Ordering providers not following ACR guidance for knee MRI referrals

Adherence to the American College of Radiology (ACR) Appropriateness Criteria is low among ordering providers when referring patients to get MRIs for nontraumatic knee pain, according to a study published in the Journal of the American College of Radiology.

“The initial workup of a patient with nontraumatic knee pain should involve a thorough history and physical examination, followed by prudent and appropriate use of diagnostic imaging,” wrote lead author Felix M. Gonzalez, MD, of the Emory University School of Medicine in Atlanta.

The ACR created an “evidence-based and expert-vetted” ACR Appropriateness Criteria in 1995, seeking to guide referring physicians when selecting appropriate imaging exams.

The organization updated the criteria in 2012; however, the researchers noted, many ordering providers have not been adhering to the recommendations. In fact, previous studies have established that less than 3 percent of physicians use the ACR criteria as a first or second resource when ordering imaging exams.

“Even radiologists underutilize the guidelines,” Gonzalez and colleagues wrote.

The researchers assessed 196 MRI exams for nontraumatic knee pain ordered over an 18-month period by primary care providers. ACR Appropriateness Criteria scores for nontraumatic knee pain were calculated from medical records, and the researchers also examined whether knee MRI changed care management. Tests were performed according to differences in age, body mass index (BMI), gender and ethnicity among “appropriate and inappropriate” MRIs.

They found that, of the 108 knee MRIs studied, 57 percent had “usually appropriate” appropriateness criteria scores and 43 percent had “usually not appropriate” scores. Clinical management changed in 26 percent of knee MRIs with “usually appropriate” scores and 20 percent of knee MRIs with “usually not appropriate” scores.

Gonzalez and colleagues found 70 percent of the knee MRIs with “usually appropriate” scores and 61 percent of the knee MRIs with “usually not appropriate” scores have moderate to severe osteoarthritis. Lastly, they found age, BMI, gender and ethnicity did not significantly impact appropriateness criteria scores.

The researchers suggested better guidelines and tactics to reduce MRI ordering are needed in patients with moderate to severe osteoarthritis. One measure to take, they wrote, is to implement what the Centers for Medicare and Medicaid Services (CMS) is now mandating—the usage of clinical decision-support (CDS) software with computerized physician or provider order entry (CPOE).

“Previous studies have shown that robust CDS-CPOE software improves adherence to expert guidelines, reduces overall and inappropriate imaging utilization, and increases high-yield and decreases low-yield imaging, particularly among primary care providers,” they wrote.

Also, educational improvement about the ACR Appropriateness Criteria may be helpful “because habits developed during training predict habits in post training practice,” Gonzalez et al. noted. Education is not enough, they note, as patient expectations may also influence imaging orders and can also impact the prescribing and referral habits of physicians.

ACR Appropriateness Criteria is due for some fine-tuning, the authors concluded. “ACR Appropriateness Criteria need to be further tested,” Gonzalez and colleagues wrote, “in the context of treating physicians in academic and nonacademic organizations without orthopedic training to assess how to improve the ordering practices in the workup of knee pain.”