of 96% and 100% of being cost-effective at month 3 and 6 considering traditional willingness-to-pay thresholds in the United Kingdom.

CONCLUSIONS

The use of immediate MRI in the management of suspected scaphoid fractures is cost-saving and cost-effective. These findings have recently led to a transformation of the standard of care pathway at a Central Hospital in London to include the MRI intervention.