Musculoskeletal problems generate high costs. Of these disorders, patients with knee problems are commonly seen by GPs. Magnetic resonance imaging (MRI) of the knee is an accurate diagnostic test, but there is uncertainty as to whether GP access to MRI for these patients is a cost-effective policy. AimTo investigate the cost-effectiveness of GP referral to early MRI and a provisional orthopaedic appointment, compared with referral to an orthopaedic specialist without prior MRI for patients with continuing knee problems. Design of studyCost-effectiveness analysis alongside a pragmatic randomised trial. SettingFive-hundred and thirty-three patients consulting their GP about a knee problem were recruited from 163 general practices at 11 sites across the UK. MethodTwo-year costs were estimated from the NHS perspective. Health outcomes were expressed in terms of quality-adjusted life years (QALYs), based on patient responses to the EQ-5D questionnaire administered at baseline, and at 6, 12, and 24 months' follow-up. ResultsEarly MRI is associated with a higher NHS cost, by £294 ($581; €435) per patient (95% confidence interval [CI] = £31 to £573), and a larger number of QALYs, by 0.05 (95% CI = 0.025 to 0.118). Mean differences in cost and QALYs generated an incremental cost per QALY gained of £5840 ($11 538; €8642). At a cost per QALY threshold of £20 000, there is a 0.81 probability that early MRI is a cost-effective use of NHS resources. ConclusionGP access to MRI for patients presenting in primary care with a continuing knee problem represents a costeffective use of health service resources.
GPs commonly see patients with knee problems. Magnetic resonance imaging (MRI) of the knee is an accurate diagnostic test for meniscus and ligament injuries of the knee, but there is uncertainty about the appropriate use of MRI and when it should enter the diagnostic pathway for patients with these problems. AimTo assess the effectiveness of GP referral to early MRI and a provisional orthopaedic appointment, compared with referral to an orthopaedic specialist without prior MRI for patients with continuing knee problems. Design of studyPragmatic multicentre randomised trial with two parallel groups. SettingA total of 553 patients consulting their GP about a continuing knee problem were recruited from 163 general practices at 11 sites across the UK. MethodPatients were randomised to MRI within 12 weeks of GP referral including a provisional orthopaedic appointment, or orthopaedic appointment without prior MRI within a maximum of 9 months from GP referral. The primary outcome measures were the Short Form 36-item (SF-36) physical functioning scale and the Knee Quality of Life 26-item Questionnaire (KQoL-26) at 6, 12, and 24 months. ResultsPatients randomised to MRI improved mean SF-36 physical functioning scores by 2.81 (95% confidence interval [CI] = -0.26 to 5.89) more than those referred to orthopaedics (P = 0.072). Patients randomised to MRI improved mean KQoL-26 physical functioning scores by 3.65 (95% CI = 1.03 to 6.28) more than controls (P = 0.007). There were no other significant differences. ConclusionGP access to MRI yielded small, but statistically significant, benefits in patients' knee-related quality of life but non-significant improvements in physical functioning.
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