Of Course, There Is a (New) Test to Confirm Your Diagnosis

Editor’s note: The Final Cut is a recurring editorial series written by a member of the AAOS Now Editorial Board.

Medicine has always been reliant on technological advancement. From the early days of radiographs to today’s weight-bearing CT scans, high-resolution ultrasounds, and advanced biomedical optics, we have witnessed significant and impactful increases in accuracy and precision, whether making previously difficult diagnoses or guiding our ever-shrinking minimally invasive interventions. It also has allowed us to make better decisions when it comes to high-risk or high-cost interventions, such as proceeding with two-stage revision joint replacement when it is not always clear that we are dealing with a prosthetic joint infection.

At the same time, as with every other technological advancement, we have to take a step back before we rush onto the bandwagon. We should think about the purpose and added value of the diagnostic tests we are ordering. For the individual orthopaedic surgeon, it does not cost much to order a test. The collective decisions we make as a profession, however, do cost a lot to our society at large and to our patients individually. Thus, we must think about what we are trying to do and the utility of the information we obtain by ordering one particular test.

Here is a simple example: Do we need a nerve test to establish the diagnosis of carpal tunnel syndrome? Clinical tests are highly accurate and reliable, yet we still see a lot of patients presenting with straightforward carpal tunnel syndrome coming in with nerve test results in hand. Electrodiagnostic studies cost money, time, and effort; are unpleasant; and, for the most part, do not add value to the decision-making process. Yet, we keep ordering those tests. What is the purpose of doing so? For most patients considered to have carpal tunnel syndrome based on clinical assessment, it is well established that electrodiagnostic tests do not change the probability of diagnosis to a clinically relevant extent. The senior author recalls participating in an international hand surgery meeting several years ago, during which the participants were surveyed about their utilization of nerve tests. The surgeons outside of the United States ordered them in about 10 percent of cases, when they felt the diagnosis was not straightforward. Conversely, the American surgeons estimated ordering them 90 percent of the time. This discrepancy indicates that at least some of those tests are done for reasons that fall outside medical judgment and have to do with the culture of medicine and other non-medical reasons, such as prior authorization requirements and perceived protection from potential litigation.

As time has gone by, it appears surgeons in the United States have regressed toward the global mean, as those tests delayed and added to the cost of treatment and the disability of the condition. We still see too many of them done before they show up for consultation. In the case of cubital tunnel syndrome, it is even worse. Most studies estimate the sensitivity of nerve tests at 80 percent. Who is willing to make a medical decision based on a test with 80 percent sensitivity?

On the other hand, simple diagnostic assessments can have significant impact on patients’ lives and cost nothing. Taking a closer look at a hand radiograph can help a patient recognize and address underlying osteoporosis and prevent catastrophic injuries in the future. The price tag? $0.00. How valuable is that?

In a world where provision of medical care is constrained by economic realities, authorities and health systems alike have to allocate resources sustainably. Economic constraints can lead to increased demand for assessments of safety and cost-effectiveness of medical technology. In the field of orthopaedics, most such analyses address treatment approaches, with a few studies focusing on diagnostic modalities.

One example is the cost-effectiveness of diagnostic strategies for suspected scaphoid fractures. A 2015 study from Yin et al in the Journal of Orthopaedic Trauma used an incremental cost-effectiveness ratio to compare immediate and delayed advanced imaging for suspected fracture. They found that immediate advanced imaging was most cost-effective in cases where wrist immobilization could impact or reduce the patient’s productivity. Factors that influenced the choice included availability, willingness-to-pay threshold for each scaphoid fracture detected, and pretest probability of true fractures among suspected ones. This study and similar analyses demonstrate that, although advancement in testing can provide improved accuracy and a shorter time to diagnosis, the economics of testing have real and tangible effects that should be taken into consideration at the individual and societal levels.

As the leaders of musculoskeletal care in our communities, we should always strive to improve the accuracy, efficiency, and effectiveness of what we do and how deliver care to our patients. It is of the utmost importance to pay attention to our purpose and to make sure that what we do takes our patients to a better place without burdening society at various levels with unnecessary and marginally impactful tests.

Shafic Sraj, MD, MBA, FAAOS, is a hand surgeon and associate professor at West Virginia University in Morgantown, West Virginia. Dr. Sraj is a member of the AAOS Now Editorial Board.

John Taras, MD, FAAOS, is a hand surgeon and professor at West Virginia University in Morgantown, West Virginia. Dr. Taras is a former member of the AAOS Now Editorial Board.

References

1. Graham B: The value added by electrodiagnostic testing in the diagnosis of carpal tunnel syndrome. J Bone Joint Surg Am 2008;90(12):2587-93.
2. Brauer CA, Neumann PJ, Rosen AB: Trends in cost effectiveness analyses in orthopaedic surgery. Clin Orthop Relat Res 2007;457:42-8.
3. Yin ZG, Zhang JB, Gong KT: Cost-effectiveness of diagnostic strategies for suspected scaphoid fractures. J Orthop Trauma 2015;29(8):e245-52.