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Use of Ankle Magnetic Resonance Imaging in the Active Duty Military Population: The Results of a Process Improvement Project.

The active duty military population is an athletic community that participates in a variety of physically challenging activities and is subject to a wide variety of musculoskeletal injuries. Specifically, ankle injuries are among the most common injuries, with reported incidence rates as high as 58.4 per 1,000 person-years among cadets at the United States Military Academy, amounting to a 10-fold increase compared to civilian epidemiologic reports. (1) Performing a thorough history and physical examination and obtaining appropriate radiographs should be the first step in identifying the diagnosis of a musculoskeletal complaint. When these modalities fail to elicit an appropriate diagnosis, primary care providers are frequently ordering advanced imaging, including magnetic resonance imaging (MRI) studies, prior to referral to specialists. (2) Avoiding unnecessary, costly advanced imaging and preventing overuse of MRI in a primary care setting for diagnosing ankle pathology was the goal of a recent process improvement project at a military treatment facility.

Magnetic resonance imaging is best used in eases where the differential diagnosis is narrow, and a precise understanding of the pathology is required for preoperative planning. (3) Current trends, however, show magnetic resonance imaging being used more frequently as a screening tool. (4) Magnetic resonance imaging can be overly sensitive in demonstrating findings that are not clinically significant, and can lead to misdiagnosis or overdiagnosis and treatment. (5) Increasing medical costs, decreasing reimbursements, and overuse of imaging modalities have led to a growing interest in processes to decrease use of costly, oftentimes unnecessary, tests. (6)

Concern regarding the use of ankle MRI studies prompted fellowship-trained foot and ankle surgeons at our institution to hypothesize that ankle MRI was overused in the military setting, and inspired a process improvement initiative. The purpose of the initiative was to: evaluate the use of ankle MRI studies ordered by all health care providers in the military population; correlate the MRI results to their treatment pathway of operative or non-operative treatment; and propose solutions to improve use of ankle MRI. To evaluate this, we studied the MRI ordering patterns of both orthopaedic surgeons and non-orthopaedic providers (NOPs) from internal medicine, family medicine, etc. Further, in an effort to improve overall ankle MRI use, we undertook an educational outreach initiative to improve understanding of NOPs of the clinical utility of advanced imaging.

Methods

This process improvement project consisted of 2 phases and was led by the Department of Orthopaedics. The radiographic database at our institution (Impax) was queried for all ankle MRI studies performed consecutively from October 1, 2009 to March 31, 2010 (Phase 1). We limited the results of the seareh to only active duty servicemembers aged 18 years and older. The data collected from the electronic radiographic database included the chief complaint, clinical indication, findings of the ankle MRI, date of the MRI, and specialty of provider who ordered the study. Next, the orthopaedic clinical scheduling system (AHLTA) was queried and cross-referenced to the list of ankle MRI studies to determine if patients were ultimately referred for orthopaedic evaluation. Finally, the surgery scheduling system (S3) was referenced to determine what surgeries were performed on patients from the ankle MRI studies list. No personal patient identifiers were recorded. The clinical indication for the MRI and subsequent operative procedure(s) were assessed with the primary outcome measure defined by whether or not the patient underwent an orthopaedic operative intervention. Secondary measures evaluated included the specialty of the provider ordering the study, changes in referral patterns, and whether or not plain radiographs were obtained prior to MRI.

The results of Phase 1 of the process improvement project were then presented to hospital leadership, and an education plan was developed and implemented. Approved measures were implemented from August to November 2012 and included updated clinical referral guidelines on the health system intranet available to all providers. This update specifically stated that ankle MRIs should not be ordered prior to referral to an orthopaedic surgeon, and included recommendations for ordering plain radiographs prior to referral to an orthopaedic surgeon. This update was announced to all providers electronically as well as at 3 different professional staff meetings for the hospital. Sincc quarterly attendance at this meeting is mandated by hospital leadership, it was felt that the information would be disseminated appropriately. Finally, the orthopaedic foot and ankle surgeons provided 3 inservices on indications for advanced imaging, including MRI, for outlier clinics and the Departments of Internal Medicine and Family Medicine. Once the education process was completed, the radiographic database was once again searehed from December 1, 2012 to August 30, 2013 (Phase 2) with the same criteria as the initial time period. Statistical analysis was performed using Fisher's exact test (GraphPad Software, Inc, La Jolla, CA). Statistical significance was set at P<.05.

