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Hofmann BM, Brandsaeter IØ, Andersen ER, Porthun J, Kjelle E. Temporal and geographical variations in diagnostic imaging in Norway. BMC Health Serv Res 2024; 24:463. [PMID: 38610021 PMCID: PMC11015609 DOI: 10.1186/s12913-024-10869-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 03/14/2024] [Indexed: 04/14/2024] Open
Abstract
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.
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Affiliation(s)
- Bjørn Morten Hofmann
- Department of Health Sciences Gjøvik, Norwegian University of Science and Technology (NTNU), NTNU Gjøvik, PO Box 191, 2802, Gjøvik, Norway.
- Centre for Medical Ethics, University of Oslo, PO Box 1130, 0318, Blindern, Oslo, Norway.
| | - Ingrid Øfsti Brandsaeter
- Department of Health Sciences Gjøvik, Norwegian University of Science and Technology (NTNU), NTNU Gjøvik, PO Box 191, 2802, Gjøvik, Norway
| | - Eivind Richter Andersen
- Department of Health Sciences Gjøvik, Norwegian University of Science and Technology (NTNU), NTNU Gjøvik, PO Box 191, 2802, Gjøvik, Norway
| | - Jan Porthun
- Department of Health Sciences Gjøvik, Norwegian University of Science and Technology (NTNU), NTNU Gjøvik, PO Box 191, 2802, Gjøvik, Norway
| | - Elin Kjelle
- Department of Health Sciences Gjøvik, Norwegian University of Science and Technology (NTNU), NTNU Gjøvik, PO Box 191, 2802, Gjøvik, Norway
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Hofmann B, Håvik V, Andersen ER, Brandsæter IØ, Kjelle E. 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. BMJ Open 2024; 14:e081860. [PMID: 38485174 PMCID: PMC10941154 DOI: 10.1136/bmjopen-2023-081860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/01/2024] [Indexed: 03/17/2024] Open
Abstract
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.
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Affiliation(s)
- Bjørn Hofmann
- Department of Health Sciences in Gjøvik, Norwegian University of Science and Technology, Faculty of Medicine and Health Sciences, Gjøvik, Norway
- Centre of Medical Ethics, University of Oslo, Norway, Oslo, Norway
| | - Vegard Håvik
- Department for Medical Reimbursement, Norwegian Directorate of Health, Oslo, Norway
| | - Eivind Richter Andersen
- Department of Health Sciences in Gjøvik, Norwegian University of Science and Technology, Faculty of Medicine and Health Sciences, Gjøvik, Norway
| | - Ingrid Øfsti Brandsæter
- Department of Health Sciences in Gjøvik, Norwegian University of Science and Technology, Faculty of Medicine and Health Sciences, Gjøvik, Norway
| | - Elin Kjelle
- Department of Health Sciences in Gjøvik, Norwegian University of Science and Technology, Faculty of Medicine and Health Sciences, Gjøvik, Norway
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Kuhrij LS, Marang-van de Mheen PJ, van Lier L, Alimahomed R, Nelissen RGHH, van Bodegom-Vos L. Reduction in use of MRI and arthroscopy among patients with degenerative knee disease in independent treatment centers versus general hospitals: a time series analysis. Int J Qual Health Care 2024; 36:mzae004. [PMID: 38252692 PMCID: PMC10849166 DOI: 10.1093/intqhc/mzae004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/16/2023] [Accepted: 01/21/2024] [Indexed: 01/24/2024] Open
Abstract
The use of MRI and arthroscopy are considered low-value care in most patients with degenerative knee disease. To reduce these modalities, there have been multiple efforts to increase awareness. Reductions have been shown for general hospitals (GH), but it is unclear whether this may be partly explained by a shift of patients receiving these modalities in independent treatment centers (ITCs). The aims of this study were to assess (i) whether the trend in use of MRI and arthroscopy in patients with degenerative knee disease differs between ITCs and GH, and (ii) whether the Dutch efforts to raise awareness on these recommendations were associated with a change in the trend for both types of providers. All patients insured by a Dutch healthcare insurer aged ≥50 years with a degenerative knee disease who were treated in a GH or ITC between July 2014 and December 2019 were included. Linear regression was used with the quarterly percentage of patients receiving an MRI or knee arthroscopy weighted by center volume, as the primary outcome. Interrupted time-series analysis was used to evaluate the effect of the Dutch efforts to raise awareness. A total of 14 702 patients included were treated in 90 GHs (n = 13 303, 90.5%) and 29 ITCs (n = 1399, 9.5%). Across the study period, ITCs on an average had a 16% higher MRI use (P < .001) and 9% higher arthroscopy use (P = .003). MRI use did not change in both provider types, but arthroscopy use significantly decreased and became stronger in ITCs (P = .01). The Dutch efforts to increase awareness did not significantly influence either MRI or arthroscopy use in ITCs (P = .55 and P = .84) and GHs (P = .13 and P = .70). MRI and arthroscopy uses were higher in ITCs than GHs. MRI use did not change significantly among patients ≥ 50 years with degenerative knee disease in both provider types between 2014 and 2019. MRI- and arthroscopy use decreased with ITCs on average having higher rates for both modalities, but also showing a stronger decrease in arthroscopy use. The Dutch efforts to increase awareness did not accelerate the already declining trend in the Netherlands.
