MRI Referrals Research Articles

Evaluating acute nipple inversion, imaging findings and outcomes

PurposeAcute nipple inversion can be unsettling for patients and is sometimes associated with an underlying breast malignancy. It also poses a diagnostic challenge with lack of consensus management guidelines. This study reviewed institutional experience with new nipple inversion, including malignant association, imaging utilization, and outcomes, in an effort to improve management. MethodsA multisite institutional retrospective review was conducted of all breast imaging reports from 1/2010 to 6/2022 mentioning nipple inversion as an indication or finding. Patients with new nipple inversion, defined as arising since the time of last breast imaging exam or if reported as new by the patient/provider, were included for analysis. Retroareolar imaging findings, BI-RADS assessments/recommendations, pathology obtained from percutaneous or excisional biopsies, and follow-up imaging and clinical exams were collated. Cases of chronic or stable nipple inversion were excluded. Descriptive statistics were performed. ResultsA total of 414 patients had new nipple inversion, 387/414 (93.5 %) with benign or negative results at initial imaging and 27/414 (6.5 %) with malignant lesions. Diagnostic mammography/ultrasound detected 25/27 (92.6 %) cancers (sensitivity 92.6 %, specificity 75.5 %, PPV 20.8 %, NPV 99.3 %). Of 62 breast MRI exams performed in patients with negative mammogram/ultrasound, no cancers were detected in the retroareolar space with 2 incidental malignant lesions discovered distant from the nipple. ConclusionDiagnostic mammography/ultrasound is reliable in workups of acute nipple inversion, with a high sensitivity and NPV for excluding malignancy. Breast MRI and surgical referral should be reserved for patients with suspicious associated symptoms or clinical findings.

CSP2023: 298 - Evaluation of the appropriateness and outcomes of MRI referrals in a Physiotherapist led acute soft tissue knee clinic

CSP2023: 298 - Evaluation of the appropriateness and outcomes of MRI referrals in a Physiotherapist led acute soft tissue knee clinic

Preoperative breast MRI positively impacts surgical outcomes of needle biopsy–diagnosed pure DCIS: a patient-matched analysis from the MIPA study

ObjectivesTo investigate the influence of preoperative breast MRI on mastectomy and reoperation rates in patients with pure ductal carcinoma in situ (DCIS).MethodsThe MIPA observational study database (7245 patients) was searched for patients aged 18–80 years with pure unilateral DCIS diagnosed at core needle or vacuum-assisted biopsy (CNB/VAB) and planned for primary surgery. Patients who underwent preoperative MRI (MRI group) were matched (1:1) to those who did not receive MRI (noMRI group) according to 8 confounding covariates that drive referral to MRI (age; hormonal status; familial risk; posterior-to-nipple diameter; BI-RADS category; lesion diameter; lesion presentation; surgical planning at conventional imaging). Surgical outcomes were compared between the matched groups with nonparametric statistics after calculating odds ratios (ORs).ResultsOf 1005 women with pure unilateral DCIS at CNB/VAB (507 MRI group, 498 noMRI group), 309 remained in each group after matching. First-line mastectomy rate in the MRI group was 20.1% (62/309 patients, OR 2.03) compared to 11.0% in the noMRI group (34/309 patients, p = 0.003). The reoperation rate was 10.0% in the MRI group (31/309, OR for reoperation 0.40) and 22.0% in the noMRI group (68/309, p < 0.001), with a 2.53 OR of avoiding reoperation in the MRI group. The overall mastectomy rate was 23.3% in the MRI group (72/309, OR 1.40) and 17.8% in the noMRI group (55/309, p = 0.111).ConclusionsCompared to those going directly to surgery, patients with pure DCIS at CNB/VAB who underwent preoperative MRI had a higher OR for first-line mastectomy but a substantially lower OR for reoperation.Clinical relevance statementWhen confounding factors behind MRI referral are accounted for in the comparison of patients with CNB/VAB-diagnosed pure unilateral DCIS, preoperative MRI yields a reduction of reoperations that is more than twice as high as the increase in overall mastectomies.Key Points• Confounding factors cause imbalance when investigating the influence of preoperative MRI on surgical outcomes of pure DCIS.• When patient matching is applied to women with pure unilateral DCIS, reoperation rates are significantly reduced in women who underwent preoperative MRI.• The reduction of reoperations brought about by preoperative MRI is more than double the increase in overall mastectomies.

