Low-value MRI of the knee in Norway: a register-based study to identify the proportion of potentially low-value MRIs and estimate the related costs

OBJECTIVES

The objective of this study is to investigate the proportion of potentially low-value knee MRI in Norway and to provide an estimate of the related costs.

DESIGN

Register study based on conditional data extraction and analysis of data from Control and Reimbursement of Healthcare Claims registry in Norway.

SETTING

MRI in public specialist healthcare with universal health coverage (Norway).

PARTICIPANTS

48 212 MRIs for 41 456 unique patients and 45 946 reimbursement claims.

OUTCOME MEASURES

Proportion of MRIs of the knee that (1) did not have a relevant tentative diagnosis prior to the knee MRI, (2) did not have a relevant alternative image of the knee before the MRI or (3) did not have a relevant code from the specialist care within 6 months after the MRI, and those that had combinations of 1, 2 and 3. Estimated costs for those that had combinations of 1, 2 and 3.

RESULTS

Very few patients (6.4%) had a relevant diagnosis code or prior imaging examination when having the MRI and only 14.6% got a knee-related diagnosis code from the specialist care within 6 months after the MRI. 21.8% of the patients had knee X-ray, CT or ultrasound within 6 months before the MRI. Between 58% and 85% of patients having knee MRIs in Norway have no relevant examinations or diagnoses six months prior to or after the MRI examination. These examinations are unlikely to benefit patients and they correspond to between 24 108 and 35 416 MRIs at a cost of €6.7-€9.8 million per year.

CONCLUSION

A substantial proportion of MRIs of the knee in Norway have no relevant examinations or diagnoses before or after the MRI and are potentially of low value. Reducing low-value MRIs could free resources for high-value imaging, reduce waiting times, improve the quality of care and increase patient safety and professional integrity.

The Rationality to Requesting in-ward Magnetic Resonance Imaging Investigation

Background

Magnetic Resonance imaging (MRI) is a valuable diagnostic tool by its non-invasive/non-ionizing nature.

Objective

This study aims to determine justification of MRI in hospitalized patients at a tertiary provincial referent medical center in a one-year period.

Material and Methods

In the present retrospective and descriptive cross-sectional study, 438 admitted patients referred for MRI during 2017 were selected using systematic random sampling. The age, gender, investigated organ, the specialty of requesting physician, MRI with and without contrast, MRI diagnostic outcome were collected using checklists. Descriptive statistics and chi-square test were used for data analysis.

Results

The mean age of the patients was 42±26 years-old and female represented 53% of enrolled patients. The most and less prevalent investigated organs were the cerebrum and the orbit. After excluding cancer diagnosis, cancer staging, and therapeutic follow-up exams, MRI request was oriented in 64.3% and 77.2% of positive results was concordant with aforementioned diagnostic orientation (P<0.001). Oriented diagnostic MRI requesting is influenced by age, medical specialists and, investigated organ (P<0.001). The positive MRI is influenced significantly by oriented MRI request, gender, medical specialists and investigated organ (P<0.001). The diagnosis concordance of MRI is influenced significantly by oriented MRI request, medical specialists and investigated organ (P<0.001).

Conclusion

Appropriate implementation of medical imaging requires boosting employed rationality by the concerned physicians. The current suboptimal results to requesting MRI rationality should mandate supplementary educational programs as to incite the medical corpus more closely implementing the published medical practice guidelines.

GNRB® laximeter with magnetic resonance imaging in clinical practice for complete and partial anterior cruciate ligament tears detection: A prospective diagnostic study with arthroscopic validation on 214 patients

BACKGROUND

Accurate diagnosis of anterior cruciate ligament (ACL) injury is not always obtained with magnetic resonance imaging (MRI). Other tools, such as the GNRB® arthrometer, help to accurately identify the type of ACL tear. The aim of this study was to show that the GNRB® could be a relevant complementary solution to MRI in ACL injuries detection.

