1
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Shrestha R, Tulk AH, Shah AS, Buckner-Petty SA, Long JR, Fox MG. Does MRI alter management in patients 60 years and older with chronic knee pain: correlation with radiographs and clinical parameters. Skeletal Radiol 2024:10.1007/s00256-024-04691-7. [PMID: 38683469 DOI: 10.1007/s00256-024-04691-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/06/2024] [Accepted: 04/18/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVE To determine if MRI altered management in patients ≥ 60 years old with chronic knee pain. MATERIALS AND METHODS Consecutive patients ≥ 60 years old with knee MRI and radiographs within 90 days were included. Exclusion criteria included mass/malignancy, recent trauma, and infection. Standing AP and PA flexion views were evaluated using Kellgren-Lawrence (KL) and International Knee Documentation Committee (IKDC) scales. Pertinent clinical history was recorded. MRIs were considered to alter management if subchondral fracture was identified or subsequent arthroscopy was performed due to an MRI finding. RESULTS Eighty-five knee MRI/radiograph exams were reviewed; mean 68.2 years (60-88), 47:38 F:M. Twenty knee MRIs (24%) had either a subchondral fracture (n = 9) or meniscal tear (n = 11) prompting arthroscopy. On PA flexion view, 0/20 of these studies had KL grade 4 and 70% (14/20) had KL grade 0-1 compared to the remaining MRIs having 15.4% (10/65) KL grade 4 and 38.5% (25/65) KL grade 0-1 (p = 0.03). A 10-pack-year tobacco history, 38% vs 18%, was associated with a subchondral fracture or arthroscopy (p = 0.06). Subchondral fractures were more prevalent in older patients (mean 72.4 vs 67.7 years; p = 0.03). CONCLUSION In patients ≥ 60 years old with chronic knee pain, MRI altered management in ~ 24% of cases; 70% in patients with KL grade 0-1, and none in patients with KL grade 4. MRI may benefit older patients with minimal osteoarthritis but not those with end-stage disease. Patients with ≥ 10 pack years of smoking may also benefit from MRI.
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2
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Liu K, Li X, Weng Q, Wang Y, Wei J, Zeng C, Lei G, Jiang T. Diagnostic Accuracy of Ultrasound for Assessment of Synovial Abnormalities Among Patients With Knee Pain: A Meta-Analysis. Arthritis Care Res (Hoboken) 2024; 76:295-303. [PMID: 37522287 DOI: 10.1002/acr.25205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 06/20/2023] [Accepted: 07/18/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE Synovial abnormalities, which are modifiable treatment targets for knee pain, affect ~25% of adults. Ultrasound is a safe, inexpensive, and easily accessible imaging modality for assessing synovial abnormalities, but its diagnostic accuracy is still controversial. We conducted a meta-analysis by comparing ultrasound with the "reference standard" method, ie, magnetic resonance imaging (MRI), in assessing synovial abnormalities among patients with knee pain. METHODS PubMed, Embase, and Web of Science were searched from inception to January 7, 2022, to retrieve studies including patients with knee pain for evaluating 1) the diagnostic accuracy of ultrasound versus MRI for synovial abnormalities (synovitis and synovial effusion) and 2) the correlations of synovial abnormalities assessed by ultrasound and MRI. The summary of diagnostic accuracy was analyzed using the bivariate model, and the correlation coefficients were pooled using the random effects model. RESULTS Fourteen studies were included, representing a total of 755 patients. The pooled sensitivity, specificity, and area under the curve were 0.88 (95% confidence interval [95% CI] 0.65-0.96), 0.70 (95% CI 0.51-0.84), and 0.81 (95% CI 0.77-0.84) for synovitis and 0.90 (95% CI 0.81-0.95), 0.86 (95% CI 0.77-0.92), and 0.94 (95% CI 0.91-0.96) for synovial effusion, respectively. Strong correlations between ultrasound- and MRI-diagnosed synovitis (r = 0.64, 95% CI 0.56-0.71) and synovial effusion (r = 0.63, 95% CI 0.52-0.73) were observed. CONCLUSION Ultrasound demonstrated a promising accuracy in detecting synovial abnormalities among patients with knee pain. The use of ultrasound provides equivalent synovial information to MRI but is less expensive and more accessible. Therefore, it is recommended as an adjuvant for managing patients with knee pain during diagnostic strategy and individualized treatment decision-making.
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Affiliation(s)
- Ke Liu
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xiaoxiao Li
- Hunan Key Laboratory of Joint Degeneration and Injury, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qianlin Weng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yilun Wang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Joint Degeneration and Injury, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jie Wei
- Health Management Center, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Chao Zeng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Joint Degeneration and Injury, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Guanghua Lei
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Key Laboratory of Joint Degeneration and Injury, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ting Jiang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Department of Ultrasonography, Xiangya Hospital, Central South University, Changsha, Hunan, China
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3
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Romero A, Lynch D, Johnson E, Zhu X, Kirkpatrick J. MRI order appropriateness for chronic neck pain: Comparison of ordering practices and treatment outcomes for primary care physicians and specialists. J Orthop Res 2024; 42:425-433. [PMID: 37525551 DOI: 10.1002/jor.25669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 07/06/2023] [Accepted: 07/26/2023] [Indexed: 08/02/2023]
Abstract
Chronic neck pain is a common reason for doctor visits in the United States. This diagnosis can be evaluated through patient history, physical examination, and judicious use of radiographs. However, possible inappropriate magnetic resonance imaging (MRI) ordering persists. We hypothesized that no difference in ordering practices, ordering appropriateness, and subsequent intervention would be appreciated regarding physician specialty, location, patient characteristics, and history and physical exam findings. A multisite retrospective review of cervical spine MRI between 2014 and 2018 was performed. A total of 332 patients were included. Statistical analysis was used to assess MRI order appropriateness, detail of history and physical exam findings, and intervention decision-making among different specialties. If significant differences were found, multiple linear regression was performed to evaluate the association of MRI order appropriateness regarding physician specialty, location, patient characteristics and history, and physical exam findings. The significance level for all tests was set at <0.05 Orthopedic surgeons ordered MRIs most appropriately with an average American College of Radiology (ACR) score of 8.4 (p < 0.005). Orthopedic surgeons had more comprehensive physical exams as compared to the remaining specialties. The decision for intervention did not vary by physician specialty or ACR score, except for patients of pain medicine physicians who received pain management (p = 0.000). Orthopedic surgeons utilize MRI most appropriately and have more comprehensive physical exams. These findings suggest a need for increased physician education on what indicates an appropriate MRI order to improve the use of resources and further protect patient risk-benefit profiles. Further research elucidating factors to minimize negative findings in "appropriate" MRIs is indicated. Clinical significance: More detailed physical exams may lead to more appropriately ordered MRIs, subsequently resulting in surgery or procedures being performed when appropriately indicated. This suggests the need for increased physician education on when MRI ordering is appropriate for chronic neck pain to improve the use of resources and further protect patient risk-benefit profiles.