Results

Phase 1

From October 1,2009 to March 31,2010,230 ankle MRI studies were performed on active duty personnel. Of the 230 active duty servicemembers with ankle MRI studies, 143 (62%) patients had an MRI ordered by NOPs and 87 patients (38%) had an MRI ordered by an orthopaedic provider. There were 17 patients (7%) who did not have plain radiographs performed prior to the MRI. Of the 143 MRI scans ordered by the NOPs, 98 patients (69%) were referred to an orthopaedic provider. During Phase 1 of the process improvement initiative, 185 of 230 patients, (80%) of this cohort were evaluated and treated by the orthopaedic surgery department at our facility. The most common complaints stated as reasons for obtaining an MRI were pain followed by instability. The most common diagnoses obtained by MRI included chronic injuries to the lateral ankle ligaments, talus osteochondral defects, and Achilles tendinosis.

Of the entire cohort of patients undergoing ankle MRI, 59 of 230 patients (25%) were eventually indicated for surgery. Of the 143 patients for which an ankle MRI study was ordered by NOPs, 98 (69%) patients were referred to orthopaedics for evaluation, and of those, 33 (23%) underwent an operative procedure (Figure 1). By comparison, the orthopaedic group ordered 87 ankle MRI studies and 26 (30%) patients underwent an operative procedure (Figure 2). Within the orthopaedic group, foot and ankle surgeons and podiatrists were evaluated as groups separate from the rest of the orthopaedic department. Ankle MRI studies ordered by podiatrists resulted in 6 out of 40 (15%) patients undergoing an operative procedure, while 20 of 47 (43%) patients with MRI studies ordered by an orthopaedic surgeon underwent an operative procedure. When fellowship-trained foot and ankle orthopaedic surgeons were excluded from this analysis, only 8 of 26 patients (30%) underwent an operative procedure. Of the 21 patients evaluated by a fellowship-trained foot and ankle surgeon, 12 (57%) underwent an operative procedure.

When comparing the NOPs to the orthopaedic group, there was no significant difference in yield of operative patients with ankle MRI studies between the 2 groups (P=.28). However, there was a significant difference in the proportion of patients with ankle MRI associated with an eventual operative intervention ordered by fellowship-trained foot and ankle orthopaedic surgeons compared to those with ankle MRI ordered by NOPs (P=.003). When comparing fellowship-trained foot and ankle orthopaedic surgeons and orthopaedic surgeons, there was no significant difference in yield of operative patients with ankle MRI studies between the 2 groups (P=.08). The most common operative procedures performed are listed in the Table.

Phase 2

From December 1, 2012 to August 30, 2013, 347 ankle MRI studies were performed on active duty personnel. Of the 347 active duty servicemembers with ankle MRI studies, 228 (66%) patients had ankle MRI studies ordered by NOPs and 119 patients (34%) had an MRI ordered by an orthopaedic provider. There were 58 patients (17%) who did not have plain radiographs performed prior to the MRI. Of the 228 MRI studies ordered by the NOPs, 143 patients (63%) were referred to an orthopaedic provider, which was not significantly different from Phase 1 (P=.27). There were 262 of 347 (76%) patients evaluated and treated by the orthopaedic surgery department, which was not significantly different from Phase 1 (P=.19). Pain and instability remained the most common patient complaints, and there were no changes in the most common diagnoses obtained by MRI.
The most common procedures performed
on patients with preoperative ankle MRI
studies.

Lateral ankle ligament reconstruction

Ankle arthroscopy with debridement

Microfracture of osteochondral defects

Reconstruction of cavovarus foot

Reconstruction of planovalgus foot

Excision of osteophytes


Of the entire cohort of patients undergoing ankle MRI, 58 of 347 (17%) patients were eventually indicated for surgery. Of the 228 patients for which an ankle MRI study was ordered by NOPs, 143 (63%) patients were referred to orthopaedics for evaluation, and of those, 29 (13%) underwent an operative procedure (Figure 3). By comparison, the orthopaedic group ordered 119 ankle MRI studies and 29 (24%) patients underwent an operative procedure (Figure 4). Foot and ankle surgeons as well as podiatrists were evaluated as groups separate from the rest of the orthopaedic department once again. Ankle MRI studies ordered by podiatrists resulted in 4 out of 29 (14%) of patients undergoing an operative procedure, while 25 out of 90 (28%) of patients with MRI studies ordered by an orthopaedic surgeon underwent an operative procedure. When the foot and ankle surgeons were excluded from this analysis, only 9 of 50 patients (18%) underwent an operative procedure. Of the 40 patients with ankle MRI studies ordered by foot and ankle surgeons, 16 (40%) had an operative procedure performed.

