ADVANCED IMAGING IS OVERUSED PRIOR TO REFERRAL TO A MUSCULOSKELETAL ONCOLOGIST: A PROSPECTIVE, MULTI-CENTER INVESTIGATION Benjamin J. Miller, MD, MS on behalf of the Musculoskeletal Oncology Research Initiative

Conflicts of Interest Nothing to disclose

Background Bone and soft tissue tumors initially seen

by general orthopaedist or PCP No clear guidelines for use of advanced

imaging (MRI, CT, bone scan, U/S, PET) Medical imaging identified as contributor

to overspending

Reducing superfluous imaging studies prior to referral is important

Prior studies Aboulafia et al, CORR, 2002

Prospective, single center, 100 patients 34% unnecessary MRI scans

Martin et al, CORR, 2012 Retrospective, single-center, 920 patients 3% unnecessary MRI

Questions Is there regional variation in the use of

advanced imaging? Are there common characteristics

predictive of excessive studies?

Materials and Methods

8 centers Prospective 50 patients or 6 months of

referrals Bone and soft tissue tumors All anatomic locations

Data elements Patient details

Age, sex, race, insurance Tumor type

Bone or soft tissue Specialty of referring MD Distance travelled Studies performed prior to referral

Subjective material Determined only by the single treating

orthopaedic oncologist What happens in actual practice?

Presumptive diagnosis Likely benign (Benign tumor or non-

neoplastic) Likely malignant (Malignant tumor or

unknown) Necessary or excessive study

“Necessary study” criteria Needed for routine work-up of condition Helpful in determining diagnosis

Borderline studies considered “necessary” Benefit of the doubt given to referring

physician

“Necessary study” criteria MRI specifically

Soft tissue Biopsy proven sarcoma >5 cm Deep to fascia Painful Growing

Bone Concern for sarcoma on x-ray

Statistical analysis Chi-square and t test Univariate and multivariate logistic

regression

Post hoc power analysis 90% power to detect 20% difference

between centers

Results 371 patients 301 (81%) with at least 1 study

263 (71%) with MRI 54 (15%) with CT 40 (11%) with bone scan 21 (6%) with ultrasound 14 (4%) with PET scan

81 (22%) with multiple studies

Results Regions differed by age, race, insurance

status, and distance travelled Demographics variable

No differences in use of prereferral imaging by region (p=0.164) Range 66% to 88%

Results 113 (30%) with unnecessary studies

46 (17%) MRI 40 (74%) CT 25 (62%) bone scan 16 (76%) ultrasound 7 (50%) PET scan

No difference between orthopaedic or PCP referrals (p=0.940)

Univariate analysis Benign bone tumors more likely to have

excessive imaging (OR 2.18, 95% CI 1.39-3.43)

Differences by practice location

Findings held in multivariate analysis

Effect of Region No obvious differences in number or types of

studies Generalizable results

Differences in labeling “unnecessary” Substantial variation between fellowship-trained

tumor surgeons Consistent with prior studies

Minimum 3% (Martin 3%) and maximum 31% (Aboulafia 34%)

Need for clearer guidelines based on objective, reproducible criteria

Summary Helpful – MRI

Most utilized study (71%) 83% deemed necessary Use contrast, visualize entire compartment

6% repeated Not helpful – everything else

High rate of “unnecessary” Should be left to treating team

Recommendations Appropriate advanced imaging is

beneficial Goal is not to totally eliminate

No imaging other than MRI No MRI in radiographically benign bone

tumors

Would change 30% excessive studies to 4%

MORI participants Raffi Avedian Judd Cummings Tessa Balach Kevin MacDonald Lee Leddy Jeremy White Raj Rajani Ben Miller