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Affiliation(s)
- Andrew Romero
- Department of Orthopaedic Surgery, University of Central Florida/HCA Healthcare GME Consortium, Ocala, Florida, USA
| | - Daniel Lynch
- Department of Orthopaedic Surgery, University of Central Florida/HCA Healthcare GME Consortium, Ocala, Florida, USA
| | - Evan Johnson
- Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, Memphis, Tennessee, USA
| | - Xiang Zhu
- Department of Orthopaedic Surgery, University of Central Florida College of Medicine, Orlando, Florida, USA
| | - John Kirkpatrick
- Department of Orthopaedic Surgery, Orlando VA Healthcare System, Orlando, Florida, USA
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4
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Stanley AL, Edwards TC, Jaere MD, Lex JR, Jones GG. An automated, web-based triage tool may optimise referral pathways in elective orthopaedic surgery: A proof-of-concept study. Digit Health 2023; 9:20552076231152177. [PMID: 36762026 PMCID: PMC9903022 DOI: 10.1177/20552076231152177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 01/03/2023] [Indexed: 01/28/2023] Open
Abstract
Introduction Knee pain is caused by various pathologies, making evaluation in primary-care challenging. Subsequently, an over-reliance on imaging, such as radiographs and MRI exists. Electronic-triage tools represent an innovative solution to this problem. The aims of this study were to establish the magnitude of unnecessary knee imaging prior to orthopaedic surgeon referral, and ascertain whether an e-triage tool outperforms existing clinical pathways to recommend correct imaging. Methods Patients ≥18 years presenting with knee pain treated with arthroscopy or arthroplasty at a single academic hospital between 2015 and 2020 were retrospectively identified. The timing and appropriateness of imaging were assessed according to national guidelines, and classified as 'necessary', 'unnecessary' or 'required MRI'. Based on an eDelphi consensus study, a symptom-based e-triage tool was developed and piloted to preliminarily diagnose five common knee pathologies and suggest appropriate imaging. Results 1462 patients were identified. 17.2% (n = 132) of arthroplasty patients received an 'unnecessary MRI', 27.6% (n = 192) of arthroscopy patients did not have a 'necessary MRI', requiring follow-up. Forty-one patients trialled the e-triage pilot (mean age: 58.4 years, 58.5% female). Preliminary diagnoses were available for 33 patients. The e-triage tool correctly identified three of the four knee pathologies (one pathology did not present). 79.2% (n = 19) of participants would use the tool again. Conclusion A substantial number of knee pain patients receive incorrect imaging, incurring delays and unnecessary costs. A symptom-based e-triage tool was developed, with promising performance and user feedback. With refinement using larger datasets, this tool has the potential to improve wait-times, referral quality and reduce cost.
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Affiliation(s)
| | - Thomas C. Edwards
- Faculty of Medicine, Imperial College London, London, UK,MSk Lab, Imperial College London, London, UK
| | - Martin D. Jaere
- Faculty of Medicine, Imperial College London, London, UK,MSk Lab, Imperial College London, London, UK
| | - Johnathan R. Lex
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Gareth G. Jones
- Faculty of Medicine, Imperial College London, London, UK,MSk Lab, Imperial College London, London, UK,Gareth G. Jones, MSk Lab, Sir Michael Uren Hub, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK.
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5
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Mulcaire-Jones E, Barker AM, Beck JP, Lawrence P, Cannon GW, Battistone MJ. Impact of a Musculoskeletal "Mini-Residency" Professional Development Program on Knee Magnetic Resonance Imaging Orders by Primary Care Providers. J Clin Rheumatol 2022; 28:245-249. [PMID: 35358112 PMCID: PMC9336568 DOI: 10.1097/rhu.0000000000001842] [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] [Indexed: 11/25/2022]
Abstract
BACKGROUND The US Department of Veterans Affairs has created a portfolio of educational programs to train primary care providers (PCPs) in the evaluation and management of common musculoskeletal (MSK) conditions. Appropriate resource utilization for evaluation of knee pain, including limiting unnecessary magnetic resonance imaging (MRI) studies, is an important theme of these initiatives. The objective of this study was to report the utilization of knee MRI by PCP providers before and after the MSK education program and to determine the appropriateness of these MRI orders. METHODS Twenty-six PCPs participated in the MSK Mini-Residency educational program held in Salt Lake City between April 2012 and October 2014. Knee MRI orders submitted by these providers 12 months before and 12 months after their participation were reviewed. Magnetic resonance imaging orders were categorized as "inappropriate," "probably inappropriate," or "possibly appropriate," based on accepted guidelines for knee MRI utilization. Differences in the numbers of precourse and postcourse MRI orders for each of these categories were compared using Student t test. RESULTS Following our program, MRI orders decreased from 130 (precourse) to 93 (postcourse), a reduction of 28% ( p = 0.04). This reduction was observed entirely within the "inappropriate" and "probably inappropriate" categories; the number of orders categorized as "possibly appropriate" increased, but not significantly. CONCLUSIONS The MSK Mini-Residency training program was a successful educational intervention and was associated with a reduction in inappropriate knee MRI utilization for some participants, while keeping appropriate MRI utilization stable.
