How one hospital system is using patient-centered referral forms to reduce unnecessary CT and MRI scans

The inappropriate use of imaging tests to assess headaches and lower back pain is an ongoing issue in Canada, one that’s contributing to ballooning care costs and long wait times.

Wanting to better understand and address this issue, researchers from three Ontario academic institutions devised a new patient-centered referral form for primary care and other providers to fill out. The document incorporates red flag markers, established by Choosing Wisely Canada, which caution physicians who are considering CT or MRI scans for certain types of pain when such scans would not add value to treatment.

They’ve found early success with the new patient-focused forms, dropping the number of “incomplete” requisitions for imaging exams from 36.3% down to 13.15%, according to their study, published Thursday, Nov. 14, in the Journal of Medical Imaging and Radiation Sciences. And while the change in the number of “inappropriate” requests for CT and MRI scans was insignificant, researchers found the intervention helped to educate local physicians about the information required upfront to request such imaging studies for headaches and lower back pain.

“These data strongly suggest that both the educational aspect and the recommended use of the patient-centered referral forms within this intervention raised awareness of the Choosing Wisely guidelines for CT and MRI scans,” concluded Mark Khoury, with the faculty of applied health sciences at Brock University, and colleagues. “Together, these interventions intend to maximize the efficient use of CT and MRI examination resources,” they added later.

To reach their conclusions, Khoury and colleagues reviewed about 400 MRI and CT lumbar and head scans conducted in the Ontario care system, measuring them against Choosing Wisely guidelines. Those stipulate, for instance, that uncomplicated headaches accompanied by a rapid increase in severity, dizziness, lack of coordination or a history of cancer constitute a “red flag” and require an MRI. “Inappropriate” referrals lack the sufficient clinical indicators listed in these guidelines, while “incomplete” referrals don’t have enough information to validate their necessity.

Researchers found that about 52% of scans could be deemed as appropriate, 36% were incomplete, and 12% were inappropriate.

They then distributed new patient-centered referral forms that incorporated evidence-based red flags for head and lumbar MRI/CT scans. About 150 local family physicians received the forms, accompanied by pamphlets summarizing why it’s necessary to reduce such imaging for head and back pain.

After the intervention, Khoury and colleagues found that referrals for inappropriate CT scans actually increased slightly, while inappropriate MRIs stayed flat. However, incompleteness dipped considerably across all modalities. Data gathered before the study suggest that lack of awareness of the Choosing Wisely red flags among family physicians may have fueled inappropriate testing, and the researchers believe they may be closing that knowledge gap. They hope to conduct further focus groups with regional stakeholders to develop best practices for spreading the project to a wider audience.