DO YOU REALLY NEED THAT MRI

Too many tests at the doctor's office could cost you more than just dollars. In addition to the huge hit to your wallet, there's also the potential harm of false positives, and just because a test has traditionally been done for a condition doesn't mean it's the best way to treat it

U-M neurologist Brian Callaghan, M.D., M.S., is helping lead a national push to determine what neurologic tests or services are performed more than they should be.

It comes out of a campaign called Choosing Wisely, an initiative of the ABIM Foundation, which works with more than 70 medical specialty societies to encourage conversations between clinicians and patients about avoiding wasteful or unnecessary medical tests, treatments and procedures. Each society, including the American Academy of Neurology (AAN), got together to identify an initial list of five medical services that may be unnecessary. Many societies have returned with second, or even third, lists of five.

Callaghan's neurology group started by looking into the AAN's list, and then went further to identify a whopping 74 items to look into from other recommendations that addressed neurological care, such as from the American Academy of Sleep Medicine and the American Academy of Neurological Surgeons. Many were duplicates, which might indicate a consensus of areas to focus on.

"The two biggest areas that might be done more than they should are imaging for low back pain and imaging for headaches," Callaghan said. "It's a big problem and it costs a lot of money -- we're talking a billion dollars a year on just headache imaging."

The other test/treatment appearing most often was opioids, or pain medications.

The diseases/symptoms that appear most often are

·         Low back pain

·         Dementia/delirium

·         Headache

·         Concussion

·         Stroke

Callaghan and his colleagues aren't encouraging you to say no if your doctor wants to image your low back pain or headache, but instead, they hope to inspire more thought and discussion about the specific purpose of a test.

"Ordering an MRI for a headache is very quick, and it actually takes longer to describe to the patient why that's not the best route," Callaghan said. "These guidelines are meant for physicians and patients both, to trigger a conversation."

The next step is to get the doctor-patient discussions going, so Callaghan's group is now researching how to make it easier for physicians to follow the guidelines.

"These are all areas where lots of physicians agree that you're more likely to get harmed by doing the procedures," Callaghan said.

The team also came up with areas that need more recommendations, including movement disorders, neuromuscular disease, epilepsy and multiple sclerosis.

Is An MRI An Appropriate Test For Neuropathy

Today's post from painmedicinenews.com (see link below) talks about the ongoing doubt amongst medical experts as to what the best form of testing for neuropathy actually is. The high incidence of MRI testing, especially in North America, is intended to rule out other potential problems, rather than to establish neuropathy (which it can't really do). This stems from the fact that doctors are frequently doubtful that they're dealing with a neuropathy problem and want to make sure they're not missing anything else. Considering the high cost of MRIs, this does seem a little wasteful when other tests and the patient's own accounts can be far more accurate indicators of neuropathic problems.

High Rate of MRI Found in Study of Peripheral Neuropathy Diagnosis

But analysis did not examine whether imaging was appropriate or not.

ISSUE: APRIL 2012 by Rosemary Frei, MSc

With more than one dozen diagnostic tools, identifying peripheral neuropathy (PN) can be complex and costly. That is why investigators at the University of Michigan attempted to define diagnostic practice patterns in order to identify opportunities to improve efficiency of PN care.

The researchers identified 1,031 individuals diagnosed with PN between 1996 and 2007 through the Health and Retirement Study and the linked Medicare Standard Analytical Files (Ann Intern Med 2011;172:127-132). They included patients who were at least 65 years old in 1996, and created a matched comparison group. Among the subjects, 41.5% had diabetes and 44.4% of these had diabetic neuropathy; 80% of the nondiabetic individuals had idiopathic neuropathy.

The researchers focused on 15 relevant tests for PN to determine the number and patterns of tests used six months before and after the incident neuropathy diagnosis. After assessing 15 PN diagnosis tests, the investigators found that four were performed most often, on average, but testing patterns were highly variable, with more than 400 different patterns identified. The most common testing pattern was used only in 4.8% of patients.

About one-fourth—23.2%—had at least one magnetic resonance imaging (MRI) of the brain or spine, whereas a glucose tolerance test was rarely obtained (1%). Almost one-fifth (19.8%) of patients with neuropathy received electromyography. A complete blood cell count was ordered in 73.1% of patients, thyrotropin level in 55.2%, comprehensive metabolic panel in 53.2%, erythrocyte sedimentation rate in 28.7% and an antinuclear antibody test in 11.2%.

Additionally, a fasting glucose level test was ordered in 23.4% of patients with neuropathy. A hemoglobin A_1c level was ordered in 43.2% of those with neuropathy and 17.1% of nondiabetic patients. Vitamin B₁₂ levels were ordered in 32.6% of patients with neuropathy and in 40.6% of nondiabetic patients.
The large number of tests translated into high levels of Medicare expenses during the diagnostic period, at $14,362 per patient per year.

“High MRI use is probably for many reasons including physicians not being confident that someone has PN, the fact that no cause is identified for many cases with neuropathy, which pushes physicians to order more tests and because patients often prefer more testing, especially MRIs,” said Brian Callaghan, MD, assistant professor of neurology at University of Michigan Medical School, Ann Arbor.

The team concluded that more research is needed on the optimal approach for diagnosing PN. “First, I think we need to firmly establish what the best tests are for the evaluation of this condition. Next, we need to increase awareness among physicians including internists and neurologists that see this common condition,” said Dr. Callaghan.

Despite the high use of MRI, the evidence indicates two-hour oral glucose tolerance, fasting glucose, vitamin B₁₂ levels and serum protein electrophoresis provide the highest true-positive rate and the greatest potential for guiding subsequent interventions (Neurology 2009;72:185-192).

Vera Bril, MD, suggested that the high use of MRI likely is linked to testing for comorbid conditions, rather than for PN itself. “You need to know why the physicians ordered the MRIs; it’s a leap to assume it’s inappropriate,” said Dr. Bril, professor of neurology at the University of Toronto and head of neurology at the University Health Network and Mount Sinai Hospital, Toronto, Canada.
“The patients in my clinic of this age often have spinal degenerative disease in addition to PN. I don’t do MRIs in my straightforward PN patients, but if they have spinal involvement. I’ll look further at it, including possibly with MRI.”

http://www.painmedicinenews.com/ViewArticle.aspx?d=Clinical%2bPain%2bMedicine&d_id=82&i=April+2012&i_id=826&a_id=20593