膝部MRI往往過度使用了


  【24drs.com】根據研究者於美國骨科醫學會2011年年會上報告的研究結果,超過一半至骨科就診的急性膝疼痛患者,在轉介醫師的要求下進行了不必要的核磁共振(MRI)檢查。
  
  馬里蘭巴爾的摩西納醫院羅賓高等骨科機構髖骨與膝關節置換主任Harpal Singh Khanuja醫師表示,MRI在診斷許多膝部病變上是有用的,且是降低診斷性膝關節鏡需求一個符合經濟效益的方法,當適當進行時,其風險是很低的。
  
  然而,這是個昂貴的篩檢工具,臨床醫師們對於適當使用這個工具的知識需要不斷更新。
  
  Khanuja醫師與同事們針對108位新發生持續單側膝疼痛的患者進行評估,這些患者在過去三個月內被轉介至2位成人膝關節重建外科醫師。
  
  研究人員讓每位病患完成問卷,以了解主要照護醫師要求的MRI膝關節檢查,在診斷或選擇治療療程上是否必要。
  
  【經常醫囑不必要的醫療檢查】
  Khanuja醫師指出,美國是全世界個人健康照護花費最高的國家,健康照護費用目前佔了國內生產總值(GDP)的15%,且預計在未來的12年內增加到20%,因此,健康照護提供者找出控制費用但不會影響照護品質的方法就越形重要;過度使用醫療檢查是個問題,特別是影像檢查。
  
  診斷膝部疾病要結合病史、理學檢查,且往往需要輔以影像檢查。Khanuja醫師指出,雖然MRI可以協助診斷膝部疾病,但較便宜的影像設備有時也是個可靠的替代方案。
  
  【MRI需求條件未被重視】
  在這項研究中,需要進行MRI的患者,主治醫師以特定的條件決定是否需要MRI來確認診斷;如果患者一開始時即有以下事實,則MRI檢查會被認為是不需要的:
  * 能以平面X光即建立診斷。
  * 患者有髕骨疼痛,但韌帶與半月板檢查結果正常。
  * 患者的膝疼痛自行緩解,或在轉介到骨科醫師之前就緩解。
  * MRI檢查結果對治療預後沒有影響。
  
  如果病史/理學檢查後,為了要評估半月板、韌帶、或骨軟骨損傷或骨壞死、或是患者有影響治療的意外發現,那麼,MRI檢查會是必要的。
  
  整體來說,66位(61%)患者由初級照護醫師轉介,25位(23%)患者由非初級照護醫師(例如風濕科醫師)轉介、10位(9%)患者是自行前來,7位(6%)患者的轉介醫師未知。
  
  【過度使用MRI是有問題的】
  在33位(31%)接受MRI檢查的患者中,18次(55%)掃描被認為是不需要的,因為可以根據病史、理學及X光檢查就完成診斷;而6次由骨科醫師轉介的MRI檢查中,有2次是不需要的。
  
  剩下的75位(69%)就診但未接受MRI的患者中,只有4位需要更多的MRI評估,3位患者暫定診斷為半月板撕裂、1位患者暫定診斷為骨壞死。
  
  整個群體中,最常見的最終診斷是骨關節炎,有41位(38%),其次是髕骨症候群,有14位(31%),之後是半月板撕裂,有8位(7%)。
  
  Khanuja醫師指出,潛在的研究限制包括樣本數目較少,且資料收集時間較短。除此之外,該研究檢驗特定地理區域且是城市的執業模式,可能與其他地區不同。
  
  芝加哥西北大學骨科主席、美國骨科醫學會交流顧問團主席Michael F. Schafer醫師表示,這確實是我們在執業時所看到的。事實上,我百分之百認同這項研究結果,絕大多數由初級照護醫師轉介來看骨科醫師的病患,並不需要MRI檢查。
  
  他附帶表示,MRI濫用按理來說應該追溯到醫學院;提供骨骼肌肉課程的學校數目甚至是下降的,然而,當我們有機會和醫學生共事時,我們可以在短時間內訓練他們這些技巧;他認為透過教導初級照護醫師有關如何適當使用診斷影像的課程計畫是比較適當的。
  
  Khanuja醫師與Schafer醫師表示沒有相關資金上的往來。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=6464&x_classno=0&x_chkdelpoint=Y
  

MRI of the Knee Often Overused

By Jill Stein
Medscape Medical News

February 18, 2011 (San Diego, California) — More than half of patients presenting to an orthopaedic surgeon with acute knee pain have had a magnetic resonance imaging (MRI) scan at the request of their referring physician that was not necessary, researchers reported here at the American Academy of Orthopaedic Surgeons 2011 Annual Meeting.

