Evidence for Policy Making: Clinical Appropriateness Study of Lumbar Spine MRI Prescriptions Using RAND Appropriateness Method

Salari, Hedayat; Ostovar, Rahim; Esfandiari, Atefeh; Keshtkaran, Ali; Akbari Sari, Ali; Yousefi Manesh, Hossein; Rakhshan, Amir

doi:10.15171/ijhpm.2013.04

Evidence for Policy Making: Clinical Appropriateness Study of Lumbar Spine MRI Prescriptions Using RAND Appropriateness Method

Document Type : Original Article

Authors

¹ Department of Health Economics and Management, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

² Research Center for Health Services Management, Kerman University of Medical Sciences, Kerman, Iran

³ Social Determinants of Health Research Center, Yasuj University of Medical Sciences, Yasuj, Iran

⁴ Department of Medical Informatics and Management, Shiraz University of Medical Sciences, Shiraz, Iran

⁵ Department of medicine, Shiraz Medical Students Research Committee, Shiraz University of Medical Science, Shiraz, Iran

⁶ Department of Foreign Languages, Tehran University of Medical Sciences, Tehran, Iran

10.15171/ijhpm.2013.04

Abstract

Background
MRI is a new and expensive diagnostic technology, which has been used increasingly all over the world. Low back pain is a worldwide prevalent disorder and MRI technique is one of the several ways to diagnose it. This paper aims to identify the appropriateness of lumbar spine MRI prescriptions in Shiraz teaching hospitals using standardized RAND Appropriateness Method (RAM) criteria in 2012.

Methods
This study consisted of two phases. The first phase involved a qualitative enquiry and the second phase had a quantitative cross-sectional nature. In the first phase RAM was used for developing lumbar spine MRI indications and scenarios. In the second phase, the finalized scenarios were compared with the history and physical examination of 300 patients with low back pain. The rate of appropriateness of lumbar spine MRI prescription was then calculated.

Results
Of 300 cases of lumbar spine MRI prescriptions, approximately 167 (56%) were considered inappropriate, 72 (24%) were uncertain, and 61 (20%) were deemed to be appropriate. The economic burden of inappropriate prescriptions was calculated at 88,009,000 Rials. In addition, the types of expertise and physical examination were considered as related factors to appropriateness of prescriptions.

Conclusion
In conclusion, a large proportion of lumbar spine MRI prescriptions, which result in financial burden on the insurance companies and the patients alike is unnecessary. This study suggests that policy makers consider this evidence while decision-making. Our findings highlight the imperative role of Health Technology Assessment (HTA) and Clinical Practice Guidelines (CPGs). As a result, developing local clinical guidelines may create the commitment needed in physicians in prescribing appropriate prescriptions within the health sector. The study further recommends that appropriate scenarios should be considered as a criterion for payment and reimbursement.

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References

1. Ostovar R, Rashidian A, Pourreza A, Rashidi BH, Hantooshzadeh S, Ardebili HE, et al. Developing criteria for cesarean section using the RAND appropriateness method. BMC Pregnancy Childbirth 2010; 10: 52. doi:10.1186/1471-2393-10-52

2. Borowitz M, Sheldon T. Controlling health care: from economic incentives to micro-clinical regulation. Health Econ 1993; 2: 201-4. doi: 10.1002/hec.4730020302

3. Phelps CE. The methodologic foundations of studies of the appropriateness of medical care. N Engl J Med 1993; 329: 1241-5. doi: 10.1056/NEJM199310213291707

4. Fitch K, Bernstein SJ, Aguilar MD, Burnand B, LaCalle JR, Lazaro P, et al. The RAND/UCLA Appropriateness Method: Users Manual. RAND Europe; 2001.

5. KanouseDE, Brook RH, Winkler JD, Kosecoff J, Berry SH, Carter GM, et al. Changing medical practice through technology assessment. RAND Corporation; 1989.

6. Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. BMJ 1999; 318: 593-6. doi: http://dx.doi.org/10.1136/bmj.318.7183.593

7. PennsylvaniaHealth Care Cost Containment Council. The growth in Additional file 1: Contains the appendix 1. Additional file 2: Contains the appendix 2. diagnostic imaging utilization. Accessed 2007 July. Available from: http://www.phc4.org/ reports/FYI/fyi27.htm

8. Palesh M, Fredrikson S, Jamshidi H, Jonsson PM, Tomson G. Diffusion of magnetic resonance imaging in Iran. Int J Technol Assess Health Care 2007; 23: 278-85.

9. Gilbert FJ, Grant AM, Gillan MG, Vale LD, Campbell MK, Scott NW, et al. Low back pain: influence of early MR imaging or CT on treatment and outcome--multicenter randomized trial. Radiology 2004; 231: 343-51. doi: http://dx.doi.org/10.1148/radiol.2312030886

10. Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey. Spine (Phila Pa 1976) 1995; 20: 11-9.

11. Lower Back Pain Fact Sheet. National Institute of Neurological Disorders and Stroke. Accessed 2011 December 5. Available from: http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm.

12. Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine (Phila Pa 1976)2006; 31: 2724-7.

13. Keshtkaran A, Bagheri MH, Ostovar R, Salari H, Farokhi MR, Esfandiari A, et al. Developing criteria for lumbar spine magnetic resonance imaging (MRI) using RAND appropriateness method (RAM). Iran J Radiol 2012; 9: 130-8. doi: 10.5812/iranjradiol.4063

14. Lehnert BE, Bree RL. Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support? J Am Coll Radiol 2010; 7: 192-7. doi: http://dx.doi.org/10.1016/j.jacr.2009.11.010

15. Emery DJ, Shojania KG, Forster AJ, Mojaverian N, Feasby TE. Overuse of magnetic resonance imaging. JAMA Intern Med2013; 25: 1-3. doi: 10.1001/jamainternmed.2013.3804

16. Thom DH, Kravitz RL, Kelly-Reif S, Sprinkle RV, Hopkins JR, Rubenstein LV. A new instrument to measure appropriateness of services in primary care. Int J Qual Health Care2004; 16: 133-40.

17. Palesh M, Tishelman C, Fredrikson S, Jamshidi H, Tomson G, Emami A. “We noticed that suddenly the country has become full of MRI”. Policy makers’ views on diffusion and use of health technologies in Iran. Health Res Policy Syst 2010 ;8: 9. doi: 10.1186/1478-4505-8-9

18. Salamatnews. Accessed 2011 December 5. Available from: http://www.salamatnews.com /viewNews.aspx.

19. Ostovar R, Pourreza A, Rashidian A, Rashidi BH, Hantooshzadeh S, Haghollai F, et al. Appropriateness of cesarean sections using the RAND Appropriateness Method criteria. Arch Iran Med 2012; 15: 8-13.