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Affiliation(s)
| | - Andrea M. Barker
- Veterans Affairs Salt Lake City Health Care System
- Departments of Family and Preventive Medicine
| | | | | | - Grant W. Cannon
- Veterans Affairs Salt Lake City Health Care System
- Division of Rheumatology, University of Utah, Salt Lake City, UT
| | - Michael J. Battistone
- Veterans Affairs Salt Lake City Health Care System
- Division of Rheumatology, University of Utah, Salt Lake City, UT
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Arliani GG, Vergara JM, Mesquita Júnior ID, Oliveira VO, Lara PHS, Ferreira GF. Protocolo de solicitação de ressonância magnética do joelho em pacientes idosos com suspeita de osteoartrose: Redução da solicitação de exames e o impacto na conduta e no diagnóstico. Rev Bras Ortop 2022; 57:409-414. [PMID: 35785128 PMCID: PMC9246541 DOI: 10.1055/s-0040-1722576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 10/02/2020] [Indexed: 11/12/2022] Open
Abstract
Objective
To develop an evidence-based protocol to guide magnetic resonance imaging (MRI) requests in elderly patients with suspected knee osteoarthrosis and to evaluate its effectiveness after implementation.
Methods
The institutional protocol was developed after reviewing the literature during the first semester of 2018. The control group was defined as patients cared for in the first semester of 2018, before the implementation/dissemination of the institutional protocol, and the study group was composed by patients cared for during the second semester of 2018 after the standardization of MRI requests for suspected knee osteoarthrosis.
Results
Our sample included 826 patients undergoing knee MRI, with a mean age of 69.3 years. Protocol implementation decreased MRI requests and increased radiograph requests (
p
< 0.001). After the implementation of the protocol, the MRI changed the diagnosis or treatment in only 11.2% of the cases.
Conclusion
Protocol implementation resulted in a 47.5% reduction in the number of requests for knee MRI, with most (89%) patients with alteration in diagnosis or treatment. Level of evidence: case-control study (IIIB).
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Affiliation(s)
| | - Juliana Munhoz Vergara
- Departamento de Ortopedia e Traumatologia, Instituto Prevent Senior, São Paulo, SP, Brasil
| | | | - Victor Otávio Oliveira
- Departamento de Ortopedia e Traumatologia, Instituto Prevent Senior, São Paulo, SP, Brasil
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7
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Mohammed HT, Payson LA, Gillan C, Mathews J, Diep J, Sadri-Gerrior J, Hamann K, Brodrecht D. 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. J Eval Clin Pract 2022; 28:247-259. [PMID: 34514681 DOI: 10.1111/jep.13617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
| | - Lori-Anne Payson
- eServices Program, eHealth Centre of Excellence, Kitchener, Ontario, Canada.,Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Caitlin Gillan
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Jisla Mathews
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Justin Diep
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jessica Sadri-Gerrior
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Karyssa Hamann
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Diana Brodrecht
- Department of Diagnostic Imaging, Grand River Hospital, Kitchener, Ontario, Canada
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8
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de Ga K, Noblett D, Bateni C. Ankle MRI and preceding radiographs: an evaluation of physician ordering practices. Skeletal Radiol 2022; 51:2263-2268. [PMID: 35666294 PMCID: PMC9560948 DOI: 10.1007/s00256-022-04084-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 05/25/2022] [Accepted: 05/25/2022] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Kristopher de Ga
- Department of Radiology, University of California Davis Medical Center, 4860 Y Street, Suite 3100, Sacramento, CA 95817 USA
| | - Dylan Noblett
- Department of Radiology, University of California Davis Medical Center, 4860 Y Street, Suite 3100, Sacramento, CA 95817 USA
| | - Cyrus Bateni
- Department of Radiology, University of California Davis Medical Center, 4860 Y Street, Suite 3100, Sacramento, CA 95817 USA
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9
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Gamage PJ, Seker S, Orchard J, Humphries D, Fitzgerald K, Fitzpatrick J. Insights into the complexity of presentation and management of patients: the Sport and Exercise Physician's perspective. BMJ Open Sport Exerc Med 2021; 7:e001228. [PMID: 34925878 PMCID: PMC8628332 DOI: 10.1136/bmjsem-2021-001228] [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] [Accepted: 11/08/2021] [Indexed: 11/21/2022] Open
Abstract
Objectives Sport and Exercise Physicians represent a relatively new specialty focusing on exercise in complex diseases including musculoskeletal diseases. Our objective was to describe the characteristics, type and complexity of patient presentations, their management strategies and referral information in Australian practice. Methods A cross-sectional study including a cohort of 11 senior Sport and Exercise Physicians in Australia studied all new patient consultations within an 8-week period. Data were analysed relating to presentation, referral source, follow-up referrals, and patient management strategies. Results Data from 419 patients were recorded. The majority, 97% (n=406), had musculoskeletal conditions, 53% (n=222) had one or more associated comorbidities and 47% (n=195) had ongoing symptoms for >12 months. Most patients, 82% (n=355), were referred by general practitioners. Prior consultations included physiotherapy 72% (n=301) and orthopaedic 20% (n=85). A multidisciplinary network of referrals from Sport and Exercise Physicians was observed, including 210 referrals to 9 allied health specialities and 61 referrals to 17 medical specialities. Over 74% (n=311) of patients received exercise-based intervention as part of the treatment plan, including 57% (n=240) physician managed exercise interventions. Conclusion Our work shines a light on the nature and complexity of the role of Sport and Exercise Physicians in an Australian practice context. Findings will assist in implementing measures to promote patient care at the community level in managing musculoskeletal conditions. Sport and exercise medicine stakeholders and government policy makers can use this information in developing appropriate programmes to support patients and create integrated sport and exercise medicine services for the community.