When comparing the NOPs to the orthopaedic group, there was a significantly higher yield of operative patients (P=.01) with ankle MRI studies in favor of the orthopaedic group for Phase 2. There continued to be a significantly higher yield of operative patients from the subgroup of patients with an ankle MRI ordered by foot and ankle surgeons compared to those with an ankle MRI ordered by NOPs (P=.0001). When comparing fellowship-trained foot and ankle surgeons to orthopaedic surgeons, foot and ankle surgeons had a significantly higher yield of operative patients following MRI for Phase 2 (P=.03). The most common procedures performed during Phase 2 were no different compared to Phase 1.

A lower yield of patients underwent an operative procedure after the education process than before (17% versus 25%). There was a significant decrease from Phase 1 to Phase 2 in the overall number of operative patients with an ankle MRI study, regardless of which provider ordered the ankle MRI (P=.01). There was no difference in patient referral rates to orthopaedies in Phase 1 versus Phase 2 following the order of an ankle MRI by NOPs {P=21). Significantly fewer plain films were ordered prior to ordering advanced imaging in Phase 2 compared to Phase 1 (P=.001). There was no change in the number of ankle MRI studies ordered each month (38.3 ordered in the preeducation process, and 38.5 posteducation).

Comment

Throughout both phases of the process improvement initiative, fellowship-trained foot and ankle surgeons produced the highest yield of operative patients with their MRI ordering practices (P=.003 and P=.0001 for Phase 1 and Phase 2 respectively). Following the educational initiative, there was no decrease in the number of monthly ankle MRI studies performed, fewer patients with ankle MRI studies underwent operative procedures, and fewer radiographs were ordered before advanced imaging. Additionally, the decrease in operative candidates between orthopaedics surgeons and fellowship-trained foot and ankle surgeons in Phase 2 could suggest that the necessity of ongoing training on the indications for ankle MRI is not isolated to the NOPs, and should include orthopaedic surgeons as well. The fact that referral rates did not change also raises concern that there remains a large group of patients (>30% in both phases) that may have undergone unnecessary advanced imaging.

Few studies in the orthopaedic literature evaluate use of MRI. In a study by Tocci et al, researchers identified 201 patients that were evaluated over a 3-month period; 19.9 % had MRI studies of the ankle during their coursc of treatment, 15.4% presented to the initial visit with a MRI scan from an outside provider, and 4.5% of the patients received an MRI scan ordered by the foot and ankle specialist." This study further mentions that 87% of the prereferral MRI scans were thought to be unnecessary, and all 9 MRI studies ordered by the foot and ankle specialist were useful in the care of the patient. (3) Bradley et al evaluated the use of MRI in chronic shoulder pain patients and identified that the majority of the preevaluation MRI scans had no effect on the outcomes of the patients, and although not statistically significant, further analysis revealed a tendency towards patients with an MRI to choose surgery over nonoperative treatment when patients had knowledge of pathologic anatomy from an advanced imaging modality. (4) These authors concluded that routine preevaluation with MRI docs not appear to have a significant effect on the treatment or outcome and should not be used as a screening tool for atraumatic shoulder pain before a comprehensive clinical evaluation of the shoulder. (4) When ordering an MRI, caution must also be taken, as false positive results occur and can further alter the perception of the diagnosis and subsequent treatment plan.

Saxcna et al evaluated 100 patients with asymptomatic ankles who had an ankle MRI performed, and noted that 66% of the patients had no history of an ankle sprain and 34% had a history of at least one ankle sprain. (5) Results from the study showed that 30% of asymptomatic patients had abnormal findings with the anterior talofibular ligament and peroneal tendons, and 11% had an abnormal calcancofibular ligament. (5) Schneck et al have documented that 90% of patients with lateral ankle instability can be treated nonoperatively. (6) In our process improvement initiative, 93% of patients had a radiographic abnormality, but few underwent an operative procedure. This is further highlighted by the fact that Achilles tendinosis appeared as one of the most common diagnoses based on MRI findings. However, Achilles procedures are not among most commonly performed procedures as shown earlier in the Table. The large number of radiographic abnormalities docs not necessarily correlate with the necessity for operative intervention, confirming results previously published.

