Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care

Abstract

ObjectivesThe largest proportion of general practitioner (GP) magnetic resonance imaging (MRI is musculoskeletal (MSK), with consistent annual growth. With limited supporting evidence and potential harms from early imaging overuse, we evaluated practice to improve pathways and patient safety.MethodsCohort evaluation of routinely collected diagnostic and general practice data across a UK metropolitan primary care population. We reviewed patient characteristics, results and healthcare utilisation.ResultsOf 306 MSK-MRIs requested by 107 clinicians across 29 practices, only 4.9% (95% CI ±2.4%) appeared clearly indicated and only 16.0% (95% CI ±4.1%) received appropriate prior therapy. 37.0% (95% CI ±5.5%) documented patient imaging request. Most had chronic symptoms and half had psychosocial flags. Mental health was addressed in only 11.8% (95% CI ±6.3%) of chronic sufferers with psychiatric illness, suggesting a solely pathoanatomical approach to MSK care. Only 7.8% (95% CI ±3.0%) of all patients were appropriately managed without additional referral. 1.3% (95% CI ±1.3%) of scans revealed diagnoses leading to change in treatment (therapeutic yield). Most imaged patients received pathoanatomical explanations to their symptoms, often based on expected age or activity-related changes. Only 16.7% (95% CI ±4.2%) of results appeared correctly interpreted by GPs, with spurious overperception of surgical targets in 65.4% (95% CI ±5.3%) who suffered ‘low-value’ (ineffective, harmful or wasteful) post-MRI referral cascades due to misdiagnosis and overdiagnosis. Typically, 20%–30% of GP specialist referrals convert to a procedure, whereas MRI-triggered referrals showed near-zero conversion rate. Imaged patients experienced considerable delay to appropriate care. Cascade costs exceeded direct-MRI costs and GP-MSK-MRI potentially more than doubles expenditure compared with physiotherapist-led assessment services, for little-to-no added therapeutic yield, unjustifiable by cost–consequence or cost–utility analysis.ConclusionUnfettered GP-MSK-MRI use has reached unaccceptable indication creep and disutility. Considerable avoidable harm occurs through ubiquitous misinterpretation and salient low-value referral cascades for two-thirds of imaged patients, for almost no change in treatment. Any marginally earlier procedural intervention for a tiny fraction of patients is eclipsed by negative consequences for the vast majority. Only 1–2 patients need to be scanned for one to suffer mismanagement. Direct-access imaging is neither clinically, nor cost-effective and deimplementation could be considered in this setting. GP-MSK-MRI fuels unnecessary healthcare utilisation, generating nocebic patient beliefs and expectations, whilst appropriate care is delayed and a high burden of psychosocial barriers to recovery appear neglected.

Assessment and monitoring of Achilles tendinopathy in clinical practice: a qualitative descriptive exploration of the barriers clinicians face

“…This may not necessarily be the case and was not reported by physiotherapists working within elite sport where cost is not a barrier. While several strategies exist to remove this barrier, one solution is to avoid costly assessment protocols not supported by the evidence, such as imaging, 40 and given the potential for iatrogenic effects related to overtesting this barrier might actually be useful. However, it should be acknowledged that some factors (such as geographical or cultural factors) influence whether imaging is a financial burden with many countries globally not having out-of-pocket expenses for patient imaging.…”

Assessment and Monitoring of Achilles Tendinopathy in Clinical Practice: A Qualitative Exploration of the Barrier’s Clinicians Face.

“…This may not necessarily be the case and was not reported by physiotherapists working within elite sport where cost is not a barrier. Whilst several strategies exist to remove this barrier one solution is to avoid costly assessment protocols not supported by the evidence, such as imaging, 35 and given the potential for iatrogenic effects related to over-testing this barrier might actually be useful. These resources could then be redirected to fund ideal-practice management, which could be mediated through clinician education.…”

From Where We've Come to Where We Need to Go: Physiotherapy Management of Chronic Whiplash-Associated Disorder

“…However, the clinical utility (and influence on physiotherapy practice) of such imaging findings remains unclear at this time. At present, we posit that the priority for imaging remains attempting to reduce non-guideline concordant imaging for WAD, given the known propensity for iatrogenic outcomes and increased costs ( 37 ).…”