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Affiliation(s)
- Prasanna J Gamage
- Australasian College of Sport and Exercise Physicians, Melbourne, Victoria, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Saran Seker
- Australasian College of Sport and Exercise Physicians, Melbourne, Victoria, Australia
| | - Jessica Orchard
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - David Humphries
- Australasian College of Sport and Exercise Physicians, Melbourne, Victoria, Australia.,School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Kylie Fitzgerald
- Australasian College of Sport and Exercise Physicians, Melbourne, Victoria, Australia.,School of Health & Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
| | - Jane Fitzpatrick
- Australasian College of Sport and Exercise Physicians, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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10
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Naqvi SR, Beavis RC, Mondal P, Bryce R, Leswick DA. Incidence Rates of Surgery After Knee MRI: Association According to Referring Physician Type and Patient's Age and Sex. Orthop J Sports Med 2021; 9:23259671211052560. [PMID: 34790833 PMCID: PMC8591651 DOI: 10.1177/23259671211052560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/04/2021] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Syed R Naqvi
- Department of Medical Imaging, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - R Cole Beavis
- Division of Orthopedics, Department of Surgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Prosanta Mondal
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Rhonda Bryce
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - David A Leswick
- Department of Medical Imaging, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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11
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Ahmed I, Moiz H, Carlos W, Edwin C, Staniszewska S, Parsons N, Price A, Hutchinson C, Metcalfe A. The use of magnetic resonance imaging (MRI) of the knee in current clinical practice: A retrospective evaluation of the MRI reports within a large NHS trust. Knee 2021; 29:557-563. [PMID: 33774589 DOI: 10.1016/j.knee.2021.02.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 02/08/2021] [Accepted: 02/22/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is one of the most widely used investigations for knee pain as it provides detailed assessment of the bone and soft tissues. The aim of this study is to report the frequency of each diagnosis identified on MRI scans of the knee and explore the relationship between MRI results and onward treatment. METHODS Consecutive MRI reports from a large NHS trust performed in 2017 were included in this study. The hospital electronic system was consulted to identify whether a patient underwent x-ray prior to the MRI, attended an outpatient appointment or underwent surgery. RESULTS 4466 MRI knees were performed in 2017 with 71.2% requested in primary care and 28.1% requested in secondary care. The most common diagnosis was signs of arthritis (55.2%), followed by meniscal tears (42.8%) and ACL tears (8.3%). 49.4% of patients who had an MRI attended outpatients and 15.6% underwent surgery. The rate of knee surgery was significantly higher for patients who had their scans requested in secondary care (32.9% vs 8.9%, p < 0.001). CONCLUSION The rate of surgical intervention following MRI is low and given these results it seems unlikely that the scan changes practice in most cases. The rate of surgery and outpatient follow up was significantly higher in scans requested by secondary care. We urge clinicians avoid wasteful use of MRI and recommend the use of plain radiography prior to MRI where arthritis may be present.
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Affiliation(s)
- Imran Ahmed
- Warwick Clinical Trials Unit, Clinical Sciences and Research Laboratory, University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom.
| | - Haseeb Moiz
- Warwick Clinical Trials Unit, Clinical Sciences and Research Laboratory, University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom.
| | - William Carlos
- Warwick Clinical Trials Unit, Clinical Sciences and Research Laboratory, University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom.
| | - Claire Edwin
- Warwick Clinical Trials Unit, Clinical Sciences and Research Laboratory, University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom.
| | - Sophie Staniszewska
- Warwick Clinical Trials Unit, Clinical Sciences and Research Laboratory, University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom.
| | - Nick Parsons
- Warwick Clinical Trials Unit, Clinical Sciences and Research Laboratory, University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom.
| | - Andrew Price
- Warwick Clinical Trials Unit, Clinical Sciences and Research Laboratory, University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom.
| | - Charles Hutchinson
- Warwick Clinical Trials Unit, Clinical Sciences and Research Laboratory, University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom.
| | - Andrew Metcalfe
- Warwick Clinical Trials Unit, Clinical Sciences and Research Laboratory, University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom.
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Kara S, Smart A, Officer T, Dassanayake C, Clark P, Smit A, Cavadino A. Guidelines, training and quality assurance: influence on general practitioner MRI referral quality. J Prim Health Care 2020; 11:235-242. [PMID: 32171376 DOI: 10.1071/hc19034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
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.
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Affiliation(s)
- Stephen Kara
- ProCare PHO, Level 2/110 Stanley St, Grafton, Auckland 1143, New Zealand; and Corresponding author.
| | - Alexandra Smart
- ProCare PHO, Level 2/110 Stanley St, Grafton, Auckland 1143, New Zealand
| | - Tara Officer
- Health Services Research Centre, Victoria University of Wellington 6140, New Zealand
| | - Chan Dassanayake
- Karori Medical Centre, 11 Parkvale Rd, Karori, Wellington 6012, New Zealand
| | - Phil Clark
- Mercy Radiology, 98 Mountain Rd, Epsom, Auckland 1149, New Zealand
| | - Amy Smit
- School of Medical and Health Sciences, University of Auckland, Auckland 1142, New Zealand
| | - Alana Cavadino
- Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland 1142, New Zealand
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Battistone MJ, Barker AM, Durning SJ. Interprofessional Musculoskeletal Education: A Review of National Initiatives from the Department of Veterans Affairs. Rheum Dis Clin North Am 2019; 46:135-153. [PMID: 31757281 DOI: 10.1016/j.rdc.2019.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This article reviews several national programs in musculoskeletal education initiated by the Department of Veterans Affairs over the past decade. These programs have become sustained interprofessional opportunities for learners across disciplines and along the continuum of health professions education (HPE) and training pathways. This article also describes opportunities for leaders in rheumatology and other HPE programs to join these efforts and to collaborate in the scholarship that will be necessary in constructing educational programs fit for the purpose of ensuring a well-trained, competent workforce of health care providers.
