Cost–consequence analysis
| Current pathway: gp direct-access to MSK-MRI +/− referral to community or secondary care MSK services | Alternate (recommended) pathway: all patients assessed in community MSK-interface triage service | |
| Direct imaging costs | 306 MRI referrals (£38,746.00) (see table 2) | 10 MRI referrals (£11,600.00) |
| MRI follow-up appointment with GP | 293 GP appointments (£8,790.00) | N/A |
| Community MSK-Interface referrals (tier 1) | 118 referrals (£11,800.00) | 245 referrals (£24,500.00) |
| Community MSK-Interface (tier 2 extended scope physiotherapists, orthopaedic, pain & rheumatology specialists) | 149 x tier 2 (£18,625.00) 3 × tier 2 rheumatology (£450.00) = £19,075.00 | 61 referrals (£7,625.00) |
| Secondary care referrals | 109 secondary care referrals (see table 5) = £33,805.00 | 9 × orthopaedic (£2,349.00) 3 × pain (£1,038.00) 2 × neurosurgery (£629.60) 1 × rheumatology (£612.10) = £4,628.70 |
| MSK-service-generated secondary care referrals | 9 MSK-generated referrals (£2 456.60) | (see row above) |
| Surgical procedures | 1 × total knee replacement (£5,328.00) 1 × cervical decompression (£7,332.00) 1 × arthroscopic partial meniscectomy (£3,014.00) = £15,674.00 | 1 × total knee replacement (£5,328.00) 1 × cervical decompression (£7,332.00) = £12,660.00 |
| Total pathway cost | £130,346.60 | £61,013.70 |
| Cost difference of £69,332.90 between pathways | ||
Table 6 ASSUMPTIONS:
1. Unit and episode costs explained in table 5, based on 2017/2018 NHS National Tariff. GP costs based on NHS England report.139
2. Assumes all 306 patients are referred into community MSK-interface service. Estimates suggest 80% of patients are seen in tier 1 physiotherapy, 20% in tier 2 service, 5% referred on to secondary care and 3% have MRI organised, based on published data,140 and local service contract data (North West London CCGs 2018).
3. Assumes no GP-access to MSK-MRI and that current ‘bypassing’ GP secondary care referrals would all be directed into the MSK service, as per local recommended pathway.
4. Procedure costs estimated from NHS national 2017/2018 reference costs.141
5. Since 90% of imaged patients were at some point seen in the community MSK-interface service, similar surgical outcomes can be assumed for both groups. However, a patient with osteoarthritic atraumatic knee pain, not willing for knee replacement, is unlikely to be referred for partial meniscectomy from the MSK service. Meniscectomy in osteoarthritis is not recommended by numerous guidelines, no better than physical therapy,142 nor sham-surgery24 and linked to earlier subsequent knee replacement.143 Within the community MSK-interface service, MRI or surgical referral would have been unlikely, supported by local audit (Parkunan, Healthshare NHS Community MSK Services, 2018) showing no orthopaedic referrals for degenerative meniscal tears from the service.
GP, general practitioner; MSK, musculoskeletal; N/A, not applicable.