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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Kjelle E, Brandsæter IØ, Andersen ER, Hofmann BM. Cost of Low-Value Imaging Worldwide: A Systematic Review. Appl Health Econ Health Policy 2024:10.1007/s40258-024-00876-2. [PMID: 38427217 DOI: 10.1007/s40258-024-00876-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/11/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND AND OBJECTIVE Imaging with low or no benefit for the patient undermines the quality of care and amounts to vast opportunity costs. More than 3.6 billion imaging examinations are performed annually, and about 20-50% of these are of low value. This study aimed to synthesize knowledge of the costs of low-value imaging worldwide. METHODS This systematic review was based on the PRISMA statement. The database search was developed in Medline and further adapted to Embase-Ovid, Cochrane Library, and Scopus. Primary empirical studies assessing the costs of low-value diagnostic imaging were included if published between 2012 and March 2022. Studies designed as randomized controlled trials, non-randomized trials, cohort studies, cross-sectional studies, descriptive studies, cost analysis, cost-effectiveness analysis, and mixed-methods studies were eligible. The analysis was descriptive. RESULTS Of 5,567 records identified, 106 were included. Most of the studies included were conducted in the USA (n = 76), and a hospital or medical center was the most common setting (n = 82). Thirty-eight of the included studies calculated the costs of multiple imaging modalities; in studies with only one imaging modality included, conventional radiography was the most common (n = 32). Aggregated costs for low-value examinations amounts to billions of dollars per year globally. Initiatives to reduce low-value imaging may reduce costs by up to 95% without harming patients. CONCLUSIONS This study is the first systematic review of the cost of low-value imaging worldwide, documenting a high potential for cost reduction. Given the universal challenges with resource allocation, the large amount used for low-value imaging represents a vast opportunity cost and offers great potential to improve the quality and efficiency of care.
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Affiliation(s)
- Elin Kjelle
- Department of Health Sciences, Gjøvik at the Norwegian University of Science and Technology (NTNU) at Gjøvik, Postbox 191, 2802, Gjøvik, Norway.
| | - Ingrid Øfsti Brandsæter
- Department of Health Sciences, Gjøvik at the Norwegian University of Science and Technology (NTNU) at Gjøvik, Postbox 191, 2802, Gjøvik, Norway
| | - Eivind Richter Andersen
- Department of Health Sciences, Gjøvik at the Norwegian University of Science and Technology (NTNU) at Gjøvik, Postbox 191, 2802, Gjøvik, Norway
| | - Bjørn Morten Hofmann
- Department of Health Sciences, Gjøvik at the Norwegian University of Science and Technology (NTNU) at Gjøvik, Postbox 191, 2802, Gjøvik, Norway
- Centre of Medical Ethics at the University of Oslo, Blindern, Postbox 1130, 0318, Oslo, Norway
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Andersen ER, Brandsæter IØ, Hofmann BM, Kjelle E. The use of low-value imaging: the role of referral practice and access to imaging services in a representative area of Norway. Insights Imaging 2023; 14:29. [PMID: 36746848 PMCID: PMC9902580 DOI: 10.1186/s13244-023-01375-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 01/20/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Even though imaging is essential to modern medicine, some examinations are of low value as they do not lead to any change in the management of the patient. The Choosing Wisely (CW) campaign aims to reduce the use of such services. In the Norwegian version of CW, specific magnetic resonance imaging (MRI) of the head, lower back, and knee are amongst others identified as potential low-value examinations. However, referral practice and access to imaging may drive low-value utilisation. By using registry data from 2019 and descriptive analysis, this study aimed to examine the role of referral practice and access to imaging on the use of specific CW-examinations in one representative area in Norway. RESULTS A total of 237,554 examinations were performed by four public and two private imaging facilities located within the area. Forty-two percent (19,210/45,289) of all MRI examinations were related to CW. Private imaging centres performed most of the CW-imaging. A total of 3700 referrers were identified, and 2.3% were identified as "high-referrers," accounting for 33% of all CW-examinations. Referrers' experience did not influence imaging utilisation. A subset of referrers ("super-referrers," 0.5%) accounted for 10% of CW-examinations. Distance to service had no impact on the use of CW-examinations. CONCLUSIONS This study provides valuable insight into the use of imaging and referral practice in one representative area in Norway. A great variation in referral practice was observed. Therefore, targeting referrers with high referral rates may be a promising strategy for reducing the use of low-value imaging.
