Reducing Unnecessary Shoulder MRI Examinations Within a Capitated Health Care System: A Potential Role for Shoulder Ultrasound

Scott E. Sheehan, John A. Coburn, Hardeep Singh, David Vanness, Dean F. Sittig, D. Paul Moberg, Nasia Safdar, Kenneth S. Lee, Michael C. Brunner

Research output: Contribution to journalArticle

6 Citations (Scopus)

Abstract

Purpose MRI is frequently overused. The aim of this study was to analyze shoulder MRI ordering practices within a capitated health care system and explore the potential effects of shoulder ultrasound substitution. Methods We reviewed medical records of 237 consecutive shoulder MRI examinations performed in 2013 at a Department of Veterans Affairs tertiary care hospital. Using advanced imaging guidelines, we assessed ordering appropriateness of shoulder MRI and estimated the proportion of examinations for which musculoskeletal ultrasound could have been an acceptable substitute, had it been available. We then reviewed MRI findings and assessed if ultrasound with preceding radiograph would have been adequate for diagnosis, based on literature reports of shoulder ultrasound diagnostic performance. Results Of the 237 examinations reviewed, 106 (45%) were deemed to be inappropriately ordered, most commonly because of an absent preceding radiograph (n = 98; 92%). Nonorthopedic providers had a higher frequency of inappropriate ordering (44%) relative to orthopedic specialists (17%) (P = .016; odds ratio = 3.15, 95% confidence interval = 1.24-8.01). In the 237 examinations, ultrasound could have been the indicated advanced imaging modality for 157 (66%), and most of these (133/157; 85%) could have had all relevant pathologies characterized when combined with radiographs. Regardless of indicated modality, ultrasound could have characterized 80% of all cases ordered by nonorthopedic providers and 50% of cases ordered by orthopedic specialists (P = .007). Conclusions Advanced shoulder imaging is often not ordered according to published appropriateness criteria. While nonorthopedic provider orders were more likely to be inappropriate, inappropriateness persisted among orthopedic providers. A combined ultrasound and radiograph evaluation strategy could accurately characterize shoulder pathologies for most cases.

Original languageEnglish (US)
Pages (from-to)780-787
Number of pages8
JournalJournal of the American College of Radiology
Volume13
Issue number7
DOIs
StatePublished - Jul 1 2016

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Delivery of Health Care
Orthopedics
Pathology
Veterans
Tertiary Healthcare
Tertiary Care Centers
Medical Records
Ultrasonography
Odds Ratio
Guidelines
Confidence Intervals

All Science Journal Classification (ASJC) codes

  • Radiology Nuclear Medicine and imaging

Cite this

Sheehan, Scott E. ; Coburn, John A. ; Singh, Hardeep ; Vanness, David ; Sittig, Dean F. ; Moberg, D. Paul ; Safdar, Nasia ; Lee, Kenneth S. ; Brunner, Michael C. / Reducing Unnecessary Shoulder MRI Examinations Within a Capitated Health Care System : A Potential Role for Shoulder Ultrasound. In: Journal of the American College of Radiology. 2016 ; Vol. 13, No. 7. pp. 780-787.
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abstract = "Purpose MRI is frequently overused. The aim of this study was to analyze shoulder MRI ordering practices within a capitated health care system and explore the potential effects of shoulder ultrasound substitution. Methods We reviewed medical records of 237 consecutive shoulder MRI examinations performed in 2013 at a Department of Veterans Affairs tertiary care hospital. Using advanced imaging guidelines, we assessed ordering appropriateness of shoulder MRI and estimated the proportion of examinations for which musculoskeletal ultrasound could have been an acceptable substitute, had it been available. We then reviewed MRI findings and assessed if ultrasound with preceding radiograph would have been adequate for diagnosis, based on literature reports of shoulder ultrasound diagnostic performance. Results Of the 237 examinations reviewed, 106 (45{\%}) were deemed to be inappropriately ordered, most commonly because of an absent preceding radiograph (n = 98; 92{\%}). Nonorthopedic providers had a higher frequency of inappropriate ordering (44{\%}) relative to orthopedic specialists (17{\%}) (P = .016; odds ratio = 3.15, 95{\%} confidence interval = 1.24-8.01). In the 237 examinations, ultrasound could have been the indicated advanced imaging modality for 157 (66{\%}), and most of these (133/157; 85{\%}) could have had all relevant pathologies characterized when combined with radiographs. Regardless of indicated modality, ultrasound could have characterized 80{\%} of all cases ordered by nonorthopedic providers and 50{\%} of cases ordered by orthopedic specialists (P = .007). Conclusions Advanced shoulder imaging is often not ordered according to published appropriateness criteria. While nonorthopedic provider orders were more likely to be inappropriate, inappropriateness persisted among orthopedic providers. A combined ultrasound and radiograph evaluation strategy could accurately characterize shoulder pathologies for most cases.",
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Reducing Unnecessary Shoulder MRI Examinations Within a Capitated Health Care System : A Potential Role for Shoulder Ultrasound. / Sheehan, Scott E.; Coburn, John A.; Singh, Hardeep; Vanness, David; Sittig, Dean F.; Moberg, D. Paul; Safdar, Nasia; Lee, Kenneth S.; Brunner, Michael C.

