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J Hand Microsurg
DOI: 10.1055/s-0042-1758670
Original Article

Upper Extremity Surgeon Recommendations for Imaging Do Not Correspond with Imaging Appropriateness Guidelines

Shyam S. Ramachandran
1   Texas A&M Health Science Center, School of Medicine, Dallas, Texas, United States
2   Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Texas, United States
,
David Ring
2   Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Texas, United States
,
Tom J. Crijns 
2   Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Texas, United States
,
the Science of Variation Group
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Abstract

Background Utilization of magnetic resonance imaging (MRI) and computed tomography (CT) increases annually, raising concerns about overuse. Imaging appropriateness guidelines have the potential to standardize decisions regarding imaging based on best evidence, which might reduce unhelpful or potentially misleading imaging. We studied expert use of advanced imaging for musculoskeletal illness compared to published appropriateness recommendations.

Methods First, 15 imaging guidelines with recommendations for advanced imaging of the upper extremity were collated. Next, members of the Science of Variation Group (SOVG) were invited to participate in a survey of 11 patient scenarios of common upper extremity illnesses and asked whether they would recommend MRI or CT. Guideline recommendations for imaging were compared with surgeon recommendations using Fisher's exact tests. We used Fleiss' kappa to measure the interobserver agreement among surgeons.

Results For the 11 scenarios, most imaging appropriateness guidelines suggested that MRI or CT is useful, while most surgeons (n = 108) felt it was not. There was no correlation between surgeons and guidelines recommendations for imaging (ρ = 0.28; p = 0.40). There was slight agreement among surgeons regarding imaging recommendations (kappa: 0.17; 95% confidence interval: 0.023–0.32).

Conclusion The available imaging appropriateness guidelines appear to be too permissive and therefore seem to have limited clinical utility for upper extremity surgeons. The notable surgeon-to-surgeon variation (unreliability) in recommendations for advanced imaging in this and other studies suggests a role for strategies to ensure that patient decisions about imaging are consistent with their values (what matters most to them) and not unduly influenced by patient misconceptions about imaging or by surgeon beliefs and habits.

Level Of Evidence II, diagnostic

Keywords

CT - imaging appropriateness - MRI - overuse - resource stewardship

Ethical Approval

Approval for this study was given by the Institutional Review Board at the University of Texas at Austin, Austin, Texas, United States.


This work was performed at the Dell Medical school, The University of Texas at Austin, Texas, United States of America.




Publication History

Article published online:
15 December 2022

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