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Affiliation(s)
- Eivind Richter Andersen
- Department of Health Sciences in Gjøvik, The Norwegian University of Science and Technology (NTNU), P.O. Box 1, 2802, Gjøvik, Norway.
| | - Ingrid Øfsti Brandsæter
- grid.5947.f0000 0001 1516 2393Department of Health Sciences in Gjøvik, The Norwegian University of Science and Technology (NTNU), P.O. Box 1, 2802 Gjøvik, Norway
| | - Bjørn Morten Hofmann
- grid.5947.f0000 0001 1516 2393Department of Health Sciences in Gjøvik, The Norwegian University of Science and Technology (NTNU), P.O. Box 1, 2802 Gjøvik, Norway ,grid.5510.10000 0004 1936 8921Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Elin Kjelle
- grid.5947.f0000 0001 1516 2393Department of Health Sciences in Gjøvik, The Norwegian University of Science and Technology (NTNU), P.O. Box 1, 2802 Gjøvik, Norway
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Aukan MI, Brandsæter IØ, Skårvold S, Finlayson G, Nymo S, Coutinho S, Martins C. Changes in hedonic hunger and food reward after a similar weight loss induced by a very low-energy diet or bariatric surgery. Obesity (Silver Spring) 2022; 30:1963-1972. [PMID: 36046953 PMCID: PMC9804643 DOI: 10.1002/oby.23535] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/04/2022] [Accepted: 06/20/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The aim of this study was to compare changes in hedonic hunger and food reward in individuals with severe obesity achieving 10% to 15% weight loss with a very low-energy diet (VLED) alone or VLED and bariatric surgery. METHODS Patients scheduled for sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) initiated a VLED 2 weeks prior to surgery and continued the diet for 8 weeks postoperatively. BMI-matched controls underwent a VLED for 10 weeks. Hedonic hunger was assessed with the Power of Food Scale, and food reward with the Leeds Food Preference Questionnaire, pre and post intervention. RESULTS A total of 44 participants completed the study: 15 SG, 14 RYGB, and 15 controls (61%, 79% and 69% females, respectively; BMI: 40.5 ± 0.5 kg/m2 ; age: 43.9 ± 1.4 years). Average weight loss was 18.3 ± 0.6 kg (16%), comprising 13.5 ± 0.5 kg fat mass, with no significant differences between groups. Similar reductions in hedonic hunger were observed in all groups. Overall, food reward was similarly reduced in SG and RYGB groups, whereas controls showed little or no change. CONCLUSIONS Independent of modality, weight loss seems to reduce hedonic hunger, but bariatric surgery leads to several additional favorable changes in food reward and preferences.
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Affiliation(s)
- Marthe Isaksen Aukan
- Obesity Research Group, Department of Clinical and Molecular Medicine, Faculty of MedicineNorwegian University of Science and TechnologyTrondheimNorway
- Centre of Obesity and Innovation (ObeCe), Clinic of SurgerySt. Olav University HospitalTrondheimNorway
| | - Ingrid Øfsti Brandsæter
- Obesity Research Group, Department of Clinical and Molecular Medicine, Faculty of MedicineNorwegian University of Science and TechnologyTrondheimNorway
| | - Silje Skårvold
- Obesity Research Group, Department of Clinical and Molecular Medicine, Faculty of MedicineNorwegian University of Science and TechnologyTrondheimNorway
| | | | - Siren Nymo
- Obesity Research Group, Department of Clinical and Molecular Medicine, Faculty of MedicineNorwegian University of Science and TechnologyTrondheimNorway
- Centre of Obesity and Innovation (ObeCe), Clinic of SurgerySt. Olav University HospitalTrondheimNorway
- Nord‐Trøndelag Hospital Trust, Clinic of SurgeryNamsos HospitalNamsosNorway
| | - Silvia Coutinho
- Obesity Research Group, Department of Clinical and Molecular Medicine, Faculty of MedicineNorwegian University of Science and TechnologyTrondheimNorway
- Department of Public Health Nutrition at the Institute of Basic Medical Sciences, Faculty of MedicineUniversity of OsloOsloNorway
| | - Catia Martins
- Obesity Research Group, Department of Clinical and Molecular Medicine, Faculty of MedicineNorwegian University of Science and TechnologyTrondheimNorway
- Centre of Obesity and Innovation (ObeCe), Clinic of SurgerySt. Olav University HospitalTrondheimNorway
- Department of Nutrition SciencesUniversity of Alabama at BirminghamBirminghamAlabamaUSA
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Nomme F, Jarosch-von Schweder GK, Andersen ER, Brandsæter IØ, Kjelle E, Hofmann B. Wiser referral for diagnostic imaging. Tidsskr Nor Laegeforen 2022; 142:22-0223. [PMID: 35699536 DOI: 10.4045/tidsskr.22.0223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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