METHODS

A prospective study performed between 2016 and 2020 included 214 patients who had undergone knee surgery. The study compared sensitivity/specificity pairs of MRI and the GNRB® at 134 N to detect healthy ACL, partial and complete ACL tears. Arthroscopies were the 'gold standard'. Forty-six patients had a healthy ACL with associated knee lesions, 168 patients had ACL tears where 107 were complete tears and 61 were partial tears.

RESULTS

For healthy ACL, MRI scored 100% for sensitivity (SE) and 95% for specificity (SP), and the GNRB® scored SE 95.65% and SP 97.5% at 134 N. For complete ACL tears, MRI scored 80.81% for sensitivity (SE) and 64.49% for specificity (SP), and the GNRB® scored SE 77.78% and SP 85.98% at 134 N. For partial tears, MRI scored SE 29.51% and SP 88.97%, and the GNRB® scored SE 73.77% and SP 85.52% at 134 N.

CONCLUSION

GNRB® sensitivity and specificity were equivalent to those of MRI for healthy ACL and complete ACL tear detection. However, MRI had some difficulty in detecting partial ACL tears compared with the GNRB® which showed better sensitivity.

Measuring appropriateness of diagnostic imaging: a scoping review

In radiology, the justification of diagnostic imaging is a key performance indicator. To date, specific recommendations on the measurement of appropriateness in diagnostic imaging are missing. To map the study literature concerning the definition, measures, methods and data used for analyses of appropriateness in research of diagnostic imaging. We conducted a scoping review in Medline, EMBASE, Scopus and the Cochrane Central Register of Controlled Trials. Two independent reviewers undertook screening and data extraction. After screening 6021 records, we included 50 studies. National guidelines (n = 22/50) or American College of Radiology Appropriateness Criteria (n = 23/50) were used to define and rate appropriateness. 22/50 studies did not provide methodological details about the appropriateness assessment. The included studies varied concerning modality, amount of reviewed examinations (88-13,941) and body regions. Computed tomography (27 studies, 27,168 examinations) was the most frequently analyzed modality, followed by magnetic resonance imaging (17 studies, 6559 examinations) and radiography (10 studies, 7095 examinations). Heterogeneous appropriateness rates throughout single studies (0-100%), modalities, and body regions (17-95%) were found. Research on pediatric and outpatient imaging was sparse. Multicentric, methodologically robust and indication-oriented studies would strengthen appropriateness research in diagnostic imaging and help to develop reliable key performance indicators.

Changing primary care requesting practices for MRI knee: A quality improvement project

OBJECTIVES

The objectives of this work were first to examine referral practices from primary care for MRI knee in patients ≥45 years old and then to develop a new referral pathway to reduce the number of inappropriate MRI knee referrals. Following this, the aim was to re-assess the effect of the intervention and identify further areas for improvement.

METHODS

A baseline retrospective analysis of knee MRIs requested from primary care in symptomatic patients ≥45years over a two-month period was undertaken. A new referral pathway was implemented in consensus with orthopaedic specialists and the clinical commissioning group (CCG), via the CCG resource webpage and local education. Following implementation, a repeat data analysis was undertaken.

RESULTS

The number of MRI knees acquired from primary care referrals reduced by 42% after the new pathway was implemented. 67% (46/69) were compliant with the new guidelines. The number of patients having an MRI knee without a prior plain radiograph was 14/69 (20%) compared to 55/118 (47%) prior the pathway changes.

CONCLUSION

The new referral pathway reduced the number of knee MRI acquisitions in primary care patients ≥45 years by 42%. Changing the pathway has decreased the number of patients undergoing MRI knee without a prior radiograph from 47% to 20%. These outcomes bring our standards towards the evidence-based recommendations of the Royal College of Radiology and have reduced our outpatient waiting list for MRI knee.

