Cost-effectiveness analysis of the diagnosis of meniscus tears.


BACKGROUND: Diagnostic imaging represents the fastest growing segment of costs in the US health system. This study investigated the cost-effectiveness of alternative diagnostic approaches to meniscus tears of the knee, a highly prevalent disease that traditionally relies on MRI as part of the diagnostic strategy. PURPOSE: To identify the most efficient strategy for the diagnosis of meniscus tears. STUDY DESIGN: Economic and decision analysis; Level of evidence, 1. METHODS: A simple-decision model run as a cost-utility analysis was constructed to assess the value added by MRI in various combinations with patient history and physical examination (H&P). The model examined traumatic and degenerative tears in 2 distinct settings: primary care and orthopaedic sports medicine clinic. Strategies were compared using the incremental cost-effectiveness ratio (ICER). RESULTS: In both practice settings, H&P alone was widely preferred for degenerative meniscus tears. Performing MRI to confirm a positive H&P was preferred for traumatic tears in both practice settings, with a willingness to pay of less than US$50,000 per quality-adjusted life-year. Performing an MRI for all patients was not preferred in any reasonable clinical scenario. The prevalence of a meniscus tear in a clinician's patient population was influential. For traumatic tears, MRI to confirm a positive H&P was preferred when prevalence was less than 46.7%, with H&P preferred above that. For degenerative tears, H&P was preferred until the prevalence reaches 74.2%, and then MRI to confirm a negative was the preferred strategy. In both settings, MRI to confirm positive physical examination led to more than a 10-fold lower rate of unnecessary surgeries than did any other strategy, while MRI to confirm negative physical examination led to a 2.08 and 2.26 higher rate than H&P alone in primary care and orthopaedic clinics, respectively. CONCLUSION: For all practitioners, H&P is the preferred strategy for the suspected degenerative meniscus tear. An MRI to confirm a positive H&P is preferred for traumatic tears for all practitioners. Consideration should be given to implementing alternative diagnostic strategies as well as enhancing provider education in physical examination skills to improve the reliability of H&P as a diagnostic test. CLINICAL RELEVANCE: Alternative diagnostic strategies that do not include the use of MRI may result in decreased health care costs without harm to the patient and could possibly reduce unnecessary procedures.


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Mather, Richard C, William E Garrett, Brian J Cole, Kristen Hussey, Michael P Bolognesi, Tally Lassiter and Lori A Orlando (2015). Cost-effectiveness analysis of the diagnosis of meniscus tears. Am J Sports Med, 43(1). pp. 128–137. 10.1177/0363546514557937 Retrieved from

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Richard Charles Mather

Clinical Associate in the Department of Orthopaedic Surgery

Richard C. “Chad” Mather III MD, MBA is an assistant professor and vice chairman of practice innovation in the Department of Orthopaedic Surgery at Duke University School of Medicine.  He is also a faculty member at the Duke Clinical Research Institute.  Dr. Mather is a health services researcher and decision scientist with a focus on economic analysis, health policy, health preference measurement and personalized decision-making.  His current work focuses on building tools for healthcare consumerism by facilitating measurement and communication of individual patient preferences in treatment decisions.  Additionally, he has great interest in health innovation, particularly in developing new care and payment models to foster different incentives and practice approaches.  He was a health policy fellow with the American Academy of Orthopaedic Surgeons and the Arthroscopy Association of North America. Dr. Mather received an undergraduate degree in economics from Miami University and a medical doctorate and masters in business administration from Duke, where he also completed residency training in orthopaedic surgery. He completed a sports medicine fellowship at Rush University Medical Center.  His clinical practice focuses on hip arthroscopy including both FAI and extra-articular hip endoscopy.  Specifically to the hip in addition to health service research applications he conducts translational research on biomarkers and hip instability. 


Michael Paul Bolognesi

Virginia Flowers Baker Distinguished Professor of Orthopaedic Surgery

As chief of the adult reconstruction service, the majority of my research effort has been directed toward clinical outcomes, implant survivorship, functional recovery, the biology of hip and knee arthritis and cost effectiveness.


Tally Edward Lassiter

Assistant Professor of Orthopaedic Surgery

Lori Ann Orlando

Professor of Medicine

Dr. Lori A. Orlando, MD MHS MMCI is a Professor of Medicine and Director of the Precision Medicine Program in the Center for Applied Genomics and Precision Medicine at Duke University. She attended Tulane Medical Center for both medical school (1994-1998) and Internal Medicine residency (1998-2000). There she finished AOA and received a number of awards for teaching and clinical care from the medical school and the residency programs, including the Musser-Burch-Puschett award in 2000 for academic excellence. After completing her residency, she served as Chief Medical Resident in Internal Medicine (2001) and then completed a Health Services Research Fellowship at Duke University Medical Center (2002-2004). In 2004 she also received her MHS from the Clinical Research Training Program at Duke University and joined the academic faculty at Duke. In 2005 she received the Milton W. Hamolsky Award for Outstanding Junior Faculty by the Society of General Internal Medicine. Her major research interests are decision making and patient preferences, implementation research, risk stratification for targeting preventive health services, and decision modeling. From 2004-2009 she worked with Dr. David Matchar in the Center for Clinical Heath Policy Research (CCHPR), where she specialized in decision modeling, decision making, and technology assessments. In 2009 she began working with Dr. Geoffrey Ginsburg in what is now the Center for Applied Genomics and Precision Medicine (CAGPM) and in 2014 she became the director of the Center’s Precision Medicine Program. Since joining the CAGPM she has been leading the development and implementation of MeTree, a patient-facing family health history based risk assessment and clinical decision support program designed to facilitate the uptake of risk stratified evidence-based guidelines. MeTree was designed to overcome the major barriers to collecting and using high quality family health histories to guide clinical care and has been shown to be highly effective when integrated into primary care practices. This effort started with the Genomic Medicine Model, a multi-institutional project, whose goal was to implement personalized medicine in primary care practices. The success of that project has led to funding as part of NHGRI’s IGNITE (Implementing Genomics in Clinical Practice) network. She is currently testing methods for integrating patient preferences and decision making processes into clinical decision support recommendations for patients and providers to facilitate management of patients’ risk for chronic disease using mHealth and other behavioral interventions.

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