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Affiliation(s)
- Michael J Battistone
- Division of Rheumatology, Department of Medicine, Center of Excellence in Musculoskeletal Care and Education, George E. Wahlen Veterans Affairs Salt City Health Care System, University of Utah Health Sciences Center, Salt Lake City VA Medical Center, 11/E, 500 Foothill Drive, Salt Lake City, UT 84148, USA.
| | - Andrea M Barker
- Department of Family and Preventive Medicine, Center of Excellence in Musculoskeletal Care and Education, George E. Wahlen Veterans Affairs Salt City Health Care System, University of Utah Health Sciences Center, Salt Lake City VA Medical Center, 11/E, 500 Foothill Drive, Salt Lake City, UT 84148, USA
| | - Steven J Durning
- Graduate Programs in Health Professions Education, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814-4712, USA
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Knee MRI Primary Care Ordering Practices for Nontraumatic Knee Pain: Compliance With ACR Appropriateness Criteria and Its Effect on Clinical Management. J Am Coll Radiol 2019; 16:289-294. [DOI: 10.1016/j.jacr.2018.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 08/27/2018] [Accepted: 10/11/2018] [Indexed: 12/31/2022]
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Improving Effective Magnetic Resonance Imaging (MRI) Application in Soft Tissue Wrist Injury. J Am Board Fam Med 2018; 31:795-804. [PMID: 30201676 PMCID: PMC6341471 DOI: 10.3122/jabfm.2018.05.170423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 06/01/2018] [Accepted: 06/05/2018] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Magnetic resonance imaging (MRI) for soft-tissue wrist injury may be overprescribed, contributing to ineffective health care resource use. We aimed to discern predictive factors that may improve MRI's application in soft-tissue wrist injury. METHODS We conducted a retrospective chart review of adults who underwent MRIs for possible soft-tissue wrist injury between June 2009 and June 2014. Clinical data and treatment recommendations before and after MRI were analyzed. If the MRI-directed treatment recommendation was different from before MRI, the MRI was noted to have influenced the patient's treatment (Impact MRI). RESULTS Among 140 MRI scans, 39 (28%) impacted treatment recommendation. Twenty-six Impact MRIs were ordered by hand surgeons, whereas 13 were ordered by referring physicians (P = .001). More Impact MRIs were found when an MRI was ordered for patients younger than 36 years (P = .01), within 6 weeks of symptom onset (P = .03), to question a specific anatomic injury (P = .0001), or by a board-certified hand surgeon (P = .001). Adjusting for other covariates, these 4 clinical factors were identified as independent predictive factors to Impact MRIs. CONCLUSIONS MRIs for soft-tissue wrist injuries may more likely change management when the patient is younger, ordered within 6 weeks of symptom onset, and prescribed with a specific differential diagnosis. Referral to a hand surgeon should be considered before wrist MRI for the following patients: history of hand surgery/trauma, older than 36 years likely due to confounding chronic wrist changes, symptomatic for more than 6 weeks, and without clear differential diagnoses for the symptoms.
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Post-traumatic knee MRI findings and associations with patient, trauma, and clinical characteristics: a subgroup analysis in primary care in the Netherlands. Br J Gen Pract 2018; 67:e851-e858. [PMID: 29158244 DOI: 10.3399/bjgp17x693653] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 07/06/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The added value of magnetic resonance imaging (MRI) in primary care is still being debated. A high diagnostic yield can be expected in young and active patients with post-traumatic knee complaints. AIM To determine the frequency of MRI abnormalities in young and active patients (aged 18-45 years) and the associations with patient, trauma, and clinical characteristics. DESIGN AND SETTING A subgroup analysis of 174 patients, aged 18-45 years with knee trauma of <6 months, allocated to MRI in a randomised controlled trial on the yield of MRI in primary care. Patients were recruited by 150 GPs in the Netherlands from October 2012 to November 2015. METHOD Associations were expressed using mean differences, odds ratio (OR) and predictive values. RESULTS Sixty-seven out of 174 patients (39%) had a positive MRI finding, predominantly anterior cruciate ligament (ACL) ruptures (22%) and/or traumatic meniscal tears (15%). Patients with a pre-existing musculoskeletal comorbidity had a two-fold lower prevalence of positive MRI findings (21%), OR 3.0 (95% confidence interval [CI] = 1.3 to 7.0). A 'sports related trauma' showed the highest OR of 4.6 (95% CI = 2.2 to 9.3) for a positive MRI finding. Clinical scores were statistically, significantly worse in patients with positive MRI findings, with mean differences ranging from 10 to 20%. Furthermore, increasing duration of complaints was correlated with decreasing prevalence rates of positive MRI findings. Overall, a popping sound and direct swelling showed the highest positive predictive value of 65% for the presence of positive MRI findings. CONCLUSION The results from this study enable a preselection of patients to increase the diagnostic yield of MRI in primary care.