Post-traumatic spinal hematoma in diffuse idiopathic skeletal hyperostosis (DISH)

ObjectivesTo determine the incidence of spinal hematoma and its relation to neurological deficit after trauma in patients with spinal ankylosis from diffuse idiopathic skeletal hyperostosis (DISH).Materials and methodsA retrospective review of 2256 urgent or emergency MRI referrals over a period of 8 years and nine months revealed 70 DISH patients who underwent CT and MRI scans of the spine. Spinal hematoma was the primary outcome. Additional variables were spinal cord impingement, spinal cord injury (SCI), trauma mechanism, fracture type, spinal canal narrowing, treatment type, and Frankel grades during injury, before and after treatment. Two trauma radiologists reviewed MRI scans blinded to initial reports.ResultsOf 70 post-traumatic patients (54 men, median age 73, IQR 66–81) with ankylosis of the spine from DISH, 34 (49%) had spinal epidural hematoma (SEH) and 3 (4%) had spinal subdural hematoma, 47 (67%) had spinal cord impingement, and 43 (61%) had SCI. Ground-level fall (69%) was the most common trauma mechanism. A transverse, AO classification type B spine fracture (39%) through the vertebral body was the most common injury type. Spinal canal narrowing (p < .001) correlated and spinal cord impingement (p = .004) associated with Frankel grade before treatment. Of 34 patients with SEH, one, treated conservatively, developed SCI.ConclusionsSEH is a common complication after low-energy trauma in patients with spinal ankylosis from DISH. SEH causing spinal cord impingement may progress to SCI if not treated by decompression.Clinical relevance statementLow-energy trauma may cause unstable spinal fractures in patients with spinal ankylosis caused by DISH. The diagnosis of spinal cord impingement or injury requires MRI, especially for the exclusion of spinal hematoma requiring surgical evacuation.Key Points• Spinal epidural hematoma is a common complication in post-traumatic patients with spinal ankylosis from DISH.• Most fractures and associated spinal hematomas in patients with spinal ankylosis from DISH result from low-energy trauma.• Spinal hematoma can cause spinal cord impingement, which may lead to SCI if not treated by decompression.

American College of Radiology (ACR) Appropriateness Criteria and EURO-2000 Guidelines Offer Limited Guidance for MRI Imaging of Pediatric Patients

This study aims to evaluate the clinical scenarios addressed by the EURO-2000 guidelines and the ACR appropriateness criteria for referring children to MRI and assessing the referring physician compliance with both guidelines. In January 2022, clinical scenarios reported in the last 1000 consecutive MRI requests for children (0-16 years) in one university children's hospital and two general university hospitals in Belgium, Europe, were retrospectively matched to the EURO-2000 guidelines and ACR appropriateness criteria. The number of clinical scenarios addressed and the justification for MRI referral were independently assessed for both guidelines. Pooled data from the three centers were evaluated and then analyzed by center, body area and prescriber using McNemar's test for paired proportions and χ2-tests unpaired proportions. After excluding incomplete or missing MRI requests, 2932 of 3000 requests were included in the analysis. Overall, out of 2932 clinical scenarios, 1229 (37.99%) were addressed by EURO-2000 and 1081 (36.37%) were addressed by the ACR appropriateness criteria (McNemar test, p=0.12). The proportions of clinical scenarios covered by the two guidelines were statistically similar when comparing centers, but varied across body regions (p < 0.001) and referring physician specialty (p between 0.75 and 0.001). EURO-2000 guidelines provided better coverage for head and spine (p < 0.05), while the ACR appropriateness criteria provided broader coverage for abdomen, pelvis, and musculoskeletal system (p < 0.0001). For addressed clinical scenarios, prescriber compliance for both guidelines was excellent with > 94% of justified MRI examinations in all the centers. Both the EURO-2000 guidelines and the ACR appropriateness criteria did not address two-thirds of clinical scenarios in children. Head and neck, chest and abdominal-pelvic examinations are the anatomic regions which should receive a specific attention for the future implementation of evidence-based clinical decision support tools for all referring specialists.

Agreement Between International Radiologists on the Appropriateness and Urgency in Lumbar Spine MRI Referrals.