Overuse of advanced imaging studies increases medical costs, places undue stresses on the patient's time, and can lead to adverse outcomes. (7-8) Radiologists have recognized that more expensive imaging modalities are being overused, and are taking the lead in the reform process by implementing strategics to decrease the unnecessary use. (9,10) Solutions have been proposed for improving use of medical imaging which include a national collaborative effort to develop evidence-based appropriateness criteria for imaging, greater use of practice guidelines in requesting and conducting imaging studies, decision support at point of care, education of referring physicians, accreditation of imaging facilities, management of self-referral and defensive medicine, as well as payment reform. (11-14) Decision support at the point of care can include radiologist or fellowship-trained specialist approval of advanced imaging concurrent with a patient referral. From 2000 to 2006, Medicare expenditures for diagnostic imaging represented the highest growth rate compared with all other specialties, and spending on imaging studies per beneficiary nearly doubled. (15) Even though solutions have been proposed, overuse of advanced imaging modalities continues to be an area of ongoing concern.

This study has several limitations. First, it is possible that patients were indicated for surgery outside the interval we chose to analyze; however, the percentage of patients evaluated during Phase 1 and Phase 2, 80% and 76% respectively, suggests that the patterns of evaluation and treatment among groups appear to be relatively similar. Second, the utility of advanced imaging such as an ankle MRI is multifaceted, and this study only considered the value MRI may provide in terms of preoperative planning. We concede that measuring the treatment pathway is an imperfect outcome measure to assess the utility of ankle MRI, but in this process improvement initiative, we did not intend to evaluate the effect of the MRI on surgeon decision making. Third, the process improvement strategy was limited to educational initiatives primarily targeted at primary care physicians in the clinical decision pathway, but no formal decision support system or imaging approval pathway was implemented to target overuse of MRI. Studies of managed care systems have demonstrated that preauthorization of studies or clinical decision support systems can decrease the use of advanced imaging modalities. (11-14) The importance of systematic changes to control overuse is paramount considering the high rates of turnover among military healthcare providers who may be missed by any education program during deployments and frequent changes of station. It is unclear as the extent to which provider turnover during the intervals we chose to analyze affected the current results. Finally, the percentage of patients indicated for surgery in the foot and ankle surgeon subgroup may also be artificially decreased because the foot and ankle service is often called upon as the final authority to rule out a diagnosis, and advanced imaging is often required. Results of this process improvement initiative support the assertions of the fellowship-trained foot and ankle surgeons that advanced imaging should be obtained at the discretion of the foot and ankle service.

Conclusion

Among servicemembers undergoing ankle MRI, there was a relatively low proportion of patients that ultimately underwent an operative intervention. With this in mind, physicians should reserve advanced imaging of the ankle after conservative treatment measures fail, and the decision to order advanced imaging may be best reserved for the fellowship-trained foot and ankle surgeons. Moreover, these data suggest that a process improvement initiative to decrease rates of advanced imaging use through education alone was ineffective in altering practice patterns among both orthopaedic and NOPs. Future analysis focused on education coupled with decision support systems or image utilization pathways may reveal improved use of advanced imaging in a military setting.

References

(1.) Waterman BR, Belmont PJ, Cameron KL, et al. Epidemiology of ankle sprain at the United States Military Academy. Am J Sports Med. 2010;38(4):797-803.

(2.) Baldor RA, Quirk ME, Dohan D. Magnetic resonance imaging use by primary care physicians. J Fam Prat t 1993;36:281-285.

(3.) Tocci SL, Madom IA; Bradley MP, et al. The diagnostic value of MRI in foot and ankle surgery. Foot Ankle Int. 2007;28(2): 166-168.

(4.) Bradley MP, Tung G, Green A. Overutilization of shoulder magnetic resonance imaging as a diagnostic screening tool in patients with chronic shoulder pain. J Shoulder Elbow Surg. 2005;14(3):233-237.

(5.) Saxena A, Luhadiya A, Ewen, B, et al. magnetic resonance imaging and incidental findings of lateral ankle pathologic features with asymptomatic ankles. J Foot Ankle Surg. 2011;50:413-415.