In: Journal of the American College of Radiology, Vol. 13, No. 7, 01.07.2016, p. 780-787.

Research output: Contribution to journalArticle

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T1 - Reducing Unnecessary Shoulder MRI Examinations Within a Capitated Health Care System

T2 - A Potential Role for Shoulder Ultrasound

AU - Sheehan, Scott E.

AU - Coburn, John A.

AU - Singh, Hardeep

AU - Vanness, David

AU - Sittig, Dean F.

AU - Moberg, D. Paul

AU - Safdar, Nasia

AU - Lee, Kenneth S.

AU - Brunner, Michael C.

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N2 - Purpose MRI is frequently overused. The aim of this study was to analyze shoulder MRI ordering practices within a capitated health care system and explore the potential effects of shoulder ultrasound substitution. Methods We reviewed medical records of 237 consecutive shoulder MRI examinations performed in 2013 at a Department of Veterans Affairs tertiary care hospital. Using advanced imaging guidelines, we assessed ordering appropriateness of shoulder MRI and estimated the proportion of examinations for which musculoskeletal ultrasound could have been an acceptable substitute, had it been available. We then reviewed MRI findings and assessed if ultrasound with preceding radiograph would have been adequate for diagnosis, based on literature reports of shoulder ultrasound diagnostic performance. Results Of the 237 examinations reviewed, 106 (45%) were deemed to be inappropriately ordered, most commonly because of an absent preceding radiograph (n = 98; 92%). Nonorthopedic providers had a higher frequency of inappropriate ordering (44%) relative to orthopedic specialists (17%) (P = .016; odds ratio = 3.15, 95% confidence interval = 1.24-8.01). In the 237 examinations, ultrasound could have been the indicated advanced imaging modality for 157 (66%), and most of these (133/157; 85%) could have had all relevant pathologies characterized when combined with radiographs. Regardless of indicated modality, ultrasound could have characterized 80% of all cases ordered by nonorthopedic providers and 50% of cases ordered by orthopedic specialists (P = .007). Conclusions Advanced shoulder imaging is often not ordered according to published appropriateness criteria. While nonorthopedic provider orders were more likely to be inappropriate, inappropriateness persisted among orthopedic providers. A combined ultrasound and radiograph evaluation strategy could accurately characterize shoulder pathologies for most cases.

AB - Purpose MRI is frequently overused. The aim of this study was to analyze shoulder MRI ordering practices within a capitated health care system and explore the potential effects of shoulder ultrasound substitution. Methods We reviewed medical records of 237 consecutive shoulder MRI examinations performed in 2013 at a Department of Veterans Affairs tertiary care hospital. Using advanced imaging guidelines, we assessed ordering appropriateness of shoulder MRI and estimated the proportion of examinations for which musculoskeletal ultrasound could have been an acceptable substitute, had it been available. We then reviewed MRI findings and assessed if ultrasound with preceding radiograph would have been adequate for diagnosis, based on literature reports of shoulder ultrasound diagnostic performance. Results Of the 237 examinations reviewed, 106 (45%) were deemed to be inappropriately ordered, most commonly because of an absent preceding radiograph (n = 98; 92%). Nonorthopedic providers had a higher frequency of inappropriate ordering (44%) relative to orthopedic specialists (17%) (P = .016; odds ratio = 3.15, 95% confidence interval = 1.24-8.01). In the 237 examinations, ultrasound could have been the indicated advanced imaging modality for 157 (66%), and most of these (133/157; 85%) could have had all relevant pathologies characterized when combined with radiographs. Regardless of indicated modality, ultrasound could have characterized 80% of all cases ordered by nonorthopedic providers and 50% of cases ordered by orthopedic specialists (P = .007). Conclusions Advanced shoulder imaging is often not ordered according to published appropriateness criteria. While nonorthopedic provider orders were more likely to be inappropriate, inappropriateness persisted among orthopedic providers. A combined ultrasound and radiograph evaluation strategy could accurately characterize shoulder pathologies for most cases.

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