Reducing the Volume of Low-Value Outpatient MRI Joint Examinations in Patients ≥55 Years of Age

Abstract

French

Purpose:

Magnetic resonance imaging (MRI) is not beneficial in patients with joint pain and concomitant osteoarthritis (OA). We attempt to determine whether evaluation of OA via X-rays can reduce inappropriate MRI and computed tomography (CT) arthrogram use. In our jurisdiction, CT arthrograms are used as surrogate tests because of MRI wait times.

Materials and Methods:

Our intervention required patients ≥55 years of age scheduled for outpatient MRI of the knee/hip/shoulder at an urban hospital to have X-rays (weight bearing when appropriate) from within 1 year. Red flags (ie, neoplasm, infection) were identified for which MRI would be indicated regardless. Through review of radiographs on picture archiving and communication system/digital media and use of the validated Kellgren-Lawrence (KL) OA scale, radiologists assessed the presence and degree of OA. A finding of significant OA (KL > 2) without red flags would preclude MRI. Monthly averages of MRI and CT arthrogram examinations were measured 33 months before and 23 months following introduction of the intervention.

Results:

The proportion of protocoled MRI requisitions that were avoided was 21%. If extrapolated to the province of British Columbia, 2419 of 11 700 examinations could have been prevented in the past year. The average monthly number of knee/hip/shoulder MRI examinations as a percentage of total MRI examinations decreased from 4.9% to 4.3% (P < .02) following the intervention. The average monthly number of knee/hip/shoulder CT arthrogram examinations decreased from 20.6 to 12.1 (P < .0001).

Conclusion:

We were able to decrease the number of MRI and CT arthrogram examinations in patients ≥55 years of age with joint pain by implementing an evaluation for OA via recent X-ray imaging.

Keywords

osteoarthritis diagnostic imaging choosing wisely MRI

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References

Vos

Flaxman

Naghavi

, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2163–2196. doi:10.1016/S0140-6736(12)61729-2.

HCUP Nationwide Inpatient Sample. Healthcare Cost and Utilization Project (HCUP) . Rockville, MD: Agency for Healthcare Research and Quality; 2011. www.hcup-us.ahrq.gov/nisoverview.jsp. Accessed January 8, 2019.

National Joint Registry (NJR). NJR StatsOnline. 2018. www.njrcentre.org.uk. Accessed January 8, 2019.

Englund

Guermazi

Gale

, et al. Incidental meniscal findings on knee MRI in middle-aged and elderly persons. N Engl J Med. 2008;359(11):1108–1115. doi:10.1056/NEJMoa0800777.

Bhattacharyya

Gale

Dewire

, et al. The clinical importance of meniscal tears demonstrated by magnetic resonance imaging in osteoarthritis of the knee. J Bone Joint Surg Am. 2003;85(1):4–9.

Link

Steinbach

Ghosh

, et al. Osteoarthritis: MR imaging findings in different stages of disease and correlation with clinical findings. Radiology. 2003;226(2):373–381. doi:10.1148/radiol.2262012190.

Singh

Sperling

Buchbinder

McMaken

. Surgery for shoulder osteoarthritis. Cochrane Data Syst Rev. 2010;(10):CD008089. doi:10.1002/14651858.CD008089.pub2.

Piuzzi

Slullitel

Bertona

, et al. Hip arthroscopy in osteoarthritis: a systematic review of the literature. Hip Int. 2016;26(1):8–14. doi:10.5301/hipint.5000299.

Farjo

Glick

Sampson

. Hip arthroscopy for acetabular labral tears. Arthroscopy. 1999;15(2):132–137. doi:10.1053/ar.1999.v15.015013.

10.

Norris

Iannotti

. Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study. J Shoulder Elbow Surg. 2002;11(2):130–135.

11.

Iannotti

Norris

. Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am. 2003;85(2):251–258.

12.

Goldberg

Bell

J-E

Kim

Bak

Levine

Bigliani

. Hemiarthroplasty for the rotator cuff-deficient shoulder. J Bone Joint Surg Am. 2008;90(3):554–559. doi:10.2106/jbjs.F.01029.

13.

Simone

JP SP

Athwal

Sperling

Schleck

Cofield

. Anatomical total shoulder replacement with rotator cuff repair for osteoarthritis of the shoulder. Bone Joint J. 2014;96B(2):224–228. doi:10.1302/0301-620x.96b.32890.

14.

Eajazi

Kussman

LeBedis

, et al. Rotator cuff tear arthropathy: pathophysiology, imaging characteristics, and treatment options. Am J Roentgenol. 2015;205(5):W502–W511. doi:10.2214/AJR.14.13815.

15.