(6.) Schneck R Jr, Coughlin M. Lateral ankle instability and revision surgery alternatives in the athlete. Foot Ankle Clin North Am. 2009;14:205-14.

(7.) Emery DJ, Shojania KG, Forster AJ, et al. Overuse of magnetic resonance imaging. JAMA Intern Med. 2013;173:823-825.

(8.) Flynn T, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther. 2011;41(ll):838-846.

(9.) Armao D, Semelka R, Elias J. Radiology's ethical responsibility for healthcare reform: tempering the overutilization of medical imaging and trimming down a heavyweight. J Magn Reson Imaging. 2012;35(3):512-517.

(10.) Hendee W, Becker G, Borgstede J, et al. Addressing overutilization in medical imaging. Radiology. 2010;257(l):240-245.

(11.) Bernardy M, Ullrich CG, Rawson JV, et al. Strategies for managing imaging utilization. J Am Coll Radiol. 2009:6:844-850.

(12.) Blachar A, Tal S, Mandei A, et al. Preauthorization of CT and MRI examinations: assessment of a managed care preauthorization program based on the ACR Appropriateness Criteria(r) and the Royal College of Radiology Guidelines. J Am Coll Radiol. 2006:3:851-859.

(13.) Blackmore CC, Mecklenburg RS, Kaplan GS. effectiveness of clinical decision support in controlling inappropriate imaging. J Am Coll Radiol. 2011;8:19-25.

(14.) Lehnert BE, Bree RL. Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support?. J Am Coll Radiol. 2010;7:192-197.

(15.) Sura A, Ho A. Enforcing quality metrics over equipment utilization rates as means to reduce centers for Medicare and Medicaid services imaging costs and improve quality of care. J Clin Imaging Sci. 2011;1(2):28-31.

Maj Harold J. Goldstein, USAF, MC

CPT Richard K. Hurley, Jr, MC, USA

Maj Andrew J. Sheean, USAF, MC

Maj Michael Tompkins, USAF, MC

Col Patrick M. Osborn, USAF, MC

Maj Goldstein is the Orthopedic Surgeon at the Medical Treatment Facilty, Osan Air Base, Republic of Korea.

CPT Hurley and Maj Sheean are with the Department of Orthopaedic Surgery, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas.

When this article was written, Maj Tompkins was with the Department of Orthopaedic Surgery, USAF Hospital Langley, Joint Base Langley-Eustis, Virginia.

Col Osborn is the Residency Program Director, Department of Orthopaedic Surgery, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas.
Figure 1. Results from Phase 1: 143 patients with ankle MRI
studies ordered bv nonorthopaedic providers.

N=143

33 patients
(23% n)
underwent an
operative
procedure

98 patients
(69% N)
referred to
orthopaedics

45 patients
(31% N) not
referred to
orthopaedics

Figure 2. Results of Phase 1 data collection. Percentages represent
the yield of operative patients based on the provider group that
ordered the ankle MRI. Included next to percentages are the number
of operative patients relative to the total number of ankle MRIs
ordered. Note: * indicates statistical significance.

Foot and Ankle Surgeons    57%(12/12)*
Orthopaedic Surgeons       30%(8/26)
Nonorthopaedic Providers   23%(33/143)
Podiatrists                15%(6/40)

Note: Table made from bar graph.

Figure 3. Results from Phase 2: 228 patients with ankle MRI
studies ordered by nonorthopaedic providers.

N=228

85 patients
(37% N) not
referred to
orthopaedics

29 patients
(13% N)
underwent an
operative
procedure

143 patients
(63% N)
referred to
orthopaedics

Figure 4. Results of Phase 4 data collection. Percentages represent
the yield of operative patients based on the provider group that
ordered the ankle MRI. Included next to percentages are the number
of operative patients relative to the total number of ankle MRIs
ordered. Note: * indicates statistical significance.

Foot and Ankle Surgeons    40%(16/40)*
Orthopaedic Surgeons       18%(9/50)
Podiatrists                14%(4/29)
Nonorthopaedic Providers   13%(29/228)

Note: Table made from bar graph.
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Author:Goldstein, Harold J.; Hurley, Richard K., Jr.; Sheean, Andrew J.; Tompkins, Michael; Osborn, Patrick
Publication:U.S. Army Medical Department Journal
Article Type:Report
Geographic Code:1USA
Date:Oct 1, 2017
Words:3755
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