PurposeTo determine how radiologists across health-care jurisdictions internationally assess the appropriateness and urgency levels of lumbar spine Magnetic Resonance Imaging MRI referrals.Patients and MethodsClinical information was extracted from 203 lumbar spine MRI referrals. Texts were divided into 10 datasets and embedded into a software to facilitate the classification process. Participant radiologists were recruited at the Image Perception Lab, at the Radiological Society of North America Congress, 2019 and through the institution radiology network. Radiologists were asked if they use referral guidelines in their practices. Radiologists assigned appropriateness and urgency levels based on the referral text. Appropriateness level descriptors were: indicated, indicated but needs more information or not indicated. Urgency levels were categorized: urgent, semi-urgent, or not urgent. All cases containing neurological symptoms with/without red flags were extracted and exact agreement between radiologists’ responses on the indication status was calculated.ResultsSeventy radiologists from 25 countries participated; 42% of participants indicated non-use of referral guidelines. Poor-moderate radiology agreements were recorded for appropriateness and referral urgency level decisions. 79.6% of responses indicated that cases containing neurological symptoms with/without red flags were indicated for scanning.ConclusionDespite referral guidelines promotion, nearly half of participants stated non-usage. Subsequently, a varied agreement levels were found in assigning the appropriateness of the referrals. Appropriateness of referrals with neurological symptoms (with/without red flags) recorded good agreement.

Development of lumbar spine MRI referrals vetting models using machine learning and deep learning algorithms: Comparison models vs healthcare professionals

IntroductionReferrals vetting is a necessary daily task to ensure the appropriateness of radiology referrals. Vetting requires extensive clinical knowledge and may challenge those responsible. This study aims to develop AI models to automate the vetting process and to compare their performance with healthcare professionals. Methods1020 lumbar spine MRI referrals were collected retrospectively from two Irish hospitals. Three expert MRI radiographers classified the referrals into indicated or not indicated for scanning based on iRefer guidelines. The reference label for each referral was assigned based on the majority voting. The corpus was divided into two datasets, one for the models' development with 920 referrals, and one included 100 referrals used as a held-out for the final comparison of the AI models versus national and international MRI radiographers. Three traditional models were developed: SVM, LR, RF, and two deep neural models, including CNN and Bi-LSTM. For the traditional models, four vectorisation techniques applied: BoW, bigrams, trigrams, and TF-IDF. A textual data augmentation technique was applied to investigate the influence of data augmentation on the models' performances. ResultsRF with BoW achieved the highest AUC reaching 0.99. CNN model outperformed Bi-LSTM with AUC = 0.98. With the augmented dataset, the performance significantly improved with an increase in F1 scores ranging from 1% to 7%. All models outperformed the national and international radiographers when compared on the hold-out dataset. ConclusionThe models assigned the referrals' appropriateness with higher accuracies than the national and international radiographers. Applying data augmentation significantly improved the models' performances. Implications for practiceThe outcomes suggest that the use of AI for checking referrals' eligibility could serve as a supporting tool to improve the referrals' management in radiology departments.

Abstract PO-114: Disparities in care among patients undergoing treatment for Non-Small Cell Lung Cancer in a safety net hospital

