MRI在診斷膝蓋關節炎方面可能被過度使用


  March 7, 2008 (舊金山) — 雖然負重X光已經足夠用於診斷膝蓋關節炎之用, 但部分外科醫師和骨科醫師有時候會合併使用核磁共振造影(MRI)或者取代負重X光進行診斷;伊利諾大學醫學院骨科臨床教授、伊利諾骨關節研究中心主席Wayne M. Goldstein醫師表示,大部分的案例中以MRI診斷骨關節炎通常是不需要且花費太多。
  
  Goldstein醫師在美國骨科醫師學會(AAOS)第75屆年會中發表他的研究發現;Goldstein醫師等人在壁報中表示,檢查影像花費佔Medicare健保的10%-15%,相較於10年前只有不到5%;過度運用MRI導致高花費,特別是已經用放射線檢查證實有膝蓋骨關節炎者。
  
  Goldstein醫師等人回顧病例,並且以電話訪問50個隨機篩選的疑似骨頭對骨頭接合、曾接受他初步全膝蓋置換術(TKA)治療的關節炎病患;轉診醫師曾開立醫令對32個病患進行MRI,大部分病患在進行MRI之前未接受過X光。
  
  Goldstein醫師向Medscape骨科學表示,對於TKA病患,約有95%-98%不需要MRI;研究者在壁報中表示,MRI最好用於診斷一些罕見的膝蓋問題,如自發性骨壞死;Goldstein醫師指出,第一線的照護醫師和少部分的骨科醫師可能進行了不需要的 MRI轉診,因為他們不完整了解肌肉骨骼系統。
  
  此外,關節炎病患通常預期接受MRI診斷,而這種要求影響了MRI的使用;Goldstein 醫師向Medscape骨科學表示,我有一些病患是全膝蓋置換術且有脊椎狹窄疼痛、且膝蓋受傷,然後他們表示「我能否利用MRI檢查膝蓋的金屬植入物?」MRI看似檢查病患有無問題的萬能藥—大多數的人表示「我們進行MRI,就可以找到問題」。
  
  根據研究者表示,財政上也激勵了MRI的使用;膝蓋MRI平均給付給專科醫師合約機構的費用可能會超過 $1200, 而在同樣機構中,進行4個角度的X光檢查只約需要$193;醫院以及私人影像中心花費在膝蓋MRI的費用為 $1400- $2500。
  
  勞動者的平均補償方面,接受MRI者為$664,也高於接受膝蓋X光者$136;而2008年Medicare健保核准的補償方面,膝蓋MRI者為$457.33), 膝蓋X光為$43.39,擁有MRI機器的醫師比較可能要求進行MRI;Goldstein 醫師向Medscape骨科學表示,如果你有一台MRI,你必須有合格證書來適當運用這昂貴的科技。
  
  加州大學舊金山分校的骨科副教授Kevin J. Bozic醫師以及健康政策研究中心的Philip R. Lee向Medscape骨科學表示,這篇壁報是相當相當小型的研究,只有50個病患,這表示需要對提供肌肉骨骼照護者,如第一線照護醫師、關節炎專家、骨科醫師等有更好的教育, 不只是那些照顧關節炎病患的骨科醫師。
  
  Bozic醫師表示,有些骨科醫師辦公室,例如運動醫學開業醫師,可能比一般關節炎開業醫師如Goldstein更經常需要MRI;他指出,第一線照護醫師可能會要求不必要的MRI,因為醫師認為可以節省骨科醫師和病患的時間,這顯示醫師和轉診醫師之間對於病患的需求要有更好的溝通。Bozic醫師指出, AAOS 有診斷膝蓋疼痛的規範。
  
  Goldstein醫師的研究沒有外來資金。作者宣稱無相關資金上的往來。
  
  美國骨科醫師學會第75屆年會:壁報P145。發表於2008年3月6日 。

MRI May Be Overused in Diagnos

By Laurie Bouck
Medscape Medical News

Laurie Bouck

March 7, 2008 (San Francisco) — Although weight-bearing X-rays are sufficient to diagnose osteoarthritis of the knee, referring physicians and some orthopaedic surgeons sometimes use magnetic resonance imaging (MRI) either with or instead of weight-bearing X-rays for diagnosis. Wayne M. Goldstein, MD, clinical professor of orthopaedics at the University of Illinois at Chicago College of Medicine and chairman of the Illinois Bone and Joint Institute, Chicago, says that in most cases, diagnosing osteoarthritis with an MRI is both unnecessary and costly.