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Affiliation(s)
- Laurien S Kuhrij
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, the Netherlands
| | - Perla J Marang-van de Mheen
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, the Netherlands
| | - Lisanne van Lier
- Zorg & Zekerheid, Haagse Schouwweg 12, Leiden 2332 KG, the Netherlands
| | - Razia Alimahomed
- Zorg & Zekerheid, Haagse Schouwweg 12, Leiden 2332 KG, the Netherlands
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, the Netherlands
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, the Netherlands
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Brandsæter IØ, Andersen ER, Hofmann BM, Kjelle E. Drivers for low-value imaging: a qualitative study of stakeholders' perspectives in Norway. BMC Health Serv Res 2023; 23:295. [PMID: 36978092 PMCID: PMC10044073 DOI: 10.1186/s12913-023-09328-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/22/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND One kind of overutilization of diagnostic imaging is low-value imaging, i.e., imaging that does not lead to altered clinical pathways or improved health outcomes. Despite having well-documented extension and consequences, low-value imaging is still widespread. The objective of this study was to identify the drivers for the use of low-value imaging in the Norwegian healthcare services. METHODS We conducted individual, semi-structured interviews among representatives from the health authorities, general practitioners, specialists working in hospitals, radiologists, radiographers, and managers of imaging departments. Data analysis was carried out in line with framework analysis consisting of five steps: Familiarization, indexing, charting, mapping, and interpretation. RESULTS The analysis included 27 participants and resulted in two themes. The stakeholders identified drivers in the healthcare system and in the interaction between radiologists, referrers, and patients. The identified drivers were categorized in sub-themes, such as organization, communication, competence, expectations, defensive medicine, roles and responsibilities, and referral quality and time constraints. The drivers interact with each other and may strengthen the effect of other drivers. CONCLUSIONS Several drivers for low-value imaging in Norway were identified at all levels of the healthcare system. The drivers work simultaneously and synergistically. To free resources for high-value imaging, drivers should be targeted by appropriate measures at several levels to reduce low-value imaging.
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Affiliation(s)
- Ingrid Øfsti Brandsæter
- Department of Health Sciences Gjøvik, Norwegian University of Science and Technology (NTNU), NTNU Gjøvik, PB 191, 2802, Gjøvik, Norway.
| | - Eivind Richter Andersen
- Department of Health Sciences Gjøvik, Norwegian University of Science and Technology (NTNU), NTNU Gjøvik, PB 191, 2802, Gjøvik, Norway
| | - Bjørn Morten Hofmann
- Department of Health Sciences Gjøvik, Norwegian University of Science and Technology (NTNU), NTNU Gjøvik, PB 191, 2802, Gjøvik, Norway
- Centre for Medical Ethics, University of Oslo, Blindern, PB 1130, 0318, Oslo, Norway
| | - Elin Kjelle
- Department of Health Sciences Gjøvik, Norwegian University of Science and Technology (NTNU), NTNU Gjøvik, PB 191, 2802, Gjøvik, Norway
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Hofmann B. Ethical issues with geographical variations in the provision of health care services. BMC Med Ethics 2022; 23:127. [PMID: 36474244 PMCID: PMC9724375 DOI: 10.1186/s12910-022-00869-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 11/26/2022] [Indexed: 12/12/2022] Open
Abstract
Geographical variations are documented for a wide range of health care services. As many such variations cannot be explained by demographical or epidemiological differences, they are problematic with respect to distributive justice, quality of care, and health policy. Despite much attention, geographical variations prevail. One reason for this can be that the ethical issues of geographical variations are rarely addressed explicitly. Accordingly, the objective of this article is to analyse the ethical aspects of geographical variations in the provision of health services. Applying a principlist approach the article identifies and addresses four specific ethical issues: injustice, harm, lack of beneficence, and paternalism. Then it investigates the normative leap from the description of geographical variations to the prescription of right care. Lastly, the article argues that professional approaches such as developing guidelines, checklists, appropriateness criteria, and standards of care are important measures when addressing geographical variations, but that such efforts should be accompanied and supported by ethical analysis. Hence, geographical variations are not only a healthcare provision, management, or a policy making problem, but an ethical one. Addressing the ethical issues with geographical variations is key for handling this crucial problem in the provision of health services.
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Affiliation(s)
- Bjørn Hofmann
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU), PO Box 191, 2801, Gjøvik, Norway.
- The Centre for Medical Ethics, University of Oslo, PO Box 1130, 0318, Oslo, Norway.
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Andersen ER, Hofmann BM, Kjelle E. Reducing low-value radiological services in Norway -a qualitative multi-professional study on measures and facilitators for change. BMC Health Serv Res 2022; 22:678. [PMID: 35596215 PMCID: PMC9122550 DOI: 10.1186/s12913-022-08077-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 05/11/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Overuse, underuse, and significant variation in the utilisation of radiological services are well documented in the literature. Several radiological examinations are identified as low-value examinations as they do not lead to a change in diagnosis or course of treatment. Even so, such examinations are frequently performed. Many measures for reducing low-value imaging have been carried out with variable outcomes. While there is little evidence as to why some measures work and others do not, adjusting to the context seems important for success. The objective of this study was to investigate which measures stakeholders consider appropriate for reducing the use of low-value imaging and what it takes to make them work. METHODS Semi-structured interviews were conducted among radiographers, radiologists, radiological department managers, hospital clinicians, general practitioners, and health government/authorities' representatives. The interview guide covered two broad areas: Experience with low-value services, and possible future measures deemed appropriate for reducing low-value services. Data were analysed in line with a qualitative framework analysis. RESULTS The analysis included information from 27 participants. All participants acknowledged that low-value imaging was a problem, but few had very specific suggestions on reducing this in practice. Suggested measures were to stop referrals from being sent, provide support in assessing referrals, or change the healthcare system. Identified facilitators were categorised as management and resources, evidence, and experienced value. In general, appropriate measures should be practical, well-founded, and valuable. CONCLUSIONS This study provides insight into various stakeholders' perceptions of suitable interventions to reduce low-value imaging. While many measures for reducing low-value imaging are available, contextual sensitivity is crucial to make them work.
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Affiliation(s)
- Eivind Richter Andersen
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, PO Box 1, N-2802, Gjøvik, Norway.
| | - Bjørn Morten Hofmann
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, PO Box 1, N-2802, Gjøvik, Norway
- Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Elin Kjelle
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, PO Box 1, N-2802, Gjøvik, Norway
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Hofmann BM, Gransjøen AM. Geographical variations in the use of outpatient diagnostic imaging in Norway 2019. Acta Radiol Open 2022; 11:20584601221074561. [PMID: 35251700 PMCID: PMC8891857 DOI: 10.1177/20584601221074561] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Geographical variations in the use of outpatient imaging can reveal inappropriate use of radiological services. Knowledge about these variations is crucial in the strive for appropriate and improved services. Purpose To investigate the geographical variations in outpatient diagnostic imaging and analyze variations for main groups of examinations and for specific examinations. Material and methods Data on outpatient radiological procedures registered at the Norwegian Health Economics Administration in Norway for 2019 were accessed with county-based population rates for age adjustment accessed through Statistics Norway. Age-adjusted rates were used to calculate high/low ratios, means, standard deviations, and coefficients of variation were calculated per 10,000 inhabitants. Results There is high geographical variation for PET/CT and PET/MRI and moderate variation for neuroradiological outpatient examinations in Norway in 2019. Variations for the musculoskeletal systems and of thorax, abdomen, and vessels are almost 50%. We find high high-to-low ratios in CT—face (9.7), MRI—elbow joint (8.5), CT of the neck, thorax, abdomen, and pelvis (6.5) as well as MRI—prostate (6.2). Comparing with data from 2012–5, we find a reduction in variation for some examinations, such as MRI of the hip and MRI of the entire spine, and an increase in variations for others, such as CT of the face and MRI of the elbow joint. Conclusion Despite much attention to the problem, we demonstrate substantial variations in radiological services in Norway raising concern with respect to appropriateness, quality of care, equity, and justice. The findings provide important input for quality improvement in radiological services.
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Affiliation(s)
- Bjørn M Hofmann
- Institute for the Health Sciences, Norwegian University of Science and Technology (NTNU), Gjøvik, Norway
- Centre of Medical Ethics, University of Oslo, Oslo, Norway
| | - Ann M Gransjøen
- Institute for the Health Sciences, Norwegian University of Science and Technology (NTNU), Gjøvik, Norway
- SHARE, University of Stavanger, Stavanger, Norway
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Gransjøen AM, Thorsen K, Lysdahl KB, Wiig S, Hofmann BM. Impact on radiological practice of active guideline implementation of musculoskeletal guideline, as measured over a 12-month period. Acta Radiol Open 2021; 10:2058460120988171. [PMID: 33796335 PMCID: PMC7975584 DOI: 10.1177/2058460120988171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/27/2020] [Indexed: 12/01/2022] Open
Abstract
Background An ever-increasing technological development in the field of radiology urges
a need for guidelines to provide predictable and just health services. A
musculoskeletal guideline was developed in Norway in 2014, without active
implementation. Purpose To investigate the impact of active guideline implementation on the use of
musculoskeletal diagnostic imaging most frequently encountered in general
practice (pain in the neck, shoulders, lower back, and knees). Material and Methods The total number of outpatient radiological examinations across modalities
registered at the Norwegian Health Economics Administration between January
2013 and February 2019 was assessed using an interrupted time series
design. Results A 12% reduction in the total examination of Magnetic Resonance Imaging
shoulder and knee, and x-ray lower back and shoulder was found at a
significant level (p = 0.05). Stratified analysis (Magnetic
Resonance Imaging examination as one group and x-ray examinations as the
other) showed that this reduction mainly was due to the reduction in the use
of Magnetic Resonance Imaging examinations (shoulder and knee) which was
reduced by 24% at a significant level (p = 0.002), while
x-ray examinations had no significant level change
(p = 0.71). No other statistically significant changes were
found. Conclusion The impact of the implementation on the use of imaging of the neck, shoulder,
lower back, and knee is uncertain. Significant reductions were demonstrated
in the use of some examinations in the intervention county, but similar
effects were not seen when including a control group in the analysis. This
indicates a diffusion of the implementation, or other interventions or
events that affected both counties and occurred in the intervention
period.
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Affiliation(s)
- Ann M Gransjøen
- Department of Health Sciences, Norwegian University of Science and Technology (NTNU), Gjøvik, Norway
| | | | - Kristin B Lysdahl
- Department of Optometry, Radiography and Lighting Design, University of South-Eastern Norway, Kongsberg, Norway
| | - Siri Wiig
- SHARE-Centre for Resilience in Healthcare, University of Stavanger, Stavanger, Norway
| | - Bjørn M Hofmann
- Department of Health Sciences, Norwegian University of Science and Technology (NTNU), Gjøvik, Norway.,Center for Medical Ethics, University of Oslo, Blindern, Oslo
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Kim-Wang SY, Scribani MB, Whiteside MB, DeFrate LE, Lassiter TE, Wittstein JR. Distribution of Bone Contusion Patterns in Acute Noncontact Anterior Cruciate Ligament-Torn Knees. Am J Sports Med 2021; 49:404-409. [PMID: 33411563 PMCID: PMC8214466 DOI: 10.1177/0363546520981569] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Bone contusions are commonly observed on magnetic resonance imaging (MRI) in individuals who have sustained a noncontact anterior cruciate ligament (ACL) injury. Time from injury to image acquisition affects the ability to visualize these bone contusions, as contusions resolve with time. PURPOSE To quantify the number of bone contusions and their locations (lateral tibial plateau [LTP], lateral femoral condyle [LFC], medial tibial plateau [MTP], and medial femoral condyle [MFC]) observed on MRI scans of noncontact ACL-injured knees acquired within 6 weeks of injury. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS We retrospectively reviewed clinic notes, operative notes, and imaging of 136 patients undergoing ACL reconstruction. The following exclusion criteria were applied: MRI scans acquired beyond 6 weeks after injury, contact ACL injury, and previous knee trauma. Fat-suppressed fast spin-echo T2-weighted MRI scans were reviewed by a blinded musculoskeletal radiologist. The number of contusions and their locations (LTP, LFC, MTP, and MFC) were recorded. RESULTS Contusions were observed in 135 of 136 patients. Eight patients (6%) had 1 contusion, 39 (29%) had 2, 41 (30%) had 3, and 47 (35%) had 4. The most common contusion patterns within each of these groups were 6 (75%) with LTP for 1 contusion, 29 (74%) with LTP/LFC for 2 contusions, 33 (80%) with LTP/LFC/MTP for 3 contusions, and 47 (100%) with LTP/LFC/MTP/MFC for 4 contusions. No sex differences were detected in contusion frequency in the 4 locations (P > .05). Among the participants, 50 (37%) had medial meniscal tears and 52 (38%) had lateral meniscal tears. CONCLUSION The most common contusion patterns observed were 4 locations (LTP/LFC/MTP/MFC) and 3 locations (LTP/LFC/MTP).
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Affiliation(s)
- Sophia Y Kim-Wang
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA.,Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA
| | | | | | - Louis E DeFrate
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA.,Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA.,Department of Mechanical Engineering and Materials Science, Duke University, Durham, North Carolina, USA
| | - Tally E Lassiter
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Jocelyn R Wittstein
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
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Gransjøen AM, Lysdahl KB, Hofmann BM. Geographical variations in the use of diagnostic imaging of musculoskeletal diseases in Norway. Acta Radiol 2019; 60:1153-1158. [PMID: 30417668 DOI: 10.1177/0284185118812204] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ann Mari Gransjøen
- Department of Health Sciences, Norwegian University of Science and Technology in Gjøvik (NTNU), Gjøvik, Norway
| | - Kristin Bakke Lysdahl
- Department of Optometry, Radiography and Lighting Design, Faculty of Health Sciences, Norway and University of South-Eastern Norway, Kongsberg, Norway
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Culvenor AG, Øiestad BE, Hart HF, Stefanik JJ, Guermazi A, Crossley KM. Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. Br J Sports Med 2018; 53:1268-1278. [PMID: 29886437 PMCID: PMC6837253 DOI: 10.1136/bjsports-2018-099257] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2018] [Indexed: 11/04/2022]
Abstract
Background Knee MRI is increasingly used to inform clinical management. Features associated with osteoarthritis are often present in asymptomatic uninjured knees; however, the estimated prevalence varies substantially between studies. We performed a systematic review with meta-analysis to provide summary estimates of the prevalence of MRI features of osteoarthritis in asymptomatic uninjured knees. Methods We searched six electronic databases for studies reporting MRI osteoarthritis feature prevalence (ie, cartilage defects, meniscal tears, bone marrow lesions and osteophytes) in asymptomatic uninjured knees. Summary estimates were calculated using random-effects meta-analysis (and stratified by mean age: <40 vs ≥40 years). Meta-regression explored heterogeneity. Results We included 63 studies (5397 knees of 4751 adults). The overall pooled prevalence of cartilage defects was 24% (95% CI 15% to 34%) and meniscal tears was 10% (7% to 13%), with significantly higher prevalence with age: cartilage defect <40 years 11% (6%to 17%) and ≥40 years 43% (29% to 57%); meniscal tear <40 years 4% (2% to 7%) and ≥40 years 19% (13% to 26%). The overall pooled estimate of bone marrow lesions and osteophytes was 18% (12% to 24%) and 25% (14% to 38%), respectively, with prevalence of osteophytes (but not bone marrow lesions) increasing with age. Significant associations were found between prevalence estimates and MRI sequences used, physical activity, radiographic osteoarthritis and risk of bias. Conclusions Summary estimates of MRI osteoarthritis feature prevalence among asymptomatic uninjured knees were 4%–14% in adults aged <40 years to 19%–43% in adults ≥40 years. These imaging findings should be interpreted in the context of clinical presentations and considered in clinical decision-making.
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Affiliation(s)
- Adam G Culvenor
- Institute of Anatomy, Paracelsus Medical University Salzburg & Nuremberg, Salzburg, Austria.,La Trobe Sports and Exercise Medicine Research Centre, School of Allied Health, La Trobe University, Bundoora, Victoria, Australia
| | | | - Harvi F Hart
- La Trobe Sports and Exercise Medicine Research Centre, School of Allied Health, La Trobe University, Bundoora, Victoria, Australia
| | - Joshua J Stefanik
- Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
| | - Ali Guermazi
- Department of Radiology, Quantitative Imaging Centre, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Kay M Crossley
- La Trobe Sports and Exercise Medicine Research Centre, School of Allied Health, La Trobe University, Bundoora, Victoria, Australia
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Gómez-García JM, Gómez-Romero FJ, Arencibia-Jiménez M, Navarro-Gracia JF, Sánchez-Mollá M. Appropriateness of magnetic resonance imaging requested by primary care physicians for patients with knee pain. Int J Qual Health Care 2018; 30:565-570. [DOI: 10.1093/intqhc/mzy067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 03/21/2018] [Indexed: 12/31/2022] Open
Affiliation(s)
- J M Gómez-García
- Preventive Medicine Department, Hospital General Universitario de Elche, Camino de las Almazaras, 11, Elche, Alicante, Spain
| | - F J Gómez-Romero
- Preventive Medicine Department, Hospital General Universitario de Elche, Camino de las Almazaras, 11, Elche, Alicante, Spain
| | - M Arencibia-Jiménez
- Preventive Medicine Department, Hospital General Universitario de Elche, Camino de las Almazaras, 11, Elche, Alicante, Spain
| | - J F Navarro-Gracia
- Preventive Medicine Department, Hospital General Universitario de Elche, Camino de las Almazaras, 11, Elche, Alicante, Spain
| | - M Sánchez-Mollá
- Hospital General Universitario de Elche, Camino de las Almazaras, 11, Elche, Alicante, Spain
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Randsborg PH, Røtterud JH. [Degenerative meniscal ruptures should not be operated]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2017; 137:258. [PMID: 28225222 DOI: 10.4045/tidsskr.16.1028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Iversen T, Mokienko A. Supplementing gatekeeping with a revenue scheme for secondary care providers. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2016; 16:247-267. [PMID: 27878675 DOI: 10.1007/s10754-016-9188-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 04/11/2016] [Indexed: 06/06/2023]
Abstract
We study implications of a change in the payment scheme for radiology providers in Norway that was implemented in 2008. The change implies reduced fee-for-service and increased fixed budget for a contracted volume of services. A consequence of the change is that private providers have less incentive to conduct examinations beyond the contracted volume. Different from the situation observed before the change in 2008, the volume is no longer determined by the demand side, and a rationing of the supply occurs. We employ data on radiological examinations initiated by GPs' referrals. We apply monthly data at the physician-practice level for 2007-2010. The data set is unique because it includes information about all GPs in the Norwegian patient-list system. The results indicate that private providers conducted fewer examinations in 2008-2010 compared with previous periods and that public hospitals did either the same volume or more. We find that GPs who operate in a more competitive environment experienced a greater reduction in magnetic resonance imaging, both performed by private providers and in total for their patients. We argue that this result supports a hypothesis that patients with lower expected benefits are rationed. Hence, rationing from the supply side might supplement GP gatekeeping.
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Affiliation(s)
- Tor Iversen
- Department of Health Management and Health Economics, University of Oslo, P.O. Box 1089, Blindern, 0317, Oslo, Norway.
| | - Anastasia Mokienko
- Department of Health Management and Health Economics, University of Oslo, P.O. Box 1089, Blindern, 0317, Oslo, Norway
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Abstract
INTRODUCTION The use of MRI is increasing when evaluating patients with knee pain because it is highly sensitive for detecting intra-articular pathology. However, such changes can be associated with degenerative joint disease, which may be demonstrated with weight-bearing radiographs. The purpose of this study was to determine how often MRI was obtained before orthopaedic referral in patients aged ≥40 years with knee pain, how often weight-bearing radiographs were obtained before MRI, and whether such imaging influenced treatment recommendations. METHODS In a study of 599 new patients, participating physicians documented the presence of a prereferral MRI and/or plain radiographic studies, the results of weight-bearing radiographs, treatment recommendations, and the impact of any prereferral imaging. RESULTS Prereferral use of MRI occurred in 130 patients (22%). Of these patients, plain radiographic studies were obtained for 58% before MRI and 13% had weight-bearing radiographs. Ultimately, 17% had weight-bearing radiographs that demonstrated >50% loss of joint space. Forty-eight percent of prereferral MRIs did not contribute to treatment recommendations. In patients with >50% loss of joint space, MRI was considered unnecessary in 95% of the cases. DISCUSSION Many prereferral MRIs do not contribute to clinical decision making. Weight-bearing radiographs can help identify those patients in whom MRI is unlikely to be helpful. LEVEL OF EVIDENCE Level III.
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Pezeshki S, Vogl TJ, Pezeshki MZ, Daghighi MH, Pourisa M. Association of the type of trauma, occurrence of bone bruise, fracture and joint effusion with the injury to the menisci and ligaments in MRI of knee trauma. Muscles Ligaments Tendons J 2016; 6:161-6. [PMID: 27331046 DOI: 10.11138/mltj/2016.6.1.161] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND magnetic resonance imaging (MRI) as a noninvasive diagnostic tool may help clinicians in the evaluation of injuries to menisci and ligaments. PURPOSE this study assessed the associations between type of trauma to knee joint, bone bruise, fracture and pathological joint effusion with injuries to menisci and ligaments of knee joint. METHODS we reviewed knee joint MRI of 175 patients aged less than 45 years old who were referred to MRI center of our University. RESULTS statistical analysis showed that tearing of medial meniscus (MM) is significantly more common in sport related trauma (p= 0.045) but tearing of medial collateral ligament (MCL) is significantly more common in non-sport related trauma (p= 0.005). Existence of bone bruise in knee MRI is negatively associated with tearing of medial meniscus (MM) (p=0.004) and positively associated with tearing of anterior cruciate ligament (ACL) (p=0.00047) and medial collateral ligament (MCL) (p = 0.0001). Existence of fracture is associated with decreased risk of the tearing of ACL and MM (p=0.04, p=0.001 respectively). Pathologic joint effusion is significantly more common in ACL and MCL tearing (p=0.0001, p=0.004 respectively). CONCLUSIONS as diagnostic clues, bone bruise, fracture and joint effusion may help radiologists for better assessment of injury to menisci and ligaments in MRI of patients with knee trauma.
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Affiliation(s)
- Sina Pezeshki
- Department of Diagnostic and Interventional Radiology, Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Thomas J Vogl
- Department of Diagnostic and Interventional Radiology, Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | | | | | - Masoud Pourisa
- Department of Radiology, Tabriz University of Medical Sciences, Tabriz, Iran
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Wilson RJ, Zumsteg JW, Hartley KA, Long JH, Mesko NW, Halpern JL, Schwartz HS, Holt GE. Overutilization and Cost of Advanced Imaging for Long-Bone Cartilaginous Lesions. Ann Surg Oncol 2015; 22:3466-73. [DOI: 10.1245/s10434-014-4325-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Indexed: 12/11/2022]
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Miranda VS, deCarvalho VBF, Machado LAC, Dias JMD. Prevalence of chronic musculoskeletal disorders in elderly Brazilians: a systematic review of the literature. BMC Musculoskelet Disord 2012; 13:82. [PMID: 22642899 PMCID: PMC3419071 DOI: 10.1186/1471-2474-13-82] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 05/29/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Population ageing is a worldwide phenomenon that has recently challenged public healthcare systems. The knowledge of the burden of chronic musculoskeletal disorders in elders is still limited, particularly in the developing world. This systematic review aimed to investigate the prevalence of chronic musculoskeletal disorders in elderly Brazilians. METHODS A comprehensive literature search was performed in five electronic databases (from inception to January 2012) and completed by additional searches in reference lists. Two review authors independently selected the eligible studies and extracted data on participants' characteristics and rates of chronic musculoskeletal disorders. One review author extracted methodological quality data. We performed a critical synthesis of the results, which were grouped into the diagnoses "chronic musculoskeletal pain" or "specific musculoskeletal diagnoses". RESULTS Twenty five studies reporting on a total of 116,091 elderly Brazilians were included. Eight studies (32%) were of high methodological quality. There was a large variation in the measure of prevalence used by individual studies and in their definition of chronic pain. Prevalence estimates reached 86% for chronic musculoskeletal pain in any location. Studies investigating multiple pain sites found the lower limb and the spine to be the most prevalent complaints (50% each). Arthritis and rheumatism (including osteoarthritis) were the most prevalent specific musculoskeletal diagnoses (9% to 40%), followed by herniated disc (6% to 27%). CONCLUSIONS Despite the growth of the elderly population worldwide, high-quality research on the burden of chronic musculoskeletal disorders in the elderly is still scarce. Future healthcare research focusing on this age group should be a priority in developing countries since their public healthcare systems are not yet fully prepared to accommodate the needs of an aging population.
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Affiliation(s)
- Vivian S Miranda
- Department of Physiotherapy, Federal University of Minas Gerais, Avenida Presidente Antônio Carlos 6627 Pampulha, Belo Horizonte, MG 31.270-901, Brazil
| | - Vivielle BF deCarvalho
- Department of Physiotherapy, Federal University of Minas Gerais, Avenida Presidente Antônio Carlos 6627 Pampulha, Belo Horizonte, MG 31.270-901, Brazil
| | - Luciana AC Machado
- Faculty of Medicine, Federal University of Minas Gerais, Avenida Alfredo Balena 190, Santa Efigênia, Belo Horizonte, MG 30.190-100, Brazil
| | - João Marcos D Dias
- Department of Physiotherapy, Federal University of Minas Gerais, Avenida Presidente Antônio Carlos 6627 Pampulha, Belo Horizonte, MG 31.270-901, Brazil
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Dacombe PJ, Robinson J. Falling up the stairs: the equivalent of 'bashing it with a bible' for an ACL ganglion cyst of the knee. BMJ Case Rep 2012; 2012:bcr.01.2012.5591. [PMID: 22605799 DOI: 10.1136/bcr.01.2012.5591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Intra-articular anterior cruciate ligament (ACL) cysts are rare, the pathogenesis remains unknown, with trauma often implicated. Often asymptomatic, incidental MRI findings, 11% produce symptoms such as pain, locking or instability. Treatment of intra-articular ganglia differs from the traditional 'bash it with a bible' mantra for ganglia elsewhere with surgical debridement generally indicated for symptomatic cases. This case report describes a 43-year-old male car mechanic who presented with a symptomatic ACL cyst diagnosed on MRI. While waiting for surgery the patient fell up his stairs at home, causing forced hyperflexion of his knee. After an initial sharp pain, within 24 h the patient experienced complete resolution of symptoms. Postfall MRI showed no evidence of the initial lesion, leading to our conclusion that for this patient, a fall up the stairs was the equivalent of 'bashing it with a bible' for an ACL ganglion cyst of the knee.
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Langner I, Mikolajczyk R, Garbe E. Regional and temporal variations in coding of hospital diagnoses referring to upper gastrointestinal and oesophageal bleeding in Germany. BMC Health Serv Res 2011; 11:193. [PMID: 21849031 PMCID: PMC3170186 DOI: 10.1186/1472-6963-11-193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Accepted: 08/17/2011] [Indexed: 11/25/2022] Open
Abstract
Background Health insurance claims data are increasingly used for health services research in Germany. Hospital diagnoses in these data are coded according to the International Classification of Diseases, German modification (ICD-10-GM). Due to the historical division into West and East Germany, different coding practices might persist in both former parts. Additionally, the introduction of Diagnosis Related Groups (DRGs) in Germany in 2003/2004 might have changed the coding. The aim of this study was to investigate regional and temporal variations in coding of hospitalisation diagnoses in Germany. Methods We analysed hospitalisation diagnoses for oesophageal bleeding (OB) and upper gastrointestinal bleeding (UGIB) from the official German Hospital Statistics provided by the Federal Statistical Office. Bleeding diagnoses were classified as "specific" (origin of bleeding provided) or "unspecific" (origin of bleeding not provided) coding. We studied regional (former East versus West Germany) differences in incidence of hospitalisations with specific or unspecific coding for OB and UGIB and temporal variations between 2000 and 2005. For each year, incidence ratios of hospitalisations for former East versus West Germany were estimated with log-linear regression models adjusting for age, gender and population density. Results Significant differences in specific and unspecific coding between East and West Germany and over time were found for both, OB and UGIB hospitalisation diagnoses, respectively. For example in 2002, incidence ratios of hospitalisations for East versus West Germany were 1.24 (95% CI 1.16-1.32) for specific and 0.67 (95% CI 0.60-0.74) for unspecific OB diagnoses and 1.43 (95% CI 1.36-1.51) for specific and 0.83 (95% CI 0.80-0.87) for unspecific UGIB. Regional differences nearly disappeared and time trends were less marked when using combined specific and unspecific diagnoses of OB or UGIB, respectively. Conclusions During the study period, there were substantial regional and temporal variations in the coding of OB and UGIB diagnoses in hospitalised patients. Possible explanations for the observed regional variations are different coding preferences, further influenced by changes in coding and reimbursement rules. Analysing groups of diagnoses including specific and unspecific codes reduces the influence of varying coding practices.