Comba

Yacuzzi

Ali

Zanotti

Buttaro

Piccaluga

Joint preservation after hip arthroscopy in patients with FAI. Prospective analysis with a minimum follow-up of seven years. Muscles, Ligaments Tendons J. 2016;6(3):317–323. doi:10.11138/mltj/2016.6.3.317.

16.

Kohn

Sassoon

Fernando

. Classifications in brief: Kellgren-Lawrence classification of osteoarthritis. Clin Orthop Relat Res. 2016;474(8):1886–1893. doi:10.1007/s11999-016-4732-4.

17.

American College of Radiology. Appropriateness Criteria®. 2018. https://acsearch.acr.org/list. Accessed July 26, 2018.

18.

De Smet

Tuite

. Use of the two-slice-touch rule for the MRI diagnosis of meniscal tears. Am J Roentgenol. 2006;187(4):911–914. doi:10.2214/ajr.05.1354.

19.

Pompan

. Appropriate use of MRI for evaluating common musculoskeletal conditions. Am Fam Physician. 2011;83(8):883–884.

20.

Cullen

Hall

Golosinskiy

. Ambulatory surgery in the United States, 2006. Nati Health Stat Report. 2009;(11):1–25.

21.

Kim

Bosque

Meehan

Jamali

Marder

. Increase in outpatient knee arthroscopy in the United States: a comparison of national surveys of ambulatory surgery, 1996 and 2006. J Bone Joint Surg Am. 2011;93(11):994–1000. doi:10.2106/jbjs.I.01618.

22.

Moseley

O’Malley

Petersen

, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347(2):81–88. doi:10.1056/NEJMoa013259.

23.

Herrlin

Hallander

Wange

Weidenhielm

Werner

. Arthroscopic or conservative treatment of degenerative medial meniscal tears: a prospective randomised trial. Knee Surg Sports Traumatol Arthrosc. 2007;15(4):393–401. doi:10.1007/s00167-006-0243-2.

24.

Kirkley

Birmingham

Litchfield

, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2008;359(11):1097–1107. doi:10.1056/NEJMoa0708333.

25.

Herrlin

Wange

Lapidus

Hållander

Werner

Weidenhielm

. Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up. Knee Surg Sports Traumatol Arthrosc. 2013;21(2):358–364.

26.

Katz

Brophy

Chaisson

, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013;368(18):1675–1684. doi:10.1056/NEJMoa1301408.

27.

Sihvonen

Paavola

Malmivaara

, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013;369(26):2515–2524. doi:10.1056/NEJMoa1305189.

28.

Thorlund

Juhl

Roos

Lohmander

. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ. 2015;350:h2747. doi:10.1136/bmj.h2747.

29.

Siemieniuk

RAC

Harris

Agoritsas

, et al. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. BMJ. 2017;357:j198 2. doi:10.1136/bmj.j1982.

30.

van de Graaf

Noorduyn

JCA

Willigenburg

, et al. Effect of early surgery vs physical therapy on knee function among patients with nonobstructive meniscal tears: the ESCAPE randomized clinical trial. JAMA. 2018;320(13):1328–1337. doi:10.1001/jama.2018.13308.

31.

Fairbank

. Knee joint changes after meniscectomy. J Bone Joint Surg Br. 1948;30b(4):664–670.

32.

Tapper

Hoover

. Late results after meniscectomy. J Bone Joint Surg Am. 1969;51(3):517–526.

33.

Johnson

Kettelkamp

Clark

Leaverton

. Factors effecting late results after meniscectomy. J Bone Joint Surg Am. 1974;56(4):719–729.

34.

Lotke

Lefkoe

Ecker

. Late results following medial meniscectomy in an older population. J Bone Joint Surg Am. 1981;63(1):115–119.

35.

Allen

Denham

Swan

. Late degenerative changes after meniscectomy. Factors affecting the knee after operation. J Bone Joint Surg Br. 1984;66(5):666–671.

36.

Jorgensen

Sonne-Holm

Lauridsen

Rosenklint

Long-term follow-up of meniscectomy in athletes. a prospective longitudinal study. J Bone Joint Surg Br. 1987;69(1):80–83.

37.

Roos

Lauren

Adalberth

Roos

Jonsson

Lohmander

. Knee osteoarthritis after meniscectomy: prevalence of radiographic changes after twenty-one years, compared with matched controls. Arthritis Rheum. 1998;41(4):687–693. doi:10.1002/1529-0131(199804)41:4<687. AID-ART16>3.0.CO;2-2.

38.

Englund

Roos

Lohmander

. Impact of type of meniscal tear on radiographic and symptomatic knee osteoarthritis: a sixteen-year followup of meniscectomy with matched controls. Arthritis Rheum. 2003;48(8):2178–2187. doi:10.1002/art.11088.

39.

