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May 06, 2015

Are MRIs ordered too often for knee pain?

Unnecessary MRIs increase costs, delay treatment, and may result in misleading diagnoses

ROSEMONT, Ill. - Magnetic resonance images (MRIs) may be ordered too frequently for common knee pain, potentially causing unnecessary expense and delayed or incorrect diagnosis, according to a new study appearing in the May 6 issue of The Journal of Bone & Joint Surgery (JBJS).
More than 5.7 million doctor’s office visits are attributed to knee pain each year, nearly double the number for back pain, according to the U.S. Centers for Disease Control and Prevention (CDC). Most often, the cause of knee pain can be determined through a physical examination and the “judicious” use of X-ray images, according to the study. While MRIs are effective for diagnosing or confirming more complex injuries or conditions, or the cause of discomfort or pain when an X-ray is negative or inconclusive, routine MRIs are costly and ineffective.

“We sought to evaluate differences in MRI ordering practices between orthopaedic surgeons and primary care physicians,” said lead study author Timothy Roberts, MD. To do so, Dr. Roberts and his team reviewed the records of all new patients seen at an orthopaedic outpatient office between Jan. 1, 2010 and Dec. 31, 2011, with meniscal knee pain and unspecified sprains and strains of the knee. A total of 1,592 patients were divided into two groups: those initially evaluated and referred by their primary care physician, and those initially evaluated by an orthopaedic surgeon. The average duration of follow-up for the patients was 32 months, with a minimum of 24 months and a maximum of 42 months.
The rates of MRI-ordering were nearly identical between orthopaedic surgeons and primary care physicians (24.6 percent versus 24.8 percent). However, MRIs ordered by orthopaedic surgeons were significantly more likely to confirm the presence of a condition which could benefit from surgical (arthroscopic) interventions than those ordered by primary care physicians (41 percent versus 31.3 percent). In addition:
  • Orthopaedic surgeons ordered MRIs for patients who were generally more likely to benefit from arthroscopic surgery, including younger patients (mean age, 45.1 years versus 56.5 years), patients with acute symptoms (39.3 percent versus 22.2 percent with less severe symptoms), and patients with a history of trauma (49.3 versus 36.2 percent without a history of trauma).
  • Overall, changes in treatment plans occurred more often following surgeon-ordered MRIs, versus MRIs ordered by primary care physicians, regardless of whether or not the patient first saw an orthopaedic surgeon or primary care physician.
  • Orthopaedic surgeons were less likely to order MRIs for patients with end-stage osteoarthritis—arthritis due to wear, tear and aging—a leading cause of joint deterioration requiring total knee replacement.
“We found that knee MRIs ordered by orthopaedic surgeons ultimately resulted in more arthroscopic (surgical) interventions than those ordered by primary care or other non-orthopaedic providers,” said Dr. Roberts. “Further, orthopaedic surgeons were less likely to order knee MRIs in situations where plain radiographs usually suffice—such as advanced osteoarthritis. Significantly more patients with primary care physician ordered MRIs went on to receive total knee replacements than those with orthopaedic surgeon-ordered MRIs. 

“As the U.S. faces major health care reform, efforts to reduce unnecessary imaging and referral costs become all the more essential.”
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution) from a third-party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship in the 36 months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in his work.
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