QUEBEC CITY - The number of MRI scans used to diagnose degenerative spine disorders could be cut in half if advanced practice physiotherapists triage patients before imaging is ordered, according to a presentation at the Canadian Spine Society (CSS) annual meeting this week.
"Eliminating unnecessary imaging in spinal disorder diagnosis can save significant healthcare resources," amounting to tens of millions of dollars annually if widely implemented, concluded Dr. Y. Raja Rampersaud, a neurosurgeon in the spinal program at Toronto Western Hospital in Ontario.
Rampersaud first analyzed the diagnostic pathways of 2,046 outpatients who received a consultation with him between September 2005 and April 2008. The majority underwent a confirmatory MRI, while some had plain x-rays and others a clinical assessment without imaging.
For example, all 851 individuals who presented with lumbar disk herniation, sciatica, radiculopathy, lumbar spinal stenosis, or claudication had a confirmatory MRI, while all 190 patients with degenerative spondylolisthesis or isthmic spondylolisthesis had x-rays. The imaging results, as well as other clinical information, dictated whether the patients underwent surgery.
Rampersaud used the diagnostic information to create a mathematical model of an evidence-based diagnostic triage program. In the program, spine-focused clinical assessments and plain x-rays would be used before a CT or MRI scan is ordered. Rampersaud calculated the resulting cost from patients who were triaged compared to those who received usual care.
In the model, patients who went into the triage program had a consultation with an advanced practice physiotherapist. They then had an x-ray followed by a second advanced practice physiotherapist consult or went directly to nonsurgical treatment supervised by their primary care physician.
Those who had a second consultation were channeled into one of three streams:
- An MRI and a spine surgeon consultation
- No MRI and a spine surgeon consultation
- No MRI and no spine surgeon consultation
Those who were deemed most appropriate for nonsurgical care were then sent back to their primary care practitioner for that treatment; the rest had surgery.
In contrast, usual-care patients received an MRI, plain x-ray, and/or a CT, and then were either streamed directly into nonsurgical care supervised by their primary care physician or to a spine surgeon consultation, followed by surgery or nonsurgical treatment under family physician care.
Province-wide savings
Based on the original set of 2,046 patients, Rampersaud determined that use of the triage program would reduce the number of diagnostic MRIs needed from 3,069 to 1,228, and would lower the number of surgical candidates from 1,162 to 1,038. In total, this would lower costs by $2 million Canadian ($2 million U.S.) over the 31-month study period, or $775,000 per year. This includes $1.7 million for MRI scans that did not have to be performed, $462,000 for CT scans that were not done, and $51,000 in savings for spine surgeon consults that were not necessary.
Rampersaud calculated that the annual bill for assessing degenerative spine disorders in Ontario would be reduced by $24.2 million if the triaging approach were used province-wide.
Significant cost savings would still be accrued if primary care physicians performed the triaging instead of advanced practice physiotherapists, Rampersaud found. In addition, slightly greater savings would be gained from having neurosurgeons consult with the patients rather than orthopedic surgeons. In addition, triaging would still reduce costs compared to usual care even if the cost of MRI were significantly lower or higher than is standard across Canada, and/or if no CTs or x-rays were taken prior to spine surgeon consultation in the usual-care approach.
To what extent could the results be applied to the U.S., where imaging overutilization has become a major issue in controlling healthcare costs? Another expert in the field noted that while the study is "excellent" and such a program should be applied in the U.S., the triaging approach is difficult to apply in that country.
In the U.S. "patients have come to expect an MRI every time they have back or neck pain," said Dr. Adam Pearson, an assistant spine surgery professor at Dartmouth-Hitchcock Medical Center in New Hampshire, where clinicians try to use a similar approach.
"Unfortunately, many patients referred from the community already have undergone advanced imaging and have been informed that they have a structural problem with their spine," Pearson said. "Once this has happened, it is often quite difficult to convince patients that their MRI is actually normal for someone their age and does not explain their symptoms."
