title: MRI for the evaluation of knee pain: comparison of ordering practices of primary care physicians and orthopaedic surgeons.
abstract: BACKGROUND
  Knee pain is one of the most common reasons for outpatient visits in the U.S. The great majority of such cases can be effectively evaluated through physical examination and judicious use of radiography. Despite this, an increasing number of magnetic resonance images (MRIs) of the knee are being ordered for patients with incomplete work-ups or for inappropriate indications. We hypothesized that MRIs ordered by orthopaedic providers were more likely to result in changes in diagnoses and/or plans for care than those ordered by non-orthopaedic providers.
  
  
  METHODS
  We reviewed the charts of all consecutive new patients seen at our orthopaedic outpatient office between January 1, 2010, and December 31, 2011, with International Classification of Diseases, Ninth Revision (ICD-9) codes for meniscal or unspecific sprains and strains of the knee. A total of 1592 patients met our inclusion criteria and were divided into two groups: those initially evaluated and referred by their primary care physician (PCP) (n = 747) and those initially evaluated by one of our staff orthopaedic surgeons (n = 845).
  
  
  RESULTS
  MRI-ordering rates were nearly identical between orthopaedic surgeons and PCPs (25.0% versus 24.8%; p = 0.945). MRIs ordered by orthopaedic surgeons, however, resulted in significantly more arthroscopic interventions than those ordered by PCPs (41.2% versus 31.4%; p = 0.042). Orthopaedic surgeons ordered MRIs for patients who were more likely to benefit from arthroscopic intervention, including patients who were younger (mean age, 45.1 years versus 56.5 years for those with PCP-ordered MRIs; p < 0.001), patients with acute symptoms (39.3% versus 22.2%; p < 0.001), and patients with a history of trauma (49.3% versus 36.2%; p = 0.019). Finally, orthopaedic surgeons were less likely than PCPs to order MRIs for patients with substantial osteoarthritis who subsequently underwent total knee arthroplasty (4.3% versus 9.2%; p = 0.048).
  
  
  CONCLUSIONS
  MRI utilization by orthopaedic surgeons results in more appropriate interventions for patients with symptoms and findings most amenable to surgical intervention.
authors.affiliation: Division of Orthopedic Surgery, Albany Medical Center, 1367 Washington Avenue, Albany, NY 12208. E-mail address for T.T. Roberts: timothy.t.roberts@gmail.com.
authors.forename: Timothy T
authors.initials: TT
authors.lastname: Roberts
authors.affiliation: 97 Middlesex Drive, Slingerlands, NY 12159.
authors.forename: Natalie
authors.initials: N
authors.lastname: Singer
authors.affiliation: Division of Orthopedic Surgery, Albany Medical Center, 1367 Washington Avenue, Albany, NY 12208. E-mail address for T.T. Roberts: timothy.t.roberts@gmail.com.
authors.forename: Shazaan
authors.initials: S
authors.lastname: Hushmendy
authors.affiliation: Department of Orthopaedic Surgery, University of Virginia Health Systems, P.O. Box 801016, Charlottesville, VA 22908.
authors.forename: Ian J
authors.initials: IJ
authors.lastname: Dempsey
authors.affiliation: Division of Orthopedic Surgery, Albany Medical Center, 1367 Washington Avenue, Albany, NY 12208. E-mail address for T.T. Roberts: timothy.t.roberts@gmail.com.
authors.forename: Jared T
authors.initials: JT
authors.lastname: Roberts
authors.affiliation: Division of Orthopedic Surgery, Albany Medical Center, 1367 Washington Avenue, Albany, NY 12208. E-mail address for T.T. Roberts: timothy.t.roberts@gmail.com.
authors.forename: Richard L
authors.initials: RL
authors.lastname: Uhl
authors.affiliation: 21886 N.W. Monterey Loop, Poulsbo, WA 98370.
authors.forename: Paul E M
authors.initials: PE
authors.lastname: Johnson
mesh_terms: D005260:Female; D006801:Humans; D007719:Knee Joint / Q000601:surgery; D008279:Magnetic Resonance Imaging / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009985:Orthopedics; D010146:Pain / Q000175:diagnosis* / Q000601:surgery; D011320:Primary Health Care