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van Oudenaarde K, Swart NM, Bloem JL, Bierma-Zeinstra SMA, Algra PR, Bindels PJE, Koes BW, Nelissen RGHH, Verhaar JAN, Luijsterburg PAJ, Reijnierse M, van den Hout WB. General Practitioners Referring Adults to MR Imaging for Knee Pain: A Randomized Controlled Trial to Assess Cost-effectiveness. Radiology 2018; 288:170-176. [PMID: 29664339 DOI: 10.1148/radiol.2018171383] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Purpose To determine the cost-effectiveness of early referral by the general practitioner for magnetic resonance (MR) imaging compared with usual care alone in patients aged 18-45 years with traumatic knee symptoms. Materials and Methods Cost-utility analysis was performed parallel to a prospective multicenter randomized controlled trial in Dutch general practice. A total of 356 patients with traumatic knee symptoms were included from November 2012 to December 2015 (mean age, 33 years ± 8 [standard deviation]; 222 men [62%]). Patients were randomly assigned to usual care (n = 177; MR imaging was not performed, but patients were referred to an orthopedic surgeon when conservative treatment was unsatisfactory) or MR imaging (n = 179) within 2 weeks after injury. Main outcome measures were quality-adjusted life years (QALYs) and costs from a healthcare and societal perspective. Multiple imputation was used for missing data. The Student t test was used to assess differences in mean QALYs, costs, and net benefits. Results Mean QALYs were 0.888 in the MR imaging group and 0.899 in the usual care group (P = .255). Healthcare costs per patient were higher in the MR imaging group (€1109) than in the usual care group (€837) (P = .050), mainly due to higher costs for MR imaging, with no reduction in the number of referrals to an orthopedic surgeon in the MR imaging group. Conclusion MR imaging referral by the general practitioner was not cost-effective in patients with traumatic knee symptoms; in fact, MR imaging led to more healthcare costs, without an improvement in health outcomes.
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Affiliation(s)
- Kim van Oudenaarde
- From the Departments of Radiology (K.v.O., J.L.B., M.R.), Orthopaedics (R.G.H.H.N.), and Medical Decision Making (W.B.v.d.H.), Leiden University Medical Center, PO Box 9600, 2300 RC, Postal Zone C2-S, Leiden, the Netherlands; Departments of General Practice (N.M.S., P.J.E.B., B.W.K., P.A.J.L.) and Orthopaedics (S.M.A.B., J.A.N.V.), Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; and Department of Radiology, Northwest Clinics, Alkmaar, the Netherlands (P.R.A.)
| | - Nynke M Swart
- From the Departments of Radiology (K.v.O., J.L.B., M.R.), Orthopaedics (R.G.H.H.N.), and Medical Decision Making (W.B.v.d.H.), Leiden University Medical Center, PO Box 9600, 2300 RC, Postal Zone C2-S, Leiden, the Netherlands; Departments of General Practice (N.M.S., P.J.E.B., B.W.K., P.A.J.L.) and Orthopaedics (S.M.A.B., J.A.N.V.), Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; and Department of Radiology, Northwest Clinics, Alkmaar, the Netherlands (P.R.A.)
| | - Johan L Bloem
- From the Departments of Radiology (K.v.O., J.L.B., M.R.), Orthopaedics (R.G.H.H.N.), and Medical Decision Making (W.B.v.d.H.), Leiden University Medical Center, PO Box 9600, 2300 RC, Postal Zone C2-S, Leiden, the Netherlands; Departments of General Practice (N.M.S., P.J.E.B., B.W.K., P.A.J.L.) and Orthopaedics (S.M.A.B., J.A.N.V.), Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; and Department of Radiology, Northwest Clinics, Alkmaar, the Netherlands (P.R.A.)
| | - Sita M A Bierma-Zeinstra
- From the Departments of Radiology (K.v.O., J.L.B., M.R.), Orthopaedics (R.G.H.H.N.), and Medical Decision Making (W.B.v.d.H.), Leiden University Medical Center, PO Box 9600, 2300 RC, Postal Zone C2-S, Leiden, the Netherlands; Departments of General Practice (N.M.S., P.J.E.B., B.W.K., P.A.J.L.) and Orthopaedics (S.M.A.B., J.A.N.V.), Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; and Department of Radiology, Northwest Clinics, Alkmaar, the Netherlands (P.R.A.)
| | - Paul R Algra
- From the Departments of Radiology (K.v.O., J.L.B., M.R.), Orthopaedics (R.G.H.H.N.), and Medical Decision Making (W.B.v.d.H.), Leiden University Medical Center, PO Box 9600, 2300 RC, Postal Zone C2-S, Leiden, the Netherlands; Departments of General Practice (N.M.S., P.J.E.B., B.W.K., P.A.J.L.) and Orthopaedics (S.M.A.B., J.A.N.V.), Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; and Department of Radiology, Northwest Clinics, Alkmaar, the Netherlands (P.R.A.)
| | - Patrick J E Bindels
- From the Departments of Radiology (K.v.O., J.L.B., M.R.), Orthopaedics (R.G.H.H.N.), and Medical Decision Making (W.B.v.d.H.), Leiden University Medical Center, PO Box 9600, 2300 RC, Postal Zone C2-S, Leiden, the Netherlands; Departments of General Practice (N.M.S., P.J.E.B., B.W.K., P.A.J.L.) and Orthopaedics (S.M.A.B., J.A.N.V.), Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; and Department of Radiology, Northwest Clinics, Alkmaar, the Netherlands (P.R.A.)
| | - Bart W Koes
- From the Departments of Radiology (K.v.O., J.L.B., M.R.), Orthopaedics (R.G.H.H.N.), and Medical Decision Making (W.B.v.d.H.), Leiden University Medical Center, PO Box 9600, 2300 RC, Postal Zone C2-S, Leiden, the Netherlands; Departments of General Practice (N.M.S., P.J.E.B., B.W.K., P.A.J.L.) and Orthopaedics (S.M.A.B., J.A.N.V.), Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; and Department of Radiology, Northwest Clinics, Alkmaar, the Netherlands (P.R.A.)
| | - Rob G H H Nelissen
- From the Departments of Radiology (K.v.O., J.L.B., M.R.), Orthopaedics (R.G.H.H.N.), and Medical Decision Making (W.B.v.d.H.), Leiden University Medical Center, PO Box 9600, 2300 RC, Postal Zone C2-S, Leiden, the Netherlands; Departments of General Practice (N.M.S., P.J.E.B., B.W.K., P.A.J.L.) and Orthopaedics (S.M.A.B., J.A.N.V.), Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; and Department of Radiology, Northwest Clinics, Alkmaar, the Netherlands (P.R.A.)
