Does CT-based Rigidity Analysis Influence Clinical Decision-making in Simulations of Metastatic Bone Disease?

• Published in: Clinical orthopaedics and related research 2016-03, Vol.474 (3), p.652-659
• Main Authors: Nazarian, Ara, Entezari, Vahid, Villa-Camacho, Juan C., Zurakowski, David, Katz, Jeffrey N., Hochman, Mary, Baldini, Elizabeth H., Vartanians, Vartan, Rosen, Max P., Gebhardt, Mark C., Terek, Richard M., Damron, Timothy A., Yaszemski, Michael J., Snyder, Brian D.
• Format: Article
• Language: English
• Subjects: Bone Neoplasms - diagnostic imaging; Bone Neoplasms - secondary; Bone Neoplasms - surgery; Clinical Decision-Making; Conservative Orthopedics; Female; Focus Groups; Fractures, Spontaneous - diagnostic imaging; Fractures, Spontaneous - pathology; Fractures, Spontaneous - surgery; Humans; Male; Medicine; Medicine & Public Health; Orthopedics; Pilot Projects; Practice Patterns, Physicians; Predictive Value of Tests; Risk Assessment; Risk Factors; Sensitivity and Specificity; Sports Medicine; Surgery; Surgical Orthopedics; Symposium: 2014 Musculoskeletal Tumor Society; Tomography, X-Ray Computed - methods; Tumor
• ISSN: 0009-921X; 1528-1132
• DOI: 10.1007/s11999-015-4371-1

Background There is a need to improve the prediction of fracture risk for patients with metastatic bone disease. CT-based rigidity analysis (CTRA) is a sensitive and specific method, yet its influence on clinical decision-making has never been quantified. Questions/purposes What is the influence of CTRA on providers’ perceived risk of fracture? (2) What is the influence of CTRA on providers’ treatment recommendations in simulated clinical scenarios of metastatic bone disease of the femur? (3) Does CTRA improve interobserver agreement regarding treatment recommendations? Methods We conducted a survey among 80 academic physicians (orthopaedic oncologists, musculoskeletal radiologists, and radiation oncologists) using simulated vignettes of femoral lesions presented as three separate scenarios: (1) no CTRA input (baseline); (2) CTRA input suggesting increased risk of fracture (CTRA+); and (3) CTRA input suggesting decreased risk of fracture (CTRA−). Participants were asked to rate the patient’s risk of fracture on a scale of 0% to 100% and to provide a treatment recommendation. Overall response rate was 62.5% (50 of 80). Results When CTRA suggested an increased risk of fracture, physicians perceived the fracture risk to be slightly greater (37% ± 3% versus 42% ± 3%, p < 0.001; mean difference [95% confidence interval {CI}] = 5% [4.7%–5.2%]) and were more prone to recommend surgical stabilization (46% ± 9% versus 54% ± 9%, p < 0.001; mean difference [95% CI] = 9% [7.9–10.1]). When CTRA suggested a decreased risk of fracture, physicians perceived the risk to be slightly decreased (37% ± 25% versus 35% ± 25%, p = 0.04; mean difference [95% CI] = 2% [2.74%–2.26%]) and were less prone to recommend surgical stabilization (46% ± 9% versus 42% ± 9%, p < 0.03; mean difference [95% CI] = 4% [3.9–5.1]). The effect size of the influence of CTRA on physicians’ perception of fracture risk and treatment planning varied with lesion severity and specialty of the responders. CTRA did not increase interobserver agreement regarding treatment recommendations when compared with the baseline scenario (κ = 0.41 versus κ = 0.43, respectively). Conclusions Based on this survey study, CTRA had a small influence on perceived fracture risk and treatment recommendations and did not increase interobserver agreement. Further work is required to properly introduce this technique to physicians involved in the care of patients with metastatic lesions. Given the number of preclinical and clinic