Abstract Background: Treatment of patients (pts) with Non-Small Cell Lung Cancer (NSCLC) has changed tremendously in the last few years, however, the impact of these new therapies has been uneven; with socioeconomic, ethnic and access differences impacting the quality and outcomes experienced across pts. Methods: We identified 5,722 pts at a Safety Net Hospital system in Indianapolis, Indiana who had been diagnosed with NSCLC using ICD 9 and ICD 10 codes from 2015 to 2019 and received surgery for it. We identified possible SCLC miscoded cases by identifying and removing a priori patients who received either etoposide or irinotecan. Data was collated and analyzed using descriptive statistics and Chi-square tests through STATA software. Results: Among the 5,722 patients who underwent surgery, 69.9% pts were female(F), 49.6% pts identified as Black (B), 50.0% identified as non-Hispanic white (NHW) and 0.4% as Hispanic (H). BF made up 63.7% of all B pts, and NHW F made up 76.9% of all NHW pts. Given the low rates of H pts, we did not include them in further analysis. B pts were more likely to be uninsured (66.6%). B pts were more likely to be referred to tumor board (86.4% vs 13.5%; p-value&amp;lt;0.01) and less likely to be referred to radiation oncology (42.5% vs 55.9%; p-value &amp;lt;0.01). Rates of Brain MRI were higher among NHW pts (81.3% vs 18.4%, p-value&amp;lt;0.01); inversely PET CT rates were lowest among NHW pts (47.1% vs 52.9%, p-value&amp;lt;0.01). Among patients who underwent surgery, NHW were more likely to have received cisplatin compared to Blacks (32.08% vs 1.2%; p-value&amp;lt;0.01) and among all patients who received surgery and received cisplatin, 98.3% received it in the neoadjuvant setting, 1.4% within 60 days post-op and 0.4% after 60 days post-op. NHW pts were more likely to receive neoadjuvant cisplatin compared to Blacks (97.2% vs 2.8%; p-value&amp;lt;0.01) and B pts were more likely to receive adjuvant cisplatin both within 60 days (30.4%) and more than 60 days after surgery (8.7%). Unfortunately given limitations in data extractions, we were not able to determine histology or stage at diagnosis in our cohort. Conclusions: This large single-institution study in a safety-net hospital notes tendencies among NSCLC patients; higher rates of prevalence among F, as well as higher rates of uninsured status and less use of Brain MRI and Radiation Oncology Referrals among B pts. Among patients who underwent surgery NHW were more likely to receive cisplatin. These differences might be due to socioeconomic status, access to care or patient-dependent factors such as stage at diagnosis. Further investigation is needed to adequately identify and address these disparities. Citation Format: Manuel R. Espinoza Gutarra, Oindrila Bhattacharyya, David Haggstrom. Disparities in care among patients undergoing treatment for Non-Small Cell Lung Cancer in a safety net hospital [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-114.

Correlation of placental MR imaging signs and pathologic diagnosis of placenta accreta spectrum: Retrospective single center case series

IntroductionAlongside initial screening obstetric US, use of placental MRI has been increasing in the last few decades to aid with antenatal diagnosis and delivery planning in Placenta Accreta Spectrum (PAS). The aim of this study was to determine if the MRI pathophysiological sign subcategories described in the current literature can predict the severity of pathologic diagnosis. MethodsInstitutional imaging records were reviewed for placental MRIs performed for suspicion of PAS in the last decade. Electronic health records were searched for patient history and pathology. The 59 MRI studies were reviewed using the 11 MRI signs described by the SAR and ESUR joint consensus statement. Further breakdown of the signs was divided by underlying pathophysiologic subcategories including gross morphologic, interface and tissue architecture signs. ResultsPathologic diagnosis yielded 34 cases: accreta 4/34, incerta 14/34, percreta 10/34 and normal 6/34. Of the accreta cases all of them demonstrated at least two interface and half of the cases had tissue architecture signs, 13/14 increta cases demonstrated interface signs and 12/14 demonstrated tissue architecture signs, 9/10 percreta cases had two interface and at least six demonstrated three tissue architecture signs. Statistical analysis showed significant difference between pathologic diagnosis and the number of positive interface signs with p = 0.02. DiscussionInterface signs were the most objective and sensitive MRI subcategory. Statistical analysis determined there was a significant difference between PAS diagnosis and number of interface signs present. This subcategory has the most overlap with classic US signs which are traditionally used before MRI referral.

Categorisation of lumbar spine MRI referrals in Denmark as compliant or non-compliant to international imaging guidelines: an inter-rater reliability study

BackgroundManaging low back pain (LBP) often involves MRI despite the fact that international guidelines do not recommend routine imaging. To allow us to explore the topic and use this knowledge in further research, a reliable method to review the MRI referrals is needed. Consequently, this study aimed to assess the inter-rater reliability of a method evaluating lumbar spine MRI referrals’ appropriateness.MethodsFour inexperienced students (chiropractic master’s students) and a senior clinician (chiropractor) were included as independent raters in this inter-rater reliability study. Lumbar spine MRI referrals from primary care on patients (> 18 years) with LBP with or without leg pain were included. The referrals were classified using a modified version of the American College of Radiology (ACR) imaging appropriateness criteria for LBP. Categories of appropriate referrals included; fractures, cancer, previous surgery, candidate for surgery or suspicion of cauda equina. Inappropriate referrals included lacking information on previous non-surgical treatment, no word on non-surgical treatment duration, or “other reasons” for inappropriate referrals.After two rounds of training and consensus sessions, 50 lumbar spine MRI referrals were reviewed independently by the five raters. Inter-rater reliability was quantified using unweighted Kappa statistics, and the observed agreement was calculated with both a pairwise comparison and an overall five-rater comparison.ResultsInter-rater reliability was substantial, with a Kappa value for appropriate vs. inappropriate referrals of 0.76 (95% CI: 0.55–0.89). When six and eight subcategories were evaluated, the Kappa values were 0.77 (95% CI: 0.58–0.91) and 0.82 (95% CI: 0.72–0.92), respectively.The overall percentage of agreement for appropriate and inappropriate referrals was 92% and ranged from 88 to 98% for the pairwise comparisons of the five raters’ results. For the six and eight subcategories, the overall agreement was 92 and 88%, respectively, ranging from 88 to 98% and 84–92%, respectively, for the pairwise comparisons.ConclusionThe inter-rater reliability of the evaluation of the appropriateness of lumbar spine MRI referrals, according to the modified ACR-appropriateness criteria, was found to range from substantial to almost perfect and can be used for research and quality assurance purposes.