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Affiliation(s)
- Ingo Langner
- Bremen Institute for Prevention Research and Social Medicine, Bremen University, Germany.
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Lysdahl KB, Hofmann BM. What causes increasing and unnecessary use of radiological investigations? A survey of radiologists' perceptions. BMC Health Serv Res 2009; 9:155. [PMID: 19723302 PMCID: PMC2749824 DOI: 10.1186/1472-6963-9-155] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2009] [Accepted: 09/01/2009] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Growth in use and overuse of diagnostic imaging significantly impacts the quality and costs of health care services. What are the modifiable factors for increasing and unnecessary use of radiological services? Various factors have been identified, but little is known about their relative impact. Radiologists hold key positions for providing such knowledge. Therefore the purpose of this study was to obtain radiologists' perspective on the causes of increasing and unnecessary use of radiological investigations. METHODS In a mailed questionnaire radiologist members of the Norwegian Medical Association were asked to rate potential causes of increased investigation volume (fifteen items) and unnecessary investigations (six items), using five-point-scales. Responses were analysed by using summary statistics and Factor Analysis. Associations between variables were determined using Students' t-test, Spearman rank correlation and Chi-Square tests. RESULTS The response rate was 70% (374/537). The highest rated causes of increasing use of radiological investigations were: a) new radiological technology, b) peoples' demands, c) clinicians' intolerance for uncertainty, d) expanded clinical indications, and e) availability. 'Over-investigation' and 'insufficient referral information' were reported the most frequent causes of unnecessary investigations. Correlations between causes of increasing and unnecessary radiology use were identified. CONCLUSION In order to manage the growth in radiological imaging and curtail inappropriate investigations, the study findings point to measures that influence the supply and demand of services, specifically to support the decision-making process of physicians.
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Affiliation(s)
- Kristin B Lysdahl
- Faculty of Health Sciences, Oslo University College, Oslo, Norway
- Section for Medical Ethics, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Bjørn M Hofmann
- Section for Medical Ethics, Faculty of Medicine, University of Oslo, Oslo, Norway
- Faculty of Health Care and Nursing, Gjøvik University College, Gjøvik, Norway
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Miguel-Dasit A, Martí-Bonmatí L, Sanfeliu P. Bibliometric analysis of the Spanish MR radiological production (2001-2007). Eur J Radiol 2008; 67:384-91. [PMID: 18424037 DOI: 10.1016/j.ejrad.2008.02.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2008] [Accepted: 02/27/2008] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the number and characteristics of papers on MR imaging written by radiologists in Spain and published in 2001-2007 Medline-indexed journals, including a comparison with the MR research output from German radiological departments. MATERIALS AND METHODS Specific search profiles were devised to retrieve items from the Medline database. Relationship with the topic and major thematic areas of the articles, publication year, journal, language of publication, and mean impact factors were analyzed. Spanish and the German institutions with the highest MR productivity were identified. Also, the number of articles from Spain and Germany published in their respective official journals (Radiología and ROFO) was recorded. RESULTS There were 332 Spanish articles published in 101 different journals. The higher number of papers was published in Spanish radiology and non-radiology journals (n=105, 32%, mean IF: 0.191). The journal with the higher number of articles was Radiología (n=51, 15%). "Neuroradiology" was the most frequent topic (n=139, 42%). The Spanish productivity on MR imaging was yearly stable (p=0.67), with the higher percentage of papers (17%) published in 2006. The topic with the higher IF was "neuroradiology" (IF: 2.317). There were no yearly variations for the three major thematic areas ("Neuro imaging": p=0.64; "Body imaging": p=0.91; and "Non-clinical miscellanea": p=0.46). The highest number of MR publications was found in two Spanish institutions (Dr. Peset University Hospital and Vall d'Hebron Hospital) (both, n=28, 8%). In comparison, there were 1681 articles on MR imaging from Germany, having the two most productive institutions more than 150 papers in this period (University Hospital Essen and Eberhard-Karls University of Tübingen). The adjusted number of articles per million populations was 20.4 for Germany and 8.1 for Spain. A total of 395 (23%) articles originating from Germany were published in the official German radiological journal ROFO. The percentage of articles originating from Spain and Germany published in their respective official journals was statistically different. DISCUSSION Spanish radiologists published approximately two-third of their MR articles in several non-Spanish journals, while the official Spanish radiological journal Radiología leads the ranking of Spanish journals. Spanish radiologists are mainly active in the "neuroradiology" topic. The Spanish healthcare sector is the most active. German institutions published more in their official journal ROFO.
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