In Canada, more than half the requests for MRI scans of patients' lumbar spines were "substantially" inappropriate or of uncertain value, a finding the study's author says is probably even greater in the United States.
"The thing about Canada is that we have limited access to MRI, whereas in the United States, effectively, you don't have limits for people who can afford it; there's no waiting list and no limitations on access," says Derek J. Emery, MD, associate professor and neuroradiologist at the University of Alberta, and principal author of the paper published Monday as a Research Letter in JAMA Internal Medicine.
The overuse of such magnetic resonance imaging tests is a problem because of false positives and unnecessary excess costs. "For most patients, imaging (findings) won't contribute to their care and management," he says.
Lumbar spine MRI overuse is significant because, Emery says, such scans make up one-third of all MRI scans in some regions and add considerably to healthcare costs. In Canada, he said, the cost of these images is about $400. A quick Internet search of lumbar MRI scans in the U.S. revealed a range of between $1,700 to $2,175 each, and that's without use of contrast agents.
Overutilization of lumbar spine MRI scans for various manifestations of pain including radiculopathy or claudication, were seen as inappropriate 28.5% of the time, and of uncertain value in 27.2% of 1,000 requests studied. Only in cases where the symptom was postoperative back or leg pain was the scan deemed appropriate, which was in 95.8% of 167 cases.
"Overuse of medical interventions, such as MRI, is a considerable problem, leading to excess costs and adverse outcomes," the researchers wrote. This overutilization is driven by patient expectations, physician concerns about litigation, and lack of physician accountability for cost.
"Solutions will require strict adherence to appropriate guidelines and better education of patients," such as the Choosing Wisely campaign, an effort by numerous medical specialist organizations to reduce overuse of healthcare services.
On the other hand, researchers found that 82.8% of MRI scans of the head when patients complained of headache were seen appropriate, a much more reasonable percentage, Emery says. Reasons listed for the head MRI included migraine headache, suspect brain tumor or aneurysm, or a headache in a patient with cancer.
Emery and colleagues used the RAND-University of California Los Angeles appropriateness method to define appropriate care for just these two indications, lumbar spine pain and headaches.
The project required a thorough literature review to come up with all reasons that evidence suggests justify such a test, and for lumbar spine MRI, the research came up with hundreds of scenarios. They then convened two expert panels composed of orthopedists, neurologists, family medicine specialists, podiatrists, neuroradiologists, and others to review the cases.
When the requisitions for these imaging tests didn't specify why the test was being requested, the researchers contacted the patients directly, which they received human subject research approval to do.
"To my knowledge, this is the first time this has been looked at really rigorously, although lots of papers will quote that up to 30% of images are inappropriate," he says.
Emery says that if research on the use of MRI for both indications had each revealed large amounts of inappropriateness and overuse, one might conclude similar rates for other types of MRIs.
But because there wasn't a high rate of inappropriate for head MRI, Emery believes that overutilization rates may vary depending on the region, the symptom and body site. More research is needed to investigate appropriateness of MRI testing for other types of patients.