Benjamin J. Miller, MD, MS on behalf of the Musculoskeletal Oncology Research Initiative
description
Transcript of Benjamin J. Miller, MD, MS on behalf of the Musculoskeletal Oncology Research Initiative
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
Conflicts of Interest Nothing to disclose
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
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
Questions Is there regional variation in the use of
advanced imaging? Are there common characteristics
predictive of excessive studies?
Materials and Methods
8 centers Prospective 50 patients or 6 months of
referrals Bone and soft tissue tumors All anatomic locations
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
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
“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
“Necessary study” criteria MRI specifically
Soft tissue Biopsy proven sarcoma >5 cm Deep to fascia Painful Growing
Bone Concern for sarcoma on x-ray
Statistical analysis Chi-square and t test Univariate and multivariate logistic
regression
Post hoc power analysis 90% power to detect 20% difference
between centers
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
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%
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)
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
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
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
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%
MORI participants Raffi Avedian Judd Cummings Tessa Balach Kevin MacDonald Lee Leddy Jeremy White Raj Rajani Ben Miller