Dr. Goldstein presented his findings as senior investigator in a poster here at the American Academy of Orthopaedic Surgeons (AAOS) 75th Annual Meeting. "Medical imaging now consumes 10% to 15% of Medicare payments to physicians, compared with less than 5% only a decade ago," Dr. Goldstein and colleagues state in the poster. "Over-utilization of MRI contributes to cost, especially in a radiographically proven osteoarthritic knee."

Dr. Goldstein and colleagues performed reviewed the charts of and and made telephone calls to 50 randomly selected osteoarthritis patients with suspected bone-on-bone articulation whom he had treated surgically with primary total knee arthroplasty (TKA). The referring physician had ordered an MRI for 32 of the patients, and most of the patients did not have X-rays taken before the MRI.

Dr. Goldstein told Medscape Orthopaedics that for TKA patients, "About 95% to 98% of the time they don't need an MRI." MRIs are best used to diagnose rare knee problems such as spontaneous osteonecrosis, the investigators state in the poster. Dr. Goldstein added that primary care physicians and a small percentage of orthopaedic surgeons might make unnecessary MRI referrals because they do not understand the musculoskeletal system well.

In addition, osteoarthritis patients often expect to be diagnosed with MRIs, and this demand influences MRI use. "I've had patients come in who have a total knee [arthroplasty] and have pain from spinal stenosis, and their knee hurts, and they'll say, 'shouldn't I get an MRI of my knee, this metal implant?'" Dr. Goldstein told Medscape Orthopaedics. "[MRI] seems like the panacea for finding whatever is wrong with the patient — most people say 'we'll MRI it, and we'll find it.' "

Financial incentives also may play a role in MRI use, according to the investigators. Average knee MRI reimbursements can exceed $1200 at a specialty physician provider contracting organization he studied compared with approximately $193 for a 4-view X-ray of the knee at the same organization. The hospital and private imaging centers billed $1400 to $2500 to insurers for knee MRIs.

Average worker's compensation reimbursement is also higher for the knee MRI ($664) than for the knee X-rays ($136), and the 2008 Medicare allowable reimbursement is far higher for a knee MRI ($457.33) than for knee X-rays ($43.39). Physicians who own MRI scanners might be more likely to request an MRI. Dr. Goldstein told Medscape Orthopaedics that "if you've got an MRI, you must take a class and be credentialed to apply this expensive technology appropriately."

Kevin J. Bozic, MD, MBA, associate professor in residence at the Department of Orthopaedic Surgery and the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, told Medscape Orthopaedics that the poster was "a very, very small study" of just 50 patients. "What this points to is that there is a need for better education of people who provide musculoskeletal care, which includes primary care physicians, rheumatologists, orthopaedic surgeons — not just orthopaedic surgeons who take care of people with arthritis."

Dr. Bozic said that some orthopaedic surgery offices, such as a sports medicine practice, might require MRIs more frequently than an arthritis practice such as Dr. Goldstein's. He added that a primary care physician might order an unnecessary MRI because the physician thinks it will save the orthopaedic surgeon's and the patient's time. This action shows "a need for better communication between surgeons and referring providers about what they need to get a patient in to see them." Dr. Bozic added that the AAOS has guidelines available for diagnosing knee pain.

Dr. Goldstein's study did not receive external funding. The authors have disclosed no relevant financial relationships.

American Academy of Orthopaedic Surgeons 75th Annual Meeting: Poster P145. Presented March 6, 2008.

    
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