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Benjamin J. Miller, MD, MS on behalf of the Musculoskeletal Oncology Research Initiative

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.

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Benjamin J. Miller, MD, MS on behalf of the Musculoskeletal Oncology Research Initiative

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  1. 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

  2. Conflicts of Interest • Nothing to disclose

  3. 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

  4. Prior studies • Aboulafiaet 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

  5. Questions • Is there regional variation in the use of advanced imaging? • Are there common characteristics predictive of excessive studies?

  6. Materials and Methods • 8 centers • Prospective • 50 patients or 6 months of referrals • Bone and soft tissue tumors • All anatomic locations

  7. 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

  8. 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

  9. “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

  10. “Necessary study” criteria • MRI specifically • Soft tissue • Biopsy proven sarcoma • >5 cm • Deep to fascia • Painful • Growing • Bone • Concern for sarcoma on x-ray

  11. Statistical analysis • Chi-square and t test • Univariate and multivariate logistic regression • Post hoc power analysis • 90% power to detect 20% difference between centers

  12. 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

  13. 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%

  14. 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)

  15. 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

  16. 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

  17. 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

  18. 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%

  19. MORI participants • RaffiAvedian • Judd Cummings • Tessa Balach • Kevin MacDonald • Lee Leddy • Jeremy White • Raj Rajani • Ben Miller

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