IMPLICATIONS FOR PRACTICE

Implementing a new referral pathway with the local CCG can successfully reduce the number of inappropriate MRI knee acquisitions from primary care referrals in older symptomatic patients.

An economic impact of incorrect referrals for MRI and CT scans: A retrospective analysis

Background and Aims

Up to date, no research on the economic efficacy of diagnostic modalities, such as magnetic resonance imaging (MRI) and computerized tomography (CT), has been done in Central Asia. The aim of this study was to analyse the inappropriate appointments of MRI and CT scanning procedures in Kazakhstan.

Methods

We used the imaging diagnostic reports and medical records from 9725 planned outpatient CT and MRI exams performed in two major hospitals in Almaty. The study period was for the period 2014-2019. The independent experts-radiologists evaluated the MRI and CT exams for validity using the ACR® compliance standards and RCR recommendations.

Results

The results showed that the combined costs of MRI and CT scans increased by $17.982 between 2014 ($22.537) and 2019 ($40.519), p = 0.002. The highest rate of MRI examinations was observed in 2019, with a rate of 6.9 per 10,000 people. It was determined that in 2019 the highest rate for men who undertook CT was equal to 12.4 per 10,000 people, while for women it was equivalent to 5.7 per 10,000 patients. The majority of non-corresponding imaging examinations (n = 1304) were referred for MRI and CT scans by general practitioners. We detected the irrational referrals for head and neck radiological examinations in n = 178 (13.7%) cases, and the abdominal cavity checks in n = 249 (19.1%) cases (p = 0.001). The main portion of erroneously unreasonable referrals for examination of the abdominal organs was made by surgeons in n = 43 (3.3%) cases.

Conclusion

The findings indicated an increase in the number of referrals for unnecessary CT and MRI tests over the research period (2014-2019). It had a substantial impact on the rise in healthcare system expenses. The results demonstrate the need for the education of GPs and improving the approaches for diagnostics.

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

BACKGROUND

Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children.

METHODS

A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included.

RESULTS

A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations.

CONCLUSIONS

A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020208072.

Exploring the impact of diagnostic imaging decision support embedded in an electronic referral solution on the appropriate ordering of magnetic resonance imaging for patients with knee pain: a retrospective chart review

RATIONAL AND OBJECTIVE

Requests for magnetic resonance imaging (MRI) exams have notably increased in Canada. However, many of these exams may not always be indicated. The Joint Department of Medical Imaging and the eReferral Program have worked collaboratively to embed an integrated clinical decision support (DS) tool within the eReferral process for diagnostic imaging requests. This retrospective chart review aimed to assess the necessity of MRI exams for knee pain patients at the point of referral in relation to the referral method (no DS tools within fax- vs. DS tools within eReferral).

METHODS

Seven hundred and seventeen medical charts of routine MRI referral requests to an Ontario Hospital for patients with knee complaints were reviewed during the study period. The necessity of the MRI exams was evaluated using the supporting algorithm and knee pathway appropriateness guidelines. MRI exams were considered necessary if requested for symptoms or signs that align with best-practice standards, complemented with sound clinical assessment or history of a radiography scan before ordering an MRI.

RESULTS

In general, MRI requests made through eReferral were 13.289 times more likely to be necessary orders than those made through fax. The likelihood of referring patients for a necessary MRI exam was higher for eReferral than fax for the year 2018/2019 (53.0% vs. 26.8%, P < 0.001) and for the year 2019/2020 (58.5% vs. 16.3%, P < 0.001). In addition, the rate of ordering X-ray as the proper initial imaging scan for patients presenting with knee pain has steadily increased by 10% over the year for users of the eReferral platform compared to a decrease of 7% for those using fax.

CONCLUSION

Our findings highlight the positive impact of integrating DS tools at the point of referral in supporting the ordering of necessary MRI scans, suggesting that service re-design and implementation of automated assistive technology services would impact patient care.

