Appropriateness of the Use of Magnetic Resonance Imaging in the Diagnosis and Treatment of Wrist Soft Tissue Injury

Cost of Low-Value Imaging Worldwide: A Systematic Review

BACKGROUND AND OBJECTIVE

Imaging with low or no benefit for the patient undermines the quality of care and amounts to vast opportunity costs. More than 3.6 billion imaging examinations are performed annually, and about 20-50% of these are of low value. This study aimed to synthesize knowledge of the costs of low-value imaging worldwide.

METHODS

This systematic review was based on the PRISMA statement. The database search was developed in Medline and further adapted to Embase-Ovid, Cochrane Library, and Scopus. Primary empirical studies assessing the costs of low-value diagnostic imaging were included if published between 2012 and March 2022. Studies designed as randomized controlled trials, non-randomized trials, cohort studies, cross-sectional studies, descriptive studies, cost analysis, cost-effectiveness analysis, and mixed-methods studies were eligible. The analysis was descriptive.

RESULTS

Of 5,567 records identified, 106 were included. Most of the studies included were conducted in the USA (n = 76), and a hospital or medical center was the most common setting (n = 82). Thirty-eight of the included studies calculated the costs of multiple imaging modalities; in studies with only one imaging modality included, conventional radiography was the most common (n = 32). Aggregated costs for low-value examinations amounts to billions of dollars per year globally. Initiatives to reduce low-value imaging may reduce costs by up to 95% without harming patients.

CONCLUSIONS

This study is the first systematic review of the cost of low-value imaging worldwide, documenting a high potential for cost reduction. Given the universal challenges with resource allocation, the large amount used for low-value imaging represents a vast opportunity cost and offers great potential to improve the quality and efficiency of care.

Temporal and geographical variations in diagnostic imaging in Norway

BACKGROUND

Unwarranted temporal and geographical variations are acknowledged as a profound problem for equal access and justice in the provision of health services. Even more, they challenge the quality, safety, and efficiency of such services. This is highly relevant for imaging services.

OBJECTIVE

To analyse the temporal and geographical variation in the number of diagnostic images in Norway from 2013 to 2021.

METHODS

Data on outpatient imaging provided by the Norwegian Health Economics Administration (HELFO) and inpatient data afforded by fourteen hospital trusts and hospitals in Norway. Data include the total number of imaging examinations according to the Norwegian Classification of Radiological Procedures (NCRP). Analyses were performed with descriptive statistics.

RESULTS

More than 37 million examinations were performed in Norway during 2013-2021 giving an average of 4.2 million examinations per year. In 2021 there was performed and average of 0.8 examinations per person and 2.2 examinations per person for the age group > 80. There was a 9% increase in the total number of examinations from 2013 to 2015 and a small and stable decrease of 0.5% per year from 2015 to 2021 (with the exception of 2020 due to the pandemic). On average 71% of all examinations were outpatient examinations and 32% were conducted at private imaging centres. There were substantial variations between the health regions, with Region South-East having 53.1% more examinations per inhabitant than Region West. The geographical variation was even more outspoken when comparing catchment areas, where Oslo University Hospital Trust had twice as many examinations per inhabitant than Finnmark Hospital Trust.

CONCLUSION

As the population in Norway is homogeneous it is difficult to attribute the variations to socio-economic or demographic factors. Unwarranted and supply-sensitive variations are challenging for healthcare systems where equal access and justice traditionally are core values.

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.

Magnetic Resonance Arthrography of the Wrist: The Impact on Operative Management of Wrist Injuries

Background  There is no consensus on the utility of arthrography in the evaluation of wrist injuries. This study evaluates ordering trends of different types of magnetic resonance imaging (MRI) of the wrist and compares rates of surgery following these imaging modalities. Methods  A national claims-based database was used to identify patients who underwent MRI within 90 days of a first-instance diagnosis of wrist injury from 2010 to 2018. The utilization of MRI without intravenous (IV) contrast, MRI with IV contrast, and MRI with arthrogram was investigated. The instances of operative procedures of the wrist within 1 year of MRI study were recorded. Patient demographics, comorbidities, type of operative procedure, and ordering physician specialty were obtained. Logistic regression analysis was used to evaluate the utilization of MRI and subsequent 1-year operative intervention rates as well as association of patient-related factors. Results  Magnetic resonance arthrography use was associated with higher rates of subsequent operative treatment. Surgeons were more likely to order an arthrogram at the time of MRI. Younger patients were more likely to undergo MRI-based advanced imaging. Conclusion  Surgeons may perceive MRA of the wrist to play an important role in operative decision-making following wrist injury. Level of Evidence  This is a Level III, retrospective cohort study.

Ankle MRI and preceding radiographs: an evaluation of physician ordering practices

OBJECTIVE

Multiple guidelines have been published for appropriate imaging in patients with ankle-related symptoms which suggest radiographs as the initial imaging examination for both acute and chronic ankle abnormalities. Few studies have evaluated adherence to these imaging guidelines. This study retrospectively evaluated the utilization of ankle MRI and preceding radiographs based on ordering provider group and MRI indication.

