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The Diagnostic Value of MRI Ordered by Providers Prior to Referral to a Hand Surgeon: A Look at Efficiency and Quality of Imaging
Jesse T. Lewis, MD1; Michael D. Montague, MD1; Jaiyoung Ryu, MD1; Andrew H. Mace, MD2; Jon Kline, PA1
1Department of Orthopaedics, West Virginia University, Morgantown, WV; 2Department of Radiology, West Virginia University, Morgantown, WV

Introduction: Magnetic resonance imaging (MRI) is a valuable diagnostic tool for evaluation of upper extremity musculoskeletal pathology. As MRI has become increasingly available in communities, there appears to be increased frequency of ordering this expensive tool for screening rather than diagnostic evaluation or surgical planning. Based on observation and literature review, we hypothesized there is an abundance of unnecessarily ordered MRIs prior to referral to a treating hand surgeon. We also hypothesized community-ordered MRI is often of inadequate quality for appropriate evaluation of specific upper extremity pathology. To our knowledge, no previous study has prospectively assessed the efficiency and quality of MRIs ordered prior to referral to a hand surgeon.

Materials & Methods: Thirty-two patients presented over a five-month period with MRI obtained prior to referral to a hand surgeon. The population included all patients with previous MRI, regardless of referring diagnosis, previous treatment, gender, or age. A single experienced hand surgeon completed routine history and physical exam, and plain films were reviewed if available or completed if needed. After evaluation, the surgeon made a diagnosis and commented on whether MRI was needed for further evaluation or treatment. Only then were the previously obtained MRIs and any reports reviewed. The surgeon then commented on whether these results changed diagnosis or treatment. To assess the quality of prereferral MRIs, an experienced musculoskeletal radiologist at our institution reviewed all studies without having reviewed previous reports or diagnoses. The radiologist determined whether the studies were satisfactory for review of the anatomical area of concern, and then made diagnoses based on evaluation of the study provided.

Results: The attending hand surgeon would have routinely ordered MRIs to aid in the diagnosis or treatment for three patients. Based on these findings, we concluded 90.63 percent of studies were unnecessary. Evaluation of MRIs by the radiologist, found only 9.37 percent of studies to be “unsatisfactory” for assessment of the area of concern, but noted 53.12 percent of studies used a field of view, which was “too large” for the anatomy.

Conclusions: While MRI is a valuable diagnostic tool, it is being used inefficiently by referring providers prior to patient referral to treating hand surgeons. As MRI is expensive, this represents a large overutilization and expense waste in healthcare currently. Furthermore, studies performed in communities may be unsatisfactory for the proper evaluation of the anatomy of concern, which could result in duplicate ordering and further cost.

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