advanced imaging is overused prior to referral to a musculoskeletal oncologist: a prospective,...
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ADVANCED IMAGING IS OVERUSED PRIOR TO REFERRAL TO A MUSCULOSKELETAL ONCOLOGIST: A PROSPECTIVE, MULTI-CENTER INVESTIGATION
Benjamin J. Miller, MD, MS on behalf of the Musculoskeletal Oncology Research Initiative
Conflicts of Interest
Nothing to disclose
Background
Bone and soft tissue tumors initially seen by general orthopaedist or PCP
No clear guidelines for use of advanced imaging (MRI, CT, bone scan, U/S, PET)
Medical imaging identified as contributor to overspending
Reducing superfluous imaging studies prior to referral is important
Prior studies
Aboulafia et al, CORR, 2002 Prospective, single center, 100 patients 34% unnecessary MRI scans
Martin et al, CORR, 2012 Retrospective, single-center, 920 patients 3% unnecessary MRI
Questions
Is there regional variation in the use of advanced imaging?
Are there common characteristics predictive of excessive studies?
Materials and Methods
8 centers Prospective 50 patients or 6 months of
referrals Bone and soft tissue tumors All anatomic locations
Data elements
Patient details Age, sex, race, insurance
Tumor type Bone or soft tissue
Specialty of referring MD Distance travelled Studies performed prior to referral
Subjective material
Determined only by the single treating orthopaedic oncologist What happens in actual practice?
Presumptive diagnosis Likely benign (Benign tumor or non-
neoplastic) Likely malignant (Malignant tumor or
unknown) Necessary or excessive study
“Necessary study” criteria
Needed for routine work-up of condition Helpful in determining diagnosis
Borderline studies considered “necessary” Benefit of the doubt given to referring
physician
“Necessary study” criteria
MRI specifically Soft tissue
Biopsy proven sarcoma >5 cm Deep to fascia Painful Growing
Bone Concern for sarcoma on x-ray
Statistical analysis
Chi-square and t test Univariate and multivariate logistic
regression
Post hoc power analysis 90% power to detect 20% difference
between centers
Results
371 patients 301 (81%) with at least 1 study
263 (71%) with MRI 54 (15%) with CT 40 (11%) with bone scan 21 (6%) with ultrasound 14 (4%) with PET scan
81 (22%) with multiple studies
Results
Regions differed by age, race, insurance status, and distance travelled Demographics variable
No differences in use of prereferral imaging by region (p=0.164) Range 66% to 88%
Results
113 (30%) with unnecessary studies 46 (17%) MRI 40 (74%) CT 25 (62%) bone scan 16 (76%) ultrasound 7 (50%) PET scan
No difference between orthopaedic or PCP referrals (p=0.940)
Univariate analysis
Benign bone tumors more likely to have excessive imaging (OR 2.18, 95% CI 1.39-3.43)
Differences by practice location
Findings held in multivariate analysis
Effect of Region
No obvious differences in number or types of studies Generalizable results
Differences in labeling “unnecessary” Substantial variation between fellowship-
trained tumor surgeons Consistent with prior studies
Minimum 3% (Martin 3%) and maximum 31% (Aboulafia 34%)
Need for clearer guidelines based on objective, reproducible criteria
Summary
Helpful – MRI Most utilized study (71%) 83% deemed necessary Use contrast, visualize entire compartment
6% repeated Not helpful – everything else
High rate of “unnecessary” Should be left to treating team
Recommendations
Appropriate advanced imaging is beneficial Goal is not to totally eliminate
No imaging other than MRI No MRI in radiographically benign bone
tumors
Would change 30% excessive studies to 4%
MORI participants
Raffi Avedian Judd Cummings Tessa Balach Kevin MacDonald Lee Leddy Jeremy White Raj Rajani Ben Miller