Establishing the reference value for tibial tubercle-trochlear groove distance on MRI in Southern Chinese population and its correlation with age, sex, height, weight and size: A multi-centre study

Objective: The first objective of this study is to determine the reference Tibial Tubercle-Trochlear Groove (TT-TG) distance on MRI in Southern Chinese population. The second objective is to investigate the correlation between TT-TG distance and (i) age, (ii) sex, (iii) height, (iv) weight and (v) Body Mass Index (BMI) respectively. Method: Three hundred MRI knees performed in two different centres between August 2017 and October 2018 were included. All patients were prospectively recruited after MRI referral from Orthopaedics department. The TT-TG distances were measured by two radiologists independently. Measurement reliability was assessed using intraclass correlation coefficient (ICC). One sample t-test was used to compare the results between this study and other published studies. Spearman’s rank correlation coefficient was used to determine correlations between the TT-TG distance and age, sex, height, weight and BMI respectively. Result: There was no statistical significance between the mean of TT-TG distances from the two radiologists ( P-value = 0.32). The measurement reliability was excellent (ICC = 0.922 ± 0.02). The mean of averaged TT-TG distance was 8.32 ± 0.33 mm (range 2.01 to 17.48 mm). There were no statistical significant differences in means of TT-TG distance between laterality and gender. There were statistically significant correlations between (i) TT-TG distance and age ( p-value = 0.009), and (ii) TT-TG distance and height ( p-value = 0.014). Conclusion: The reference TT-TG distance on MRI in Southern Chinese population was 8.32 ± 0.33 mm. Statistically significant correlations were established between (i) TT-TG distance and age; and (ii) TT-TG distance and height.

Radiographers' assessment of referrals for CT and MR imaging using a web-based data collection tool

IntroductionThere is limited research related to the radiographers' role in assessing of radiology referrals to justify imaging. This study investigated radiographers' compliance with guidelines in the assessment of CT and MRI referrals and factors that influenced their performance. MethodsThis research was facilitated by the EFRS Research Hub at ECR 2019. Five radiology referral scenarios for CT and/or MRI were distributed to radiographers, as determined by their scope of practice, who volunteered at the Research Hub. A web-based data collection tool was used. The radiographers were required to determine the appropriateness of each referral, highlight any concerns and recommend suitable investigations if applicable. Linear regression analysis was used to determine whether postgraduate qualification, grade/role of the radiographer and use of guidelines influenced the radiographers' performance in assessing the referrals. ResultsParticipants originated from 24 countries (n = 51 CT, n = 40 MRI), the majority originating from the UK, Ireland, Italy, Spain, Norway and Austria. Responses consistent with guidelines were 58% and 57% for CT and MRI, respectively. Possession of an MSc qualification in CT was a significant factor of influence for a higher consistency with guidelines (p = 0.02) in CT. Employment as a radiographer in a lead professional role and/or educator was a significant factor of influence for a higher consistency with guidelines in MRI (p = 0.01). ConclusionA total of 58% for CT and 57% for MRI of the radiographers' responses complied with guidelines. Factors such as postgraduate education and leading professional roles are associated with better performance. Implications for practiceConsidering qualifications, experience and managerial role is vital before radiographers are delegated task of justifying CT and MR Imaging.

Effects of Physician Experience, Specialty Training, and Self-referral on Inappropriate Diagnostic Imaging.