Incidence Rates of Surgery After Knee MRI: Association According to Referring Physician Type and Patient's Age and Sex

Background

The utility of magnetic resonance imaging (MRI) in the primary care setting is uncertain, with a perception that there is less likelihood for surgery after MRI ordered by general practitioners (GPs) when compared with orthopaedic surgeons and sports medicine physicians. Additionally, the influence of patient age and sex on subsequent surgical intervention is currently unknown.

Purpose/Hypothesis

The purpose of this study was to compare surgical incidence after MRI referrals by orthopaedic surgeons, GPs, and sports medicine physicians, including a subset analysis for GP patients based on type of approval given by the radiologist. The authors also wanted to explore the association of age and sex on subsequent surgical intervention. They hypothesized that surgical incidence after MRI ordered by orthopaedic surgeons and sports medicine physicians would be higher than after MRI ordered by GPs.

Study Design

Cohort study; Level of evidence, 3.

Methods

Knee MRI referrals by the 3 physician cohorts during May to December 2017 were assessed. For GP patients, the types of approval or recommendation from a radiologist were categorized. Subsequent surgical intervention status was then compared among referral groups up to 2 years after MRI. Associations of age and sex with surgical occurrence were also assessed. Chi-square test, analysis of variance, and univariate/multivariable logistic regression were used for statistical analysis.

Results

Overall, 407 referrals were evaluated (GP, n = 173; orthopaedic, n = 176; sports medicine, n = 58). Surgical incidence was not significantly higher for orthopaedic and sports medicine than GP referrals at 3 months (10%, 3%, and 6%, respectively; P = .23), 6 months (20%, 17%, and 15%; P = .49), and 2 years (30%, 35%, and 24%; P = .25). Surgical incidence for GP patients was higher after discussion with a radiologist or when evaluating specific pathology on prior imaging versus less defined reasons (30.4% vs 15.7%, respectively; P = .03). Surgical incidence was lower for older patients (11% vs 31% for >60 years vs all other age groups combined; P = .002), and women were less likely to undergo surgery than men (22% vs 35%, respectively; P = .008).

Conclusion

Surgical incidence after MRI was likely appropriately lower for older patients. Lower incidence for female patients is of uncertain cause and warrants further study.

Guidelines, training and quality assurance: influence on general practitioner MRI referral quality

INTRODUCTION Magnetic resonance imaging (MRI) is an accurate diagnostic test used mainly in secondary care. Uncertainty exists regarding the ability of general practitioners (GPs) to use direct access high-tech imaging pathways appropriately when managing musculoskeletal injury. AIM To evaluate the use of primary care-centric guidelines, training and quality assurance on the appropriateness of GP MRI referrals for patients with selected musculoskeletal injuries. METHODS This is an 18-month primary care retrospective study. GPs participated in clinical musculoskeletal training, enabling patient referral for MRI on four body sites. Two reviewers categorised referral appropriateness independently, and reviewer inter-rater agreement between categorisations was measured. MRI results and patient management pathways were described. Associations of scan status and patient management were examined using logistic regression. RESULTS In total, 273 GPs from 72 practices attended training sessions to receive MRI referral accreditation. Of these, 150 (55%) GPs requested 550 MRI scans, with 527 (96%) eligible for analysis, resulting in 86% considered appropriate; 79% consistent with guidelines and 7% clinically useful but for conditions outside of guidelines. Inter-rater agreement was 75%. Cohen's weighted kappa statistic was 0.38 (95% CI: 0.28-0.48). MRI referrals consistent with guidelines were more likely to show pathology requiring specialist intervention (reviewer 1: odds ratio=2.64, 95% CI 1.51-4.62; reviewer 2: odds ratio=4.44, 95% CI 2.47-7.99), compared to scan requests graded not consistent. DISCUSSION Study findings indicate GPs use decision support guidance well, and this has resulted in appropriate MRI referrals and higher specialist intervention rates for selected conditions.