MATERIALS AND METHODS

A total of 4186 ankle MRIs performed over a 9-year period at a single institution were evaluated for the presence of preceding ankle and/or foot radiographs at two time points, within 3 months and within 6 months of the MRI examination. Ankle MRIs were then categorized based on 6 ordering provider groups and 13 MRI indications.

RESULTS

Of the 4186 MRIs evaluated, 68% had preceding radiographs within 3 months and 77% had radiographs within 6 months. Primary care, sports medicine, and podiatry had the lowest rates of preceding radiographs (73%, 68%, and 64%, respectively, within 6 months). Eighty-six percent of ankle MRIs ordered by orthopedic surgery had preceding radiographs within 6 months and 89% of ankle MRIs ordered by emergency medicine and inpatient providers had preceding radiographs. MRIs intended for evaluation of Achilles tendon or plantar fascia abnormalities were among the least likely indications to have preceding radiographs.

CONCLUSION

Based on established clinical guidelines, there was a lower-than-expected rate of obtaining preceding radiographs for ankle MRIs among most provider groups, particularly non-orthopedic outpatient providers. Additional research is needed to address the lack of adherence to clinical imaging guidelines and ensure appropriate imaging.

3D MRI of the Hand and Wrist: Technical Considerations and Clinical Applications

In the last few years, major developments have been observed in the field of magnetic resonance imaging (MRI). Advances in both scanner hardware and software technologies have witnessed great leaps, enhancing the diagnostic quality and, therefore, the value of MRI. In musculoskeletal radiology, three-dimensional (3D) MRI has become an integral component of the diagnostic pathway at our institutions. This technique is particularly relevant in patients with hand and wrist symptoms, due to the intricate nature of the anatomical structures and the wide range of differential diagnoses for most presentations. We review the benefits of 3D MRI of the hand and wrist, commonly used pulse sequences, clinical applications, limitations, and future directions. We offer guidance for enhancing the image quality and tips for image interpretation of 3D MRI of the hand and wrist.

Appropriateness of Computed Tomography Scanning in the Diagnosis of Craniosynostosis

INTRODUCTION

Although physicians from a variety of specialties encounter infants with possible craniosynostosis, judicious use of computed tomography (CT) imaging is important to avoid unnecessary radiation exposure and healthcare expense. The present study seeks to determine whether differences in specialty of ordering physician affects frequency of resulting diagnostic confirmations requiring operative intervention.

METHODS

Radiology databases from 2 institutions were queried for CT reports or indications that included "craniosynostosis" or "plagiocephaly." Patient demographics, specialty of ordering physician, confirmed diagnosis, and operative interventions were recorded. Cost analysis was performed using the fixed unit cost for a head CT to calculate the expense before 1 study led to operative intervention.

RESULTS

Three hundred eighty-two patients were included. 184 (48.2%) CT scans were ordered by craniofacial surgeons, 71 (18.6%) were ordered by neurosurgeons, and 127 (33.3%) were ordered by pediatricians. One hundred four (27.2%) patients received a diagnosis of craniosynostosis requiring operative intervention. Craniofacial surgeons and neurosurgeons were more likely than pediatricians to order CT scans that resulted in a diagnosis of craniosynostosis requiring operative intervention (P < 0.001), with no difference between craniofacial surgeons and neurosurgeons (P = 1.0). The estimated cost of obtaining an impact CT scan when ordered by neurosurgeons or craniofacial surgeons as compared to pediatricians was $2369.69 versus $13,493.75.

CONCLUSIONS

Clinicians who more frequently encounter craniosynostosis (craniofacial and neurosurgeons) had a higher likelihood of ordering CT images that resulted in a diagnosis of craniosynostosis requiring operative intervention. This study should prompt multi-disciplinary interventions aimed at improving evaluation of pretest probability before CT imaging.

Utility of Specialized Imaging for Diagnosis of Chronic Wrist Pain

Background  Patients with chronic wrist pain often undergo imaging (such as magnetic resonance imaging [MRI], computed tomography [CT], or ultrasound [US]) prior to specialist assessment. Questions  Is specialized wrist imaging performed prior to expert consultation necessary? Are there demographic differences between patients who do or do not receive preconsultation imaging? Patients and Methods  A total of 115 patients referred to a tertiary hand center for chronic wrist pain and assessed by a hand surgeon were included. At initial consultation, surgeons were blinded to referral information and previous imaging results. The specialist performed a history, physical examination and reviewed X-rays. They established a clinical diagnosis and whether any additional investigations were needed. Prior MRI, CT, and/or US results were then reviewed and the specialists' clinical diagnosis was compared with the blinded referral diagnosis. Preconsultation imaging was categorized as having no value for diagnosis/management, some value, or high value. Results  A total of 82 patients had imaging prior to specialist referral (69 MRIs, 11 CTs, and 16 ultrasounds). The majority of additional imaging (73%) was classified as unnecessary, including 77% of the MRIs and 100% of the ultrasounds. Of all the investigations performed, two CT scans were labeled highly valuable clinical aids. Older patients and those with radial-sided pain were less likely to receive preconsultation imaging. Six patients required further imaging after consultation. Conclusion  Clinical assessment and X-rays are typically sufficient for a hand specialist to diagnose and manage chronic wrist pain and few patients require additional imaging. Level of Evidence  This is a Level III study.