Although previous research has demonstrated high rates of inappropriate diagnostic imaging, the potential influence of several physician-level characteristics is not well established. To examine the influence of three types of physician characteristics on inappropriate imaging: experience, specialty training, and self-referral. A retrospective analysis of over 70,000 MRI claims submitted for commercially insured individuals. Physician characteristics were identified through a combination of administrative records and primary data collection. Multi-level modeling was used to assess relationships between physician characteristics and inappropriate MRIs. Massachusetts PARTICIPANTS: Commercially insured individuals who received an MRI between 2010 and 2013 for one of three conditions: low back pain, knee pain, and shoulder pain. Guidelines from the American College of Radiology were used to classify MRI referrals as appropriate/inappropriate. Experience was measured from the date of medical school graduation. Specialty training comprised three principal groups: general internal medicine, family medicine, and orthopedics. Two forms of self-referral were examined: (a) the same physician who ordered the procedure also performed it, and (b) the physicians who ordered and performed the procedure were members of the same group practice and the procedure was performed outside the hospital setting. Approximately 23% of claims were classified as inappropriate. Physicians with 10 or less years of experience had significantly higher odds of ordering inappropriate MRIs. Primary care physicians were almost twice as likely to order an inappropriate MRI as orthopedists. Self-referral was not associated with higher rates of inappropriate MRIs. Classification of MRIs was conducted with claims data. Not all self-referred MRIs could be detected. Inappropriate imaging continues to be a driver of wasteful health care spending. Both physician experience and specialty training were highly associated with inappropriate imaging.

Targeted rapid knee MRI exam using T2 shuffling.

MRI is commonly used to evaluate pediatric musculoskeletal pathologies, but same-day/near-term scheduling and short exams remain challenges. To investigate the feasibility of a targeted rapid pediatric knee MRI exam, with the goal of reducing cost and enabling same-day MRI access. A cost effectiveness study done prospectively. Forty-seven pediatric patients. 3T. The 10-minute protocol was based on T2 Shuffling, a four-dimensional acquisition and reconstruction of images with variable T2 contrast, and a T1 2D fast spin-echo (FSE) sequence. A distributed, compressed sensing-based reconstruction was implemented on a four-node high-performance compute cluster and integrated into the clinical workflow. In an Institutional Review Board-approved study with informed consent/assent, we implemented a targeted pediatric knee MRI exam for assessing pediatric knee pain. Pediatric patients were subselected for the exam based on insurance plan and clinical indication. Over a 2-year period, 47 subjects were recruited for the study and 49 MRIs were ordered. Date and time information was recorded for MRI referral, registration, and completion. Image quality was assessed from 0 (nondiagnostic) to 5 (outstanding) by two readers, and consensus was subsequently reached. A Wilcoxon rank-sum test assessed the null hypothesis that the targeted exam times compared with conventional knee exam times were unchanged. Of the 49 cases, 20 were completed on the same day as exam referral. Median time from registration to exam completion was 18.7 minutes. Median reconstruction time for T2 Shuffling was reduced from 18.9 minutes to 95 seconds using the distributed implementation. Technical fees charged for the targeted exam were one-third that of the routine clinical knee exam. No subject had to return for additional imaging. The targeted knee MRI exam is feasible and reduces the imaging time, cost, and barrier to same-day MRI access for pediatric patients. 2 Technical Efficacy: Stage 6 J. Magn. Reson. Imaging 2019.

Primary care referral for knee MRI in the United Kingdom: Association with demography and subsequent surgical intervention.

Since 2008 primary care physicians (GPs) in our region have been allowed open access to knee MRI scans. There are questions about whether this changes referral practice and if it is an effective use of resources. To describe the change in demographics of patients referred for knee MRI following implementation of a new referral pathway. Retrospective observational study. All primary care referrals between 2008 and 2015 for knee MRI from a population of 900,000. Not applicable. Demographic profile and number of knee MRI referrals and subsequent arthroscopies. Comparisons between urban and rural populations used the t-test. Test for normality used Shapiro-Wilks. Comparison between abnormal MRI proportions used a chi-squared test. There were 23,928 knee MRI referrals (10,695 from GPs) between 2000 and 2015. MRI knee referrals rose from 210 in 2008 to 2379 in 2015. The average age of the patient decreased from 46.8 (SD = 14.9) in 2008 to 41.3 (SD = 14.7) in 2015. Conversion to arthroscopy declined from 15.4% to 10.2%, but there was no significant change in abnormal scan proportion. Conversion rates showed no significant difference between rural (9.6%) and urban populations (10.5%). Referral rates were significantly higher in low socioeconomic status areas (47.3% vs. 34.6%). The median referral rate per 1000 patients was 13.8 (interquartile range = 8.4). Referral rates varied widely between practices. Despite a large rise in knee MRI referrals from primary care, there has been no substantial change in the age profile, suggesting that there has been no increase in inappropriate referral of elderly patients in whom MRI is unlikely to influence management. A modest decrease in the conversion rate to arthroscopy may be reasonably offset against a decrease in secondary care referrals. Socioeconomic status of the target population must be considered when planning primary care knee MRI services. 4 Technical Efficacy Stage: 6 J. Magn. Reson. Imaging 2019.

