Abstract
Background
Patients often receive advanced imaging before referral to an orthopaedic oncologist. The few studies that have evaluated the value of these tests have been single-center studies, and there were large discrepancies in the estimated frequencies of unnecessary use of diagnostic tests.
Questions/purposes
(1) Is there regional variation in the use of advanced imaging before referral to an orthopaedic oncologist? (2) Are these prereferral studies helpful to the treating orthopaedic oncologist in making a diagnosis or treatment plan? (3) Are orthopaedic surgeons less likely to order unhelpful studies than other specialties? (4) Are there any tumor or patient characteristics that are associated with the ordering of an unhelpful study?
Methods
We performed an eight-center prospective analysis of patients referred for evaluation by a fellowship-trained orthopaedic oncologist. We recorded patient factors, referral details, advanced imaging performed, and presumptive diagnosis. The treating orthopaedic oncologist determined whether each study was helpful in the diagnosis or treatment of the patient based on objective and subjective criteria used in prior investigations. We analyzed the data using bivariate methods and logistic regression to determine regional variation and risk factors predictive of unhelpful advanced imaging. Of the 371 participants available for analysis, 301 (81%) were referred with an MRI, CT scan, bone scan, ultrasound, or positron emission tomography scan.
Results
There were no regional differences in the use of advanced imaging (range of patients presenting with advanced imaging 66%–88% across centers, p = 0.164). One hundred thirteen patients (30%) had at least one unhelpful study; non-MRI advanced imaging was more likely to be unhelpful than MRIs (88 of 129 [68%] non-MRI imaging versus 46 of 263 [17%] MRIs [p < 0.001]). Orthopaedic surgeons were no less likely than nonorthopaedic surgeons to order unhelpful studies before referral to an orthopaedic oncologist (56 of 179 [31%] of patients referred by orthopaedic surgeons versus 35 of 119 [29%] referred by primary care providers and 22 of 73 [30%] referred by nonorthopaedic specialists, p = 0.940). After controlling for potential confounding variables, benign bone lesions had an increased odds of referral with an unhelpful study (59 of 145 [41%] of benign bone tumors versus 54 of 226 [24%] of soft tissue tumors and malignant bone tumors; odds ratio, 2.80; 95% confidence interval, 1.68–4.69, p < 0.001).
Conclusions
We found no evidence that the proportion of patients referred with advanced imaging varied dramatically by region. Studies other than MRI were likely to be considered unhelpful and should not be routinely ordered by referring physicians. Diligent education of orthopaedic surgeons and primary care physicians in the judicious use of advanced imaging in benign bone tumors may help mitigate unnecessary imaging.
Level of Evidence
Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
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References
Aboulafia AJ, Levin AM, Blum J. Prereferral evaluation of patients with suspected bone and soft tissue tumors. Clin Orhop Relat Res. 2002;397:83–88.
Armao D, Semelka RC, Elias J Jr. Radiology’s ethical responsibility for healthcare reform: tempering the overutilization of medical imaging and trimming down a heavyweight. J Magn Reson Imag. 2012;35:512–517.
Cammisa C, Partridge G, Ardans C, Buehrer K, Chapman B, Beckman H. Engaging physicians in change: results of a safety net quality improvement program to reduce overuse. Am J Med Qual. 2011;26:26–33.
Damron TA, Beauchamp CP, Rougraff BT, Ward WG Sr. Soft-tissue lumps and bumps. Instr Course Lect. 2004;53:625–637.
Deyo RA. Imaging idolatry: the uneasy intersection of patient satisfaction, quality of care, and overuse. Arch Intern Med. 2009;169:921–923.
Emery DJ, Shojania KG, Forster AJ, Mojaverian N, Feasby TE. Overuse of magnetic resonance imaging. JAMA. 2013;173:823–825.
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138:273–287.
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288–298.
Garrett MC, Bilgin-Freiert A, Bartels C, Everson R, Afsarmanesh N, Pouratian N. An evidence-based approach to the efficient use of computed tomography imaging in the neurosurgical patient. Neurosurgery. 2013;73:209–216.
Grimer RJ, Briggs TW. Earlier diagnosis of bone and soft-tissue tumours. J Bone Joint Surg Br. 2010;92:1489–1492.
Lavery HJ, Brajtbord JS, Levinson AW, Nabizada-Pace F, Pollard ME, Samadi DB. Unnecessary imaging for the staging of low-risk prostate cancer is common. Urology. 2011;77:274–278.
Lester MS, Liu BP. Imaging in the evaluation of headache. Med Clin North Am. 2013;97:243–265.
Lomasney LM, Lim-Dunham JE, Cappello T, Annes J. Imaging of the pediatric athlete: use and overuse. Radiol Clin North Am. 2013;51:215–226.
Mankin HJ, Lange TA, Spanier SS. The hazards of biopsy in patients with malignant primary bone and soft-tissue tumors. J Bone Joint Surg Am. 1982;64:1121–1127.
Mannan K, Briggs TW. Soft tissue tumours of the extremities. BMJ. 2005;331:590.
Martin CT, Morcuende J, Buckwalter JA, Miller BJ. Prereferral MRI use in patients with musculoskeletal tumors is not excessive. Clin Orthop Relat Res. 2012;470:3240–3245.
Melnick ER, Szlezak CM, Bentley SK, Dziura JD, Kotlyar S, Post LA. CT overuse for mild traumatic brain injury. Jt Comm J Qual Patient Safety. 2012;38:483–489.
Petron DJ, Greis PE, Aoki SK, Black S, Krete D, Sohagia KB, Burks R. Use of knee magnetic resonance imaging by primary care physicians in patients aged 40 years and older. Sports Health. 2010;2:385–390.
Rao VM, Levin DC. The overuse of diagnostic imaging and the Choosing Wisely initiative. Ann Intern Med. 2012;157:574–576.
Viera AJ, Garrett JM. Understanding interobserver agreement: the kappa statistic. Fam Med. 2005;37:360–363.
Acknowledgments
We thank Yubo Gao PhD, for his assistance with the statistical analysis.
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Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.
Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
This work was performed at the University of Iowa, Iowa City, IA, USA.
Musculoskeletal Oncology Research Initiative participating investigators: Benjamin J. Miller MD, MS, University of Iowa, Iowa City, IA, USA; Raffi S. Avedian MD, Stanford University Medical Center, Redwood City, CA, USA; Judd Cummings MD, Matthew Seidel MD, and Lauren Schwartz NP, University of Arizona, Scottsdale, AZ, USA; Tessa Balach MD, University of Connecticut, Farmington, CT, USA; Kevin MacDonald MD, Virginia Mason Medical Center, Seattle, WA, USA; Jeremy R. White MD, University of Oklahoma, Oklahoma City, OK, USA; Lee R. Leddy MD, Medical University of South Carolina, Charleston, SC, USA; and Rajiv Rajani MD, University of Texas Health Science Center, San Antonio, TX, USA.
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Miller, B.J., Avedian, R.S., Rajani, R. et al. What Is the Use of Imaging Before Referral to an Orthopaedic Oncologist? A Prospective, Multicenter Investigation. Clin Orthop Relat Res 473, 868–874 (2015). https://doi.org/10.1007/s11999-014-3649-z
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DOI: https://doi.org/10.1007/s11999-014-3649-z