Roos

Ostenberg

Roos

, et al. Long-term outcome of meniscectomy: symptoms, function, and performance tests in patients with or without radiographic osteoarthritis compared to matched controls. Osteoarthritis Cartilage. 2001;9(4):316–324. doi:10.1053/joca.2000.0391.

40.

Parker

Nazarian

Carrino

, et al. Musculoskeletal imaging: Medicare use, costs, and potential for cost substitution. J Am Coll Radiol. 2008;5(3):182–188. doi:10.1016/j.jacr.2007.07.016.

41.

Sheehy

Culham

McLean

, et al. Validity and sensitivity to change of three scales for the radiographic assessment of knee osteoarthritis using images from the Multicenter Osteoarthritis Study (MOST). Osteoarthritis Cartilage. 2015;23(9):1491–1498. doi:10.1016/j.joca.2015.05.003.

42.

Kellgren

Lawrence

. Rheumatism in miners. Part II: X-ray study. Br J Ind Med. 1952;9(3):197–207.

43.

Jordan

Helmick

Renner

, et al. Prevalence of hip symptoms and radiographic and symptomatic hip osteoarthritis in African Americans and Caucasians: the Johnston County Osteoarthritis Project. J Rheumatol. 2009;36(4):809–815. doi:10.3899/jrheum.080677.

44.

Langley

GL NK

Nolan

Normal

Provost

. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA: Jossey Bass; 2009.

45.

Ministry of Health. Thousands more MRI exams to benefit British Columbians. BC Gov News. 2018. https://news.gov.bc.ca/16706. Accessed November 19, 2018.

46.

George

Tsipas

Wozniak

, et al. MRI of the knee and shoulder performed before radiography. J Am Coll Radiol. 2014;11(11):1053–1058. doi:10.1016/j.jacr.2014.05.014.

47.

Lehnert

Bree

. Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support? J Am Coll Radiol. 2010;7(3):192–197. doi:10.1016/j.jacr.2009.11.010.

48.

Gonzalez

Kerchberger

Robertson

, et al. 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(3):289–294. doi:10.1016/j.jacr.2018.10.006.

49.

Englund

Niu

Guermazi

, et al. Effect of meniscal damage on the development of frequent knee pain, aching, or stiffness. Arthritis Rheum. 2007;56(12):4048–4054. doi:10.1002/art.23071.

50.

American Medical Society for Sports Medicine. Avoid ordering a knee MRI for a patient with anterior knee pain without mechanical symptoms or effusion unless the patient has not improved following completion of an appropriate functional rehabilitation program. Choosing Wisely. 2014. http://www.choosingwisely.org/clinician-lists/american-medical-society-sports-medicine-knee-mri-for-anterior-knee-pain/. Accessed July 26, 2018.

51.

Canadian Academy of Sport and Exercise Medicine. Five things physicians and patients should question. Choosing Wisely Canada. 2017. https://choosingwiselycanada.org/sport-exercise-medicine/. Accessed July 26, 2018.

52.

Cheung

Riblet

NBV

Osunkoya

. Use of iterative cycles in quality Improvement projects in imaging: a systematic review. J Am Coll Radiol. 2018;15(11):1587–1602. doi:10.1016/j.jacr.2018.06.007.

53.

Hendee

Becker

Borgstede

, et al. Addressing overutilization in medical imaging. Radiology. 2010;257(1):240–245. doi:10.1148/radiol.10100063.

54.

Wright

; Mars Group. Osteoarthritis classification scales: interobserver reliability and arthroscopic correlation. J Bone Joint Surg Am. 2014;96(14):1145–1151. doi:10.2106/JBJS.M.00929.

55.

Pache

Krauss

Strohm

, et al. Dual-energy CT virtual non calcium technique: detecting post traumatic bone marrow lesions—feasibility study. Radiology. 2010;256(2):617–624. doi:10.1148/radiol.10091230.

56.

Buchbinder

Harris

Sprowson

. Management of degenerative meniscal tears and the role of surgery. BMJ. 2015;350:h2212. doi:10.1136/bmj.h2212.

57.

Culvenor

Oiestad

Hart

Stefanik

Guermazi

Crossley

. Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. Br J Sports Med. 2019;53(20):1268–1278. doi:10.1136/bjsports-2018-099257.

58.

Adelani

Mall

Brophy

Halstead

Smith

Wright

. The use of mri in evaluating knee pain in patients aged 40 years and older. J Am Acad Orthop Surg. 2016;24(9):653–659. doi:10.5435/JAAOS-D-15-00681.

59.

Oren

Kebebew

Ioannidis

. Curbing unnecessary and wasted diagnostic imaging. JAMA. 2019;321(3):245–246. doi:10.1001/jama.2018.20295.