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How to eliminate MRI wait lists in the public health system

Public health care offers many examples of value waiting to be tapped.
Near the top is magnetic resonance imaging (MRI). It is a highly
valuable diagnostic tool for many conditions, but it is expensive
technology. Waiting times for non-urgent MRI are long, and more than
half the MRIs taken in Alberta may be unnecessary.

It’s the last point that offers opportunity to increase value for money in public health care.

A
recent study by Alberta and Ontario researchers found more than half of
MRIs on low back pain patients were inappropriate or of questionable
value. This suggests about 13,000 lower back MRIs conducted in Alberta
annually are not necessary.

My research at the Acute Knee Injury
Clinic in Calgary suggests similar waste occurs in diagnosing knee
injuries. This work found almost two-thirds of the knee-injured patients
who had an MRI could have been accurately diagnosed using other more
readily available and significantly less expensive techniques and tools.
Provincially, this translates to about 4,000 knee MRIs annually.

In these two areas alone, there may be 17,000 unnecessary MRIs every year in Alberta, representing a cost exceeding $15 million.

This
does not suggest MRIs find nothing. It does, however, suggest an
accurate diagnosis and effective treatment plan could be put in place
without MRI. In the case of acute knee injury, we concluded that
applying evidence-based guidelines on MRI use and training health care
providers in effective examining techniques could cut MRI use by
two-thirds.

A lower-back MRI costs the public health system
approximately $1,000 while a knee MRI costs around $550. Latest
provincial figures show the median wait for a non-urgent MRI in Alberta
was 18 weeks.

Long waits have spawned a thriving private MRI
business in Alberta. Next-day private MRIs are available at a cost to
the patient ranging from approximately $750 to $2,450. This generates no
value to patients if the MRIs they purchase are unnecessary.

The
root of the problem is the ‘system gap’ and relative ‘knowledge gap’
that exist in Alberta and, most probably, across Canada. The system gap
is in the form of slow access to specialty opinion and the absence of
guidelines that would help primary care providers know when an MRI
should be requisitioned. The knowledge gap relates to lack of training
in how to accurately diagnose knee injuries, low back pain and other
common bone and joint conditions without expensive tests.

Bridging
these gaps with provincial MRI guidelines and training in diagnostic
techniques is not necessarily a difficult undertaking, and it can be
done cost-effectively. This approach aligns with the Choosing Wisely
Canada campaign organized in partnership with the Canadian Medical
Association to reduce unnecessary medical tests, treatments and
procedures.

Most MRI requisitions in Alberta come from family
doctors. Training two or three physicians in a Primary Care Network in
diagnostic techniques for musculoskeletal conditions and having them
apply new MRI guidelines routinely in practice could eliminate the
majority of the inappropriate MRIs in this large area of medicine alone.

Introducing
incentives tied to provincial benchmarks for efficient use of public
resources could add motivation for training. The savings could be huge.
In 2012, Canadians had 1.7 million MRIs — double the number in 2004.
Demand for MRI will continue climbing as our population ages and grows.

It
is not inconceivable that, with these changes, there would be no wait
lists for MRI in the public system. Private MRI would be unnecessary.
And Albertans would see quantifiable value returned for their health
care dollars.

——–
Nick Mohtadi is an advisor with
EvidenceNetwork.ca, an orthopaedic surgeon practicing in Calgary, a
clinical professor at the University of Calgary and Director of the
Acute Knee Injury Clinic.