| | - Jan A N Verhaar
- From the Departments of Radiology (K.v.O., J.L.B., M.R.), Orthopaedics (R.G.H.H.N.), and Medical Decision Making (W.B.v.d.H.), Leiden University Medical Center, PO Box 9600, 2300 RC, Postal Zone C2-S, Leiden, the Netherlands; Departments of General Practice (N.M.S., P.J.E.B., B.W.K., P.A.J.L.) and Orthopaedics (S.M.A.B., J.A.N.V.), Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; and Department of Radiology, Northwest Clinics, Alkmaar, the Netherlands (P.R.A.)
| | - Pim A J Luijsterburg
- From the Departments of Radiology (K.v.O., J.L.B., M.R.), Orthopaedics (R.G.H.H.N.), and Medical Decision Making (W.B.v.d.H.), Leiden University Medical Center, PO Box 9600, 2300 RC, Postal Zone C2-S, Leiden, the Netherlands; Departments of General Practice (N.M.S., P.J.E.B., B.W.K., P.A.J.L.) and Orthopaedics (S.M.A.B., J.A.N.V.), Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; and Department of Radiology, Northwest Clinics, Alkmaar, the Netherlands (P.R.A.)
| | - Monique Reijnierse
- From the Departments of Radiology (K.v.O., J.L.B., M.R.), Orthopaedics (R.G.H.H.N.), and Medical Decision Making (W.B.v.d.H.), Leiden University Medical Center, PO Box 9600, 2300 RC, Postal Zone C2-S, Leiden, the Netherlands; Departments of General Practice (N.M.S., P.J.E.B., B.W.K., P.A.J.L.) and Orthopaedics (S.M.A.B., J.A.N.V.), Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; and Department of Radiology, Northwest Clinics, Alkmaar, the Netherlands (P.R.A.)
| | - Wilbert B van den Hout
- From the Departments of Radiology (K.v.O., J.L.B., M.R.), Orthopaedics (R.G.H.H.N.), and Medical Decision Making (W.B.v.d.H.), Leiden University Medical Center, PO Box 9600, 2300 RC, Postal Zone C2-S, Leiden, the Netherlands; Departments of General Practice (N.M.S., P.J.E.B., B.W.K., P.A.J.L.) and Orthopaedics (S.M.A.B., J.A.N.V.), Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; and Department of Radiology, Northwest Clinics, Alkmaar, the Netherlands (P.R.A.)
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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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Abstract
INTRODUCTION We conducted a retrospective study in patients with minimal or no radiographically evident knee osteoarthritis to determine whether presenting signs and symptoms were predictive of knee pathology that was evident on MRI and could be treated with nonarthroplasty knee surgery or could alter nonsurgical treatment. METHODS We reviewed records of patients for whom sports medicine orthopaedic surgeons had ordered an MRI of the knee. Univariate analysis identified factors that were associated with positive MRI findings (eg, surgically treatable lesion, meniscal tear) or a finding that could alter treatment. We used multivariate logistic regression to determine independent predictors of evidence of pathology on MRI. RESULTS Of the 434 patients in the study, 281 (64.7%) had evidence of knee pathology on MRI. Acute injury, effusion, and ligamentous instability were among the independent predictors of positive MRI results. Patients with evidence of knee pathology on MRI were more likely to have undergone surgery. DISCUSSION Specific aspects of patient history and physical examination are associated with evidence of knee pathology on MRI. CONCLUSIONS In patients without osteoarthritis, positive findings on knee MRI could be associated with a number of presenting signs and symptoms, and this information could aid physicians in deciding which patients should undergo knee MRIs. Additional prospective research is needed to validate the relationships discovered in our study. LEVEL OF EVIDENCE Level III retrospective study.
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Appropriateness of the Use of Magnetic Resonance Imaging in the Diagnosis and Treatment of Wrist Soft Tissue Injury. Plast Reconstr Surg 2017; 141:410-419. [PMID: 29036028 DOI: 10.1097/prs.0000000000004023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND When diagnosing wrist soft tissue injury, the authors hypothesize that magnetic resonance imaging is used injudiciously and is associated with unnecessary cost. METHODS A retrospective review was conducted of patients aged 20 to 60 years who underwent magnetic resonance imaging for possible wrist soft tissue injury at a tertiary care center between 2009 and 2014. Treatment recommendation was classified as nonoperative, operative, or equivocal. If the magnetic resonance imaging-directed treatment recommendation differed from the pre-imaging recommendation, it was noted that the imaging influenced patient care (impact study). The cost estimate of an impact study was calculated by dividing the total studies performed by the number of studies that impacted the treatment recommendation and multiplying this value by the institutional wrist magnetic resonance imaging cost ($2246 in 2016). RESULTS One hundred forty patients were included. Magnetic resonance imaging affected treatment recommendation in 28 percent of patients. Independent predictors of impact on treatment recommendation were "question specific injury" (OR, 9.46; 95 percent CI, 3.18 to 28.16; p < 0.001) and "question scapholunate injury" (OR, 2.88; 95 percent CI, 1.21 to 6.88; p = 0.02). The only independent predictor of surgery was ordering physician (hand surgeon) (OR, 3.69; 95 percent CI, 1.34 to 10.13; p = 0.01). The cost of an impact study ordered by a non-hand surgeon versus a hand surgeon was $13,359 versus $6491, respectively. CONCLUSIONS The provider must carefully consider the pretest probability of ordering a study that will affect treatment recommendation. Injudicious screening with magnetic resonance imaging ($15,565) incurred a cost nearly seven times the cost of the one imaging scan ($2246) before impacting one treatment recommendation. In the current era of cost containment and bundled payment, diagnostic test probability must be appreciated to guide physician ordering practices.
