Appropriateness of spinal imaging use in Canada – Key findings
Jason W Busse
Systematic review of the literature
There are 22 studies that have explored appropriateness of spine-related imaging, and all have found some inappropriate use. The rate of inappropriate imaging varies considerably according to which criteria are used, and there appears to be little consensus on a common definition of appropriateness. 18 studies have explored interventions to improve appropriateness of spine-related imaging, and active decision aids appear more promising than passive dissemination of educational material. Patient-important outcomes are rarely considered in studies exploring appropriateness of imaging.
Survey of Canadian spine surgeons
Most Canadian spine surgeons (84%) require imaging studies to accompany all spine related referrals. MRI is the most common form of imaging required, but there is tremendous variability in this area. Furthermore, even with imaging studies, 53% of surgeons refuse more than 20% of all referrals without a consultation, and less than 20% of patients who are assessed are surgical candidates. The current system of referring patients with spine-related complaints for surgical assessment in Canada appears to generate a substantial amount of unnecessary imaging.
Provincial utilization data
From 2001-2011, MRI spine utilization has increased markedly, but this has not reduced the use of spine x-ray or CT spine, and spine x-rays still currently account for nearly half (40%) of all spine imaging costs. Compared to Ontario, the increase in spine imaging expenditures in Manitoba has been disproportionate to the increase in the number of procedures performed because of increases in unit cost over the 10 year study period in Manitoba (i.e., fee schedule increases). Disparities in access to spinal imaging according to socioeconomic status were documented in both provinces. Improved health system coordination for patients with spinal complaints may help to improve efficiency of spine imaging use (e.g., diagnostic imaging pathways to reduce need for “lead up” testing with x-ray or CT spine before MRI; alternative and innovative models of care which provide standardized assessment of patients with low back pain could streamline referral of appropriate patients for advanced spine imaging and surgical consultation).
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