NeuroNews

Ordering MRI - How a Neurologist Decides

  

  

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With healthcare reform dominating the news recently, MRI and other imaging tests have become the (misguided) targets of many critics.  Although MRI makes up only one-half of one percent of total healthcare expenditures it is easy to demonize since the average healthcare consumer can understand imaging much easier than DRG's, hospital facility fees or insurance contracts.

It is unfortunately true that some physicians order expensive imaging tests in C.Y.A. mode but I felt it would be important to share the proper decision making criteria our clinicians utilize when making decisions about ordering these tests.

There are a variety of tools available to help make decisions about imaging a patient.  These include the Appropriateness Criteria by the American College of Radiology, the Milliman Care Guidelines - Ambulatory Care Section, and Medicare LCDs and eventually the Medicare Appropriateness Criteria Demonstration Project.  Some rely on diagnostic criteria, some on symptoms combined with evidenced based research such as the Cochrane Reports and input from various medical societies and associations.

Clinical Judgment is Irreplaceable 

But nothing can substitute for the clinical judgment of an experienced physician who understands the significance of treating the patient at the highest level of competency and is evaluating with eyes, ears and hands the patient in front of them.  The Guidelines can be used on a case-by-case basis by qualified, healthcare professionals as a tool in making medical necessity decisions, but by definition they are nothing more than "guidelines" and therefore should not be used for denying evaluation and possible treatment to patients.  Additionally, if one simply utilized guidelines like a recipe for mixing a cake, a physician would be dissuaded from determining that imaging is not required when their experience tells them it is likely unnecessary.  They must always be used in the context of a qualified and experienced healthcare professional's clinical judgment.

Imaging Decisions Should Come After, and as a Result of the Clinical Examination 

Once a decision to image the patient has been made based on the outcome of a history and physical examination of the patient, there are four important elements we consider when ordering and performing the neuroimaging.

1)  The careful selection of which body part to image and the selection of the particular MRI or MRA protocol and sequences needed to evaluate the patient's symptoms.

2)  The use of highly trained and experienced certified technicians.  Even the best equipment does not insure that the image quality will be achieved without the experience of qualified technicians.

3)  The use of an accredited (ACR or ICAMRL) Neuroimaging Center.  This assures that the equipment and procedures used meet a high level of competency and that procedures are in place to constantly evaluate and improve quality.

4)  Fellowship trained or Board Certified Neuroimaging/Neuroradiologist interpreting the images.  A general radiologist who is minimally trained in MRI and in particular central nