title: Reducing Unnecessary Shoulder MRI Examinations Within a Capitated Health Care System: A Potential Role for Shoulder Ultrasound.
abstract: OBJECTIVE
  MRI is frequently overused. The aim of this study was to analyze shoulder MRI ordering practices within a capitated health care system and explore the potential effects of shoulder ultrasound substitution.
  
  
  METHODS
  We reviewed medical records of 237 consecutive shoulder MRI examinations performed in 2013 at a Department of Veterans Affairs tertiary care hospital. Using advanced imaging guidelines, we assessed ordering appropriateness of shoulder MRI and estimated the proportion of examinations for which musculoskeletal ultrasound could have been an acceptable substitute, had it been available. We then reviewed MRI findings and assessed if ultrasound with preceding radiograph would have been adequate for diagnosis, based on literature reports of shoulder ultrasound diagnostic performance.
  
  
  RESULTS
  Of the 237 examinations reviewed, 106 (45%) were deemed to be inappropriately ordered, most commonly because of an absent preceding radiograph (n = 98; 92%). Nonorthopedic providers had a higher frequency of inappropriate ordering (44%) relative to orthopedic specialists (17%) (P = .016; odds ratio = 3.15, 95% confidence interval = 1.24-8.01). In the 237 examinations, ultrasound could have been the indicated advanced imaging modality for 157 (66%), and most of these (133/157; 85%) could have had all relevant pathologies characterized when combined with radiographs. Regardless of indicated modality, ultrasound could have characterized 80% of all cases ordered by nonorthopedic providers and 50% of cases ordered by orthopedic specialists (P = .007).
  
  
  CONCLUSIONS
  Advanced shoulder imaging is often not ordered according to published appropriateness criteria. While nonorthopedic provider orders were more likely to be inappropriate, inappropriateness persisted among orthopedic providers. A combined ultrasound and radiograph evaluation strategy could accurately characterize shoulder pathologies for most cases.
authors.affiliation: William S. Middleton Memorial Veterans Hospital and University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. Electronic address: ssheehan@uwhealth.org.
authors.forename: Scott E
authors.initials: SE
authors.lastname: Sheehan
authors.affiliation: University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
authors.forename: John A
authors.initials: JA
authors.lastname: Coburn
authors.affiliation: Houston VA Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas.
authors.forename: Hardeep
authors.initials: H
authors.lastname: Singh
authors.affiliation: University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
authors.forename: David J
authors.initials: DJ
authors.lastname: Vanness
authors.affiliation: University of Texas Health Science Center at Houston, Houston, Texas.
authors.forename: Dean F
authors.initials: DF
authors.lastname: Sittig
authors.affiliation: University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
authors.forename: D Paul
authors.initials: DP
authors.lastname: Moberg
authors.affiliation: William S. Middleton Memorial Veterans Hospital and University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
authors.forename: Nasia
authors.initials: N
authors.lastname: Safdar
authors.affiliation: University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
authors.forename: Kenneth S
authors.initials: KS
authors.lastname: Lee
authors.affiliation: William S. Middleton Memorial Veterans Hospital and University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
authors.forename: Michael C
authors.initials: MC
authors.lastname: Brunner
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002204:Capitation Fee / Q000706:statistics & numerical data*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012782:Shoulder / Q000000981:diagnostic imaging*; D020069:Shoulder Pain / Q000000981:diagnostic imaging* / Q000453:epidemiology; D014463:Ultrasonography / Q000706:statistics & numerical data*; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*; D014600:Utilization Review; D014922:Wisconsin / Q000453:epidemiology; D055815:Young Adult
keywords: MRI; Shoulder; costs; ultrasound; utilization