The use of low-value imaging: the role of referral practice and access to imaging services in a representative area of Norway

Abstract

Background Even though imaging is essential to modern medicine, some examinations are of low value as they do not lead to any change in the management of the patient. The Choosing Wisely (CW) campaign aims to reduce the use of such services. In the Norwegian version of CW, specific magnetic resonance imaging (MRI) of the head, lower back, and knee are amongst others identified as potential low-value examinations. However, referral practice and access to imaging may drive low-value utilisation. By using registry data from 2019 and descriptive analysis, this study aimed to examine the role of referral practice and access to imaging on the use of specific CW-examinations in one representative area in Norway. Results A total of 237,554 examinations were performed by four public and two private imaging facilities located within the area. Forty-two percent (19,210/45,289) of all MRI examinations were related to CW. Private imaging centres performed most of the CW-imaging. A total of 3700 referrers were identified, and 2.3% were identified as “high-referrers,” accounting for 33% of all CW-examinations. Referrers’ experience did not influence imaging utilisation. A subset of referrers (“super-referrers,” 0.5%) accounted for 10% of CW-examinations. Distance to service had no impact on the use of CW-examinations. Conclusions This study provides valuable insight into the use of imaging and referral practice in one representative area in Norway. A great variation in referral practice was observed. Therefore, targeting referrers with high referral rates may be a promising strategy for reducing the use of low-value imaging.

Temporal and geographical variations in diagnostic imaging in Norway

“…One potential explanation for access being a key factor of utilization is long wait times in the public system for very many diagnostic imaging examinations (up to 52 weeks), while wait times are much shorter in the private services (up to 12 weeks). This accounts for some imaging migration and implicit division of labor, corresponding to a recent study from Norway indicating that people are willing to travel to receive imaging services [37].…”

“…Whilst supply-sensitive services and organizational culture is documented to be determinant for overuse and low-value care [35], it is specifically documented that both patient expectations, and local culture and procedures are drivers for unnecessary imaging utilization in Norway [36]. Furthermore, the great variation in referral practice documented [37] might yield variation in imaging utilization. Consequently, the results correspond well with the findings with the Office of the Auditor General of Norway [38], with national analyses of outpatient data (https://www.skde.no/helseatlas/v2/ radiologi/), and with studies of specific examinations [17,39].…”

Hospitalizations and re-hospitalizations at the end-of-life among cancer patients; a retrospective register data study

“…Advanced imaging, such as MRI, might lead to appropriate palliative treatment approaches and de-escalate the intensity of care by reducing futile treatment. However, it can also distract patients from achievable end-of-life goals and are time-consuming and costly procedures [ 25 ].…”