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Comment & Response |

Inappropriate Use of Lumbar Magnetic Resonance Imaging: Limitations and Potential Solutions

Francisco M. Kovacs, MD, PhD1,2; Estanislao Arana, MD, PhD1,3,4; Ana Royuela, PhD1,5,6
[+] Author Affiliations
1Spanish Back Pain Research Network (REIDE), Fundación Kovacs, Palma de Mallorca, Spain
2Research Department, Fundación Kovacs, Palma de Mallorca, Spain
3Servicio de Radiología. Fundación Instituto Valenciano de Oncología, Valencia, Spain
4Fundación Instituto de Investigación en Servicios de Salud, Valencia, Spain
5Centros de Investigación Biomédica en Red Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
6Unidad de Bioestadística Clínica, Hospital Ramón y Cajal, Madrid, Spain
JAMA Intern Med. 2013;173(21):2012. doi:10.1001/jamainternmed.2013.9964.
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To the Editor A recent compelling study reports that 28.5% of prescriptions of lumbar magnetic resonance imaging (MRI) are inappropriate.1 We would like to point out the following:

  1. Criteria for defining appropriateness were developed ad hoc following the RAND–University of California, Los Angeles, method,1 instead of using existing and widely accepted evidence-based criteria.2 The validity and reproducibility of the former are suboptimal; consensus does not necessarily mean agreement.3

  2. Cases were “matched to a clinical scenario for which the appropriateness rating had been determined.”1(p823) Therefore, appropriateness was not determined by the patients’ actual signs or symptoms. Moreover, in 63.7% of the lumbar MRI requests, the information provided was insufficient to determine appropriateness, so classification was based on information from “other sources.”1 As acknowledged by the authors, this may affect validity of results.1

  3. The study does not reveal whether clinicians knew that the appropriateness of their prescriptions was going to be assessed,1 which could influence results.

  4. The study was conducted in 2 hospitals. Generalizability of results is unknown.

  5. The authors suggest that appropriateness should be assessed and compared across other health services.1 A recent study in 12 Spanish public and private hospitals across 6 regions shows that at least 11.9% of the lumbar MRI in routine practice are inappropriate; this proportion increases to 17.2% in private care and to 27.8% among patients without pain referred down to the leg.4 Differences in results may derive from limitations described in points 1 to 3 and from differences in methods, which in the Spanish study were designed to ensure that all lumbar MRIs classified as “inappropriate” were actually so, at the expense of underestimating its percentage.4

  6. To reduce the inappropriate use of lumbar MRI, we advocate for implementing electronic clinical decision support tools and empowering radiologists to decline inappropriate lumbar MRI referrals.4,5


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November 25, 2013
Derek J. Emery, MD; Thomas E. Feasby, MD, FRCPC
1Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
2Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada3Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
JAMA Intern Med. 2013;173(21):2012-2013. doi:10.1001/jamainternmed.2013.9956.
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