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Original Investigation
July 2018

Cost-effectiveness of Magnetic Resonance Imaging in Cervical Clearance of Obtunded Blunt Trauma After a Normal Computed Tomographic Finding

Author Affiliations
  • 1currently a medical student at Yale School of Medicine, New Haven, Connecticut
  • 2Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
  • 3Department of Radiology, Orlando Health, Orlando, Florida
  • 4Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
  • 5Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
  • 6Department of Economics, Yale School of Medicine, New Haven, Connecticut
  • 7Department of Management, Yale School of Medicine, New Haven, Connecticut
  • 8Department of Public Health, Yale School of Medicine, New Haven, Connecticut
  • 9Department of Radiology, Northwell Health, Manhasset, New York
JAMA Surg. 2018;153(7):625-632. doi:10.1001/jamasurg.2018.0099
Key Points

Question  What is the optimal follow-up strategy to clear the cervical spine in patients with obtunded blunt trauma after a normal computed tomographic finding?

Findings  In this cost-effectiveness analysis, magnetic resonance imaging had a lower health benefit (24.02 quality-adjusted life-years) and a higher cost ($14 185) compared with no follow-up (24.11 quality-adjusted life-years and $1059) after a normal computed tomographic finding in patients with obtunded blunt trauma to the cervical spine. The conclusion was robust in probabilistic sensitivity analysis and multiple 1- and 2-way sensitivity analyses.

Meaning  Magnetic resonance imaging may have a lower health benefit and a higher cost compared with no follow-up after a normal computed tomographic finding in patients with obtunded blunt trauma of the cervical spine.

Abstract

Importance  Magnetic resonance imaging (MRI) continues to be performed for cervical clearance of obtunded blunt trauma, despite poor evidence regarding its utility after a normal computed tomographic (CT) finding.

Objective  To evaluate the utility and cost-effectiveness of MRI vs no follow-up after a normal cervical CT finding in patients with obtunded blunt trauma.

Design, Setting and Participants  This cost-effectiveness analysis evaluated an average patient aged 40 years with blunt trauma from an institutional practice. The analysis used a Markov decision model over a lifetime horizon from a societal perspective with variables from systematic reviews and meta-analyses and reimbursement rates from the Centers for Medicare & Medicaid Services, National Spinal Cord Injury Database, and other large published studies. Data were collected from the most recent literature available.

Interventions  No follow-up vs MRI follow-up after a normal cervical CT finding.

Results  In the base case of a 40-year-old patient, the cost of MRI follow-up was $14 185 with a health benefit of 24.02 quality-adjusted life-years (QALY); the cost of no follow-up was $1059 with a health benefit of 24.11 QALY, and thus no follow-up was the dominant strategy. Probabilistic sensitivity analysis showed no follow-up to be the better strategy in all 10 000 iterations. No follow-up was the better strategy when the negative predictive value of the initial CT was relatively high (>98%) or the risk of an injury treated with a cervical collar turning into a permanent neurologic deficit was higher than 25% or when the risk of a missed injury turning into a neurologic deficit was less than 58%. The sensitivity and specificity of MRI were varied simultaneously in a 2-way sensitivity analysis, and no follow-up remained the optimal strategy.

Conclusions and Relevance  Magnetic resonance imaging had a lower health benefit and a higher cost compared with no follow-up after a normal CT finding in patients with obtunded blunt trauma to the cervical spine, a finding that does not support the use of MRI in this group of patients. The conclusion is robust in sensitivity analyses varying key variables in the model. More literature on these key variables is needed before MRI can be considered to be beneficial in the evaluation of obtunded blunt trauma.

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