Corrigendum to: Guidelines, training and quality assurance: influence on general practitioner MRI referral quality

ABSTRACT INTRODUCTIONMagnetic resonance imaging (MRI) is an accurate diagnostic test used mainly in secondary care. Uncertainty exists regarding the ability of general practitioners (GPs) to use direct access high-tech imaging pathways appropriately when managing musculoskeletal injury. AIMTo evaluate the use of primary care-centric guidelines, training and quality assurance on the appropriateness of GP MRI referrals for patients with selected musculoskeletal injuries. METHODSThis is an 18-month primary care retrospective study. GPs participated in clinical musculoskeletal training, enabling patient referral for MRI on four body sites. Two reviewers categorised referral appropriateness independently, and reviewer inter-rater agreement between categorisations was measured. MRI results and patient management pathways were described. Associations of scan status and patient management were examined using logistic regression. RESULTSIn total, 273 GPs from 72 practices attended training sessions to receive MRI referral accreditation. Of these, 150 (55%) GPs requested 550 MRI scans, with 527 (96%) eligible for analysis, resulting in 86% considered appropriate; 79% consistent with guidelines and 7% clinically useful but for conditions outside of guidelines. Inter-rater agreement was 75%. Cohen's weighted kappa statistic was 0.38 (95% CI: 0.28–0.48). MRI referrals consistent with guidelines were more likely to show pathology requiring specialist intervention (reviewer 1: odds ratio=2.64, 95% CI 1.51–4.62; reviewer 2: odds ratio=4.44, 95% CI 2.47–7.99), compared to scan requests graded not consistent. DISCUSSIONStudy findings indicate GPs use decision support guidance well, and this has resulted in appropriate MRI referrals and higher specialist intervention rates for selected conditions.

Guidelines, training and quality assurance: influence on general practitioner MRI referral quality

INTRODUCTION Magnetic resonance imaging (MRI) is an accurate diagnostic test used mainly in secondary care. Uncertainty exists regarding the ability of general practitioners (GPs) to use direct access high-tech imaging pathways appropriately when managing musculoskeletal injury. AIM To evaluate the use of primary care-centric guidelines, training and quality assurance on the appropriateness of GP MRI referrals for patients with selected musculoskeletal injuries. METHODS This is an 18-month primary care retrospective study. GPs participated in clinical musculoskeletal training, enabling patient referral for MRI on four body sites. Two reviewers categorised referral appropriateness independently, and reviewer inter-rater agreement between categorisations was measured. MRI results and patient management pathways were described. Associations of scan status and patient management were examined using logistic regression. RESULTS In total, 273 GPs from 72 practices attended training sessions to receive MRI referral accreditation. Of these, 150 (55%) GPs requested 550 MRI scans, with 527 (96%) eligible for analysis, resulting in 86% considered appropriate; 79% consistent with guidelines and 7% clinically useful but for conditions outside of guidelines. Inter-rater agreement was 75%. Cohen's weighted kappa statistic was 0.38 (95% CI: 0.28-0.48). MRI referrals consistent with guidelines were more likely to show pathology requiring specialist intervention (reviewer 1: odds ratio=2.64, 95% CI 1.51-4.62; reviewer 2: odds ratio=4.44, 95% CI 2.47-7.99), compared to scan requests graded not consistent. DISCUSSION Study findings indicate GPs use decision support guidance well, and this has resulted in appropriate MRI referrals and higher specialist intervention rates for selected conditions.