"[MRI] is useful in many diagnoses of knee pathology and can be a cost-effective means of decreasing the need for diagnostic arthroscopy and its risks when used appropriately," Harpal Singh Khanuja, MD, director of hip and knee replacement at the Rubin Institute for Advanced Orthopaedics at Sinai Hospital in Baltimore, Maryland, said.

"However, it is an expensive screening tool, and clinicians need to be up-to-date about the appropriate indications for its use," he asserted.

Dr. Khanuja and colleagues evaluated 108 consecutive patients with new-onset unilateral knee pain who were referred to 2 adult knee reconstruction surgeons over a recent 3-month period.

The investigators completed questionnaires for each patient that were intended to determine whether the MRI knee studies ordered by the primary provider were actually needed to obtain a diagnosis and select a treatment regimen.

Unnecessary Medical Tests Ordered More Often Than Not

The United States has the highest per capita healthcare expenditure worldwide, Dr. Khanuja points out. Healthcare costs currently account for 15% of the gross domestic product and have been projected to reach around 20% over the next decade. It is increasingly important for healthcare providers to identify ways to curb costs without compromising the quality of care, he says. The overuse of medical tests, and imaging studies in particular, has been frequently cited as a concern.

The diagnosis of knee conditions requires the use of an algorithm that calls for a combination of patient history, physical examination, and frequently, imaging studies. Although MRI can help diagnose knee pathology, cheaper imaging modalities are sometimes a reliable substitute, Dr. Khanuja notes.

MRI Necessity Criteria Not Heeded

In this study, for patients who presented with an MRI, the attending physician used specific criteria to determine whether an MRI was needed to establish the final diagnosis. MRI studies were considered unnecessary for patients at their initial presentation if any of the following was true:

  • the diagnosis could be established using plain X-rays alone,
  • the patient had patellofemoral pain with a normal ligamentous and meniscal exam,
  • the patient's knee pain resolved before he or she was seen by an orthopedic surgeon, or
  • the MRI findings had no effect on treatment outcome.

MRI studies were deemed necessary if they were indicated by history and/or physical examination to assess for meniscal, ligamentous, or osteochondral injury or osteonecrosis, or if the patient had an unexpected finding that affected treatment.

Overall, 66 patients (61%) were referred by their primary care physicians, 25 patients (23%) were referred by non–primary care physicians (eg, rheumatologists), 10 patients (9%) were self-referred, and the referring physician was unknown in 7 patients (6%).

MRI Overuse Problematic

Of the 33 patients (31%) who underwent MRIs, 18 scans (55%) were classified as unnecessary because it was possible to make the diagnosis with history, physical examination, and X-rays alone.

Two of 6 MRI studies ordered by referring orthopedic physicians were not necessary.

Of the remaining 75 patients (69%) who presented without an MRI study, only 4 required additional MRI evaluation, for a tentative diagnosis of a meniscal tear in 3 patients and osteonecrosis in 1 patient.

The most common final diagnosis for this cohort was osteoarthritis in 41 patients (38%), followed by patellofemoral syndrome in 14 patients (13%) and meniscal tears in 8 patients (7%).

Dr. Khanuja pointed out that potential study limitations include "a relatively small sample size with a short duration of data collection." In addition, the study examined practice patterns in a specific geographic area and urban setting, which may differ in other locations.

"This is exactly what we are seeing in our practices," Michael F. Schafer, MD, chairman of the Department of Orthopaedic Surgery at Northwestern University in Chicago, and chairman of the Communications Cabinet for the American Academy of Orthopaedic Surgeons, told Medscape Medical News. "In fact, I concur with the results of the study 100% — that the vast majority of patients who present to orthopaedic surgeons as referrals from primary care physicians do not need an MRI scan."

The tendency to overuse MRIs arguably "goes back" to medical school, he added. "There has been a decrease in the number of schools that even offer musculoskeletal education. However, when we have an opportunity to work with medical students, we can train them in a relatively short period of time."

He also pointed out that he favors the use of programs that teach primary care physicians about the appropriate use of diagnostic imaging.

Dr. Khanuja and Dr. Schafer have disclosed no relevant financial relationships.

American Academy of Orthopaedic Surgeons 2011 Annual Meeting: Abstract 299. Presented February 17, 2011.

    



回上一頁




回上一頁