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Ciarrapico AM, Ugenti R, Di Minco L, Santori E, Altobelli S, Coco I, D'Onofrio S, Simonetti G. Diagnostic imaging and spending review: extreme problems call for extreme measures. Radiol Med 2017; 122:288-293. [PMID: 28070842 DOI: 10.1007/s11547-016-0721-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 12/19/2016] [Indexed: 12/18/2022]
Abstract
The number of diagnostic imaging tests has increased dramatically over the past decade and about 5 billion diagnostic examinations are performed worldwide each year. According to Health Ministry, Italy, is in second place for the number of CT and MR tests per thousand inhabitants in 2014 with a score of 83.3 (only Germany has a higher score, 95.2) that is a long way off from the European average of 46.5. It has also the highest ratio of magnetic resonances per person with 24,6 machines per million inhabitants, followed only by Greece and Finland. The development of the New Health Information System (NSIS) in 2010 made uniformly readable the non-homogeneous clinical data from all the different Italian regions and permitted a detailed analysis of all diagnostic imaging within the public outpatient care setting in Italy in 2012. Despite that MRI examinations represented only the 10% of the total number of imaging tests performed, their cost reached 30% of the health-care expenditure for outpatient diagnostic imaging with an overwhelming contribution coming from musculoskeletal MR which accounted for the 73% of the performed MR tests. It is reasonable to assume that these phenomena are likely due to a lack of appropriateness in MR requests that is difficult to analyze due to an absence or invalid query on the prescriptions which together accounted for the 98.7% of cases. Taking into account the above-mentioned situation, this is possibly why the Ministry of Health decided to perform "linear cuts" in expenditure for some diagnostic examinations.
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Affiliation(s)
- Anna Micaela Ciarrapico
- Political Economy, Faculty of Medicine and Surgery, Department of Biomedicine and Prevention, University of "Tor Vergata", Viale Oxford 81, 00100, Rome, Italy
| | - Rossana Ugenti
- General Directorate of Health Professions and Human Resources of the SSN, Ministry of Health, Via Ribotta, 5, Rome, 00100, Italy
| | - Lidia Di Minco
- General Directorate of Digitization, of the Health Information System and Statistics, Ministry of Health, Via Ribotta, 5, 00100, Rome, Italy
| | - Elisabetta Santori
- General Directorate of Digitization, of the Health Information System and Statistics, Ministry of Health, Via Ribotta, 5, 00100, Rome, Italy
| | - Simone Altobelli
- Department of Diagnostic Imaging, Molecular Imaging, Interventional Radiology and Radiotherapy, Policlinico Tor Vergata, Viale Oxford 81, 00100, Rome, Italy.
| | - Irene Coco
- Department of Diagnostic Imaging, Molecular Imaging, Interventional Radiology and Radiotherapy, Policlinico Tor Vergata, Viale Oxford 81, 00100, Rome, Italy
| | - Silvia D'Onofrio
- Department of Diagnostic Imaging, Molecular Imaging, Interventional Radiology and Radiotherapy, Policlinico Tor Vergata, Viale Oxford 81, 00100, Rome, Italy
| | - Giovanni Simonetti
- Department of Biomedicine and Prevention, Policlinico Tor Vergata, Viale Oxford 81, 00100, Rome, Italy
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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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Deshpande BR, Losina E, Smith SR, Martin SD, Wright RJ, Katz JN. Association of MRI findings and expert diagnosis of symptomatic meniscal tear among middle-aged and older adults with knee pain. BMC Musculoskelet Disord 2016; 17:154. [PMID: 27067990 PMCID: PMC4827168 DOI: 10.1186/s12891-016-1010-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 04/01/2016] [Indexed: 11/23/2022] Open
Abstract
Background Our aim was to examine the association between an expert clinician’s impression of symptomatic meniscal tears and subsequent MRI in the context of middle-aged and older adults with knee pain. Methods Patients older than 45 were eligible for this IRB-approved substudy if they had knee pain, had not undergone MRI and saw one of two orthopaedic surgeons experienced in the diagnosis of meniscal tear. The surgeon rated their confidence that the patient’s symptoms were due to meniscal tear. The patient subsequently had a 1.5 or 3.0 T MRI within 6 months. We examined the association between presence of meniscal tear on MRI and the surgeon’s confidence that the knee pain was due to meniscal tear using a χ2 test for trend. Results Of 84 eligible patients, 63 % were female, with a mean age of 64 years and a mean BMI of 27. The surgeon was confident that symptoms emanated from a tear among 39 %. The prevalence of meniscal tear on MRI overall was 74 %. Among subjects whose surgeon indicated high confidence that symptoms were due to meniscal tear, the prevalence was 80 % (95 % CI 63–90 %). Similarly, the prevalence was 87 % (95 % CI 62–96 %) among those whose surgeon had medium confidence and 64 % (95 % CI 48–77 %) among those whose surgeon had low confidence (p = 0.12). Conclusion Meniscal tears were frequently found on MRI even when an expert clinician was confident that a patient’s knee symptoms were not due to a meniscal tear, indicating that providers should use MRI sparingly and cautiously to confirm or rule out the attribution of knee pain to meniscal tear. Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-1010-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bhushan R Deshpande
- Department of Orthopaedic Surgery, Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, 75 Francis Street, BC-4-016, Boston, MA, 02115, USA
| | - Elena Losina
- Department of Orthopaedic Surgery, Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, 75 Francis Street, BC-4-016, Boston, MA, 02115, USA.,Division of Rheumatology, Section of Clinical Sciences, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Savannah R Smith
- Department of Orthopaedic Surgery, Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, 75 Francis Street, BC-4-016, Boston, MA, 02115, USA
| | - Scott D Martin
- Harvard Medical School, Boston, MA, USA.,Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - R John Wright
- Harvard Medical School, Boston, MA, USA.,Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jeffrey N Katz
- Department of Orthopaedic Surgery, Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, 75 Francis Street, BC-4-016, Boston, MA, 02115, USA. .,Division of Rheumatology, Section of Clinical Sciences, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Departments of Epidemiology and Environmental Health, Harvard T. H. Chan School of Public Health, Boston, MA, USA.
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