A review of the appropriateness and accuracy of urgent MRI referrals in an MSK-CATS service

Purpose: The purpose of this study was to assess whether urgent MRI referrals ordered by physiotherapists, ESP and MSK GP's were appropriate and accurate in the musculoskeletal primary care setting between 2015 and 2018. Urgent MRI appointments are valuable and therefore we aimed to distinguish whether they are filled with appropriate patients who require urgent investigation and that sinister pathologies that need urgent further management are not missed. Resources outlining the criteria for urgent investigations for sinister pathology are limited and we aimed to assess whether our service followed best practice.

Nasopharyngeal Carcinoma: Knowledge amongst General Practitioners in Western Sydney

Background: The west of Sydney has a high population of Asian descent, a high risk population to nasopharyngeal carcinoma (NPC). There is a lack of primary research focused on evaluating the clinical knowledge amongst primary health providers in managing this presentation. Method: A cross-sectional study, involving surveying 113 General Practitioner (GP) practices in the Fairfield and Bankstown city region on clinical knowledge around key aspects of epidemiology, aetiology, clinical presentation and management of Nasopharyngeal Carcinoma. 42 surveys were completed. Results: GPs were well aware of many NPC symptoms, with over 90% recognizing epistaxis, nasal obstruction and cervical lymphadenopathy. Many GPs were aware of several aetiological factors for NPC, in particular smoking (95.2%), however a significant proportion were not aware that Epstein-Barr Virus (EBV), pre-existing Ear Nose & Throat (ENT) disease, and formaldehyde exposure were key risk factors (60%). All participants judged CT, MRI and specialist referral as useful management options but a significant proportion (29.7%) would chose to refer between 2-4 weeks from presentation outside the critical 2 weeks’ time frame. Nearly half of the GPs surveyed (45.2%) believed that they had insufficient knowledge of NPC and required further information (81%). Conclusion: GPs in the west of Sydney would benefit from further education in order to improve the diagnosis and management of these patients.

Preoperative Breast MRI: Surgeons' Patient Selection Patterns and Potential Bias in Outcomes Analyses.

The purpose of this study is to determine which patient- and tumor-related and clinical variables influence dedicated breast surgeons' and general surgeons' referrals for preoperative breast MRI for patients with newly diagnosed breast cancer. Surgeons who perform breast surgery responded to a survey from June 16, 2014, through August 11, 2014. Participants self-identified as breast or general surgeons and provided professional practice details. They used Likert scores (range, 1-7 with increasing likelihood to order MRI) to weigh numerous patient- and tumor-related and clinical variables. Mean likelihood scores were calculated and compared using a linear mixed model. A p ≤ 0.05 was considered statistically significant. Two hundred eighty-nine surveys from 154 (53%) breast surgeons and 135 (47%) general surgeons showed an overall likelihood to refer for patients with a BRCA mutation (mean Likert score, 6.17), familial (mean Likert score, 5.33) or personal (mean Likert score, 5.10) breast cancer history, extremely dense breasts (mean Likert score, 5.30), age younger than 40 years (mean Likert score, 5.24), axillary nodal involvement (mean Likert score, 6.22), tumor that is mammographically occult (mean Likert score, 5.62) or fixed to the pectoralis (mean Likert score, 5.49), tumor that is a candidate for neoadjuvant treatment (mean Likert score, 5.38), multifocal or multicentric disease (mean Likert score, 5.22), invasive lobular carcinoma (mean Likert score, 5.20), T3 (mean Likert score, 4.48) or T2 (mean Likert score, 4.41) tumor, triple-negative breast cancer (mean Likert score, 4.66), a patient who is a candidate for mastectomy requesting breast conservation therapy (mean Likert score, 5.27), and radiologists' recommendations (mean Likert score, 5.19). Across all patient ages, breast surgeons referred more often than did general surgeons (mean Likert score, 4.32 vs 3.92; p = 0.03), especially for patients with BRCA mutation (mean Likert score, 6.39 vs 5.93; p = 0.01) and tumors smaller than 1 cm (mean Likert score, 3.84 vs 3.40; p = 0.002). Breast surgeons referred less often than did general surgeons for multifocal or multicentric disease (mean Likert score, 5.02 vs 5.44; p = 0.001). Breast surgeons and general surgeons similarly weighed other variables. Preoperative breast MRI referral trended with certain higher risk patient- and tumor-related and clinical variables and were nonuniform between the breast surgeons and general surgeon cohorts. Selection bias could affect outcomes analyses for preoperative breast MRI.