Too Many Too Many’s – Imaging

We are thirsty in the rain.  We have too much medical care and not enough “health” care.

This is the third in the series of Too Many Too Many’s and today we would like to highlight the overutilization of diagnostic imaging in individuals with musculoskeletal pain.   In the U.S. overutilization of x-rays, MRI scans, and CT scans is well documented despite clinical practice guidelines suggesting musculoskeletal imaging should be used to rule out serious pathology or when it would substantially change clinical decision-making.   In a series of recent editorials in the British Journal of Sports Medicine there has been a concerted effort to highlight the harms caused by over imaging here & here and the reasons that clinicians frequently do not adhere to imaging guidelines.

In the USA one of the key problems is ownership of the imaging equipment and/or imaging centers by the referring providers. Given that the spending for spinal MRI scans alone is nearly $6 billion annually it is not surprising that financial incentives distort ordering behavior.  Of serious concern is the fact that increasing MRI scans result in greater volumes of injections & surgery without improved outcomes (see here & here).  It also well documented that a Physical Therapist First rather than imaging first approach decrease costs and harmful treatments.  Unfortunately this does not seem to be changing behavior as the evidence continues to mount that low value imaging is the norm.  A recent study in the JAMA Internal Medicine evaluated over a million patient encounters with over 100,000 clinicians.  The study found that when it comes to complaints of headache and low back pain clinician ownership of imaging equipment was a consistent independent predictor of low-value imaging (OR, 1.65-7.76) across all clinician types and imaging scenarios.

There is no longer debate on what improved care pathways in musculoskeletal pain should be. The challenge is creating incentives, financial and otherwise, that promote high value imaging and thus high value healthcare. We need to continue to be part of the conversation and begin decreasing the use of inappropriate imaging for musculoskeletal pain.

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