Government intervention in Canada boosts imaging appropriateness

The Ontario government implemented interventions that significantly increased the appropriateness of lumbar MRI referrals, according to a study published online March 28 by the Journal of the American College of Radiology.

Complicated back pain is often best investigated through the use of MRI due to its high sensitivity and specificity. Lead author Sean A. Kennedy, of McMaster University in Ontario, Canada, and colleagues reported that MRI orders for spinal imaging increased 600 percent from 1993 to 2004 in Canada. “Lumbar MRI studies for low back pain are a heavy burden on the Canadian health care system and studies have shown many of these referrals to be inappropriate,” wrote the authors.

As a means of cutting health care costs in May 2012, the Ontario Ministry of Health orchestrated a campaign aimed at lumbar MRI examination overutilization reduction. The researchers investigated the appropriateness of lumbar MRI referrals for low back pain at tertiary care facilities in Ontario in order to examine any changes in appropriateness of new lumbar MRI referrals once the policy changes were enacted by the government.

The study included 600 lumbar MRI referral forms which were randomly and evenly selected from before and after the policy change. The researchers utilized the ACR Appropriateness Criteria for low back pain imaging to evaluate the appropriateness of each referral. They then assigned each a score from one to nine.

Prior to the change in policy, 50.4 percent of lumbar MRI referrals were appropriate while 47.9 percent were not. Once the policy changed, appropriateness increased with a referral appropriateness percentage of 62.6 percent. Of the referrals, 37.1 percent were inappropriate after the change.

Before the policy alteration, the mean appropriateness score was 5.08, which increased significantly to 5.79 after the change. The study’s authors did not observe any significant differences in the number of new lumbar MRI referrals before and after amendment to the policy.

“Investing in evidence-based infrastructure such as mandated point-of-care decision support referral forms will likely improve the appropriateness of imaging in Canada without sacrificing high-quality patient care,” wrote Kennedy and colleagues. “This represents an important opportunity for policymakers, referring physicians, and radiologists to work together to optimize the appropriateness of lumbar MRI.”

Pointing to the power of partnership and the importance of radiologist involvement in imaging decision making, the authors concluded: “We hope that the results of this study specifically highlight the role radiologists can play in improving the appropriateness of imaging referrals. Working as an integrated unit with referring physicians, radiologists should serve as the gatekeepers to medical imaging resources.”