Benjamin J. Miller, MD, MS on behalf of the Musculoskeletal Oncology Research Initiative
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Transcript of Benjamin J. Miller, MD, MS on behalf of the Musculoskeletal Oncology Research Initiative
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ADVANCED IMAGING IS OVERUSED PRIOR TO REFERRAL TO A MUSCULOSKELETAL ONCOLOGIST: A PROSPECTIVE, MULTI-CENTER INVESTIGATION Benjamin J. Miller, MD, MS on behalf of the Musculoskeletal Oncology Research Initiative
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Conflicts of Interest Nothing to disclose
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Background Bone and soft tissue tumors initially seen
by general orthopaedist or PCP No clear guidelines for use of advanced
imaging (MRI, CT, bone scan, U/S, PET) Medical imaging identified as contributor
to overspending
Reducing superfluous imaging studies prior to referral is important
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Prior studies Aboulafia et al, CORR, 2002
Prospective, single center, 100 patients 34% unnecessary MRI scans
Martin et al, CORR, 2012 Retrospective, single-center, 920 patients 3% unnecessary MRI
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Questions Is there regional variation in the use of
advanced imaging? Are there common characteristics
predictive of excessive studies?
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Materials and Methods
8 centers Prospective 50 patients or 6 months of
referrals Bone and soft tissue tumors All anatomic locations
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Data elements Patient details
Age, sex, race, insurance Tumor type
Bone or soft tissue Specialty of referring MD Distance travelled Studies performed prior to referral
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Subjective material Determined only by the single treating
orthopaedic oncologist What happens in actual practice?
Presumptive diagnosis Likely benign (Benign tumor or non-
neoplastic) Likely malignant (Malignant tumor or
unknown) Necessary or excessive study
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“Necessary study” criteria Needed for routine work-up of condition Helpful in determining diagnosis
Borderline studies considered “necessary” Benefit of the doubt given to referring
physician
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“Necessary study” criteria MRI specifically
Soft tissue Biopsy proven sarcoma >5 cm Deep to fascia Painful Growing
Bone Concern for sarcoma on x-ray
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Statistical analysis Chi-square and t test Univariate and multivariate logistic
regression
Post hoc power analysis 90% power to detect 20% difference
between centers
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Results 371 patients 301 (81%) with at least 1 study
263 (71%) with MRI 54 (15%) with CT 40 (11%) with bone scan 21 (6%) with ultrasound 14 (4%) with PET scan
81 (22%) with multiple studies
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Results Regions differed by age, race, insurance
status, and distance travelled Demographics variable
No differences in use of prereferral imaging by region (p=0.164) Range 66% to 88%
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Results 113 (30%) with unnecessary studies
46 (17%) MRI 40 (74%) CT 25 (62%) bone scan 16 (76%) ultrasound 7 (50%) PET scan
No difference between orthopaedic or PCP referrals (p=0.940)
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Univariate analysis Benign bone tumors more likely to have
excessive imaging (OR 2.18, 95% CI 1.39-3.43)
Differences by practice location
Findings held in multivariate analysis
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Effect of Region No obvious differences in number or types of
studies Generalizable results
Differences in labeling “unnecessary” Substantial variation between fellowship-trained
tumor surgeons Consistent with prior studies
Minimum 3% (Martin 3%) and maximum 31% (Aboulafia 34%)
Need for clearer guidelines based on objective, reproducible criteria
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Summary Helpful – MRI
Most utilized study (71%) 83% deemed necessary Use contrast, visualize entire compartment
6% repeated Not helpful – everything else
High rate of “unnecessary” Should be left to treating team
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Recommendations Appropriate advanced imaging is
beneficial Goal is not to totally eliminate
No imaging other than MRI No MRI in radiographically benign bone
tumors
Would change 30% excessive studies to 4%
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MORI participants Raffi Avedian Judd Cummings Tessa Balach Kevin MacDonald Lee Leddy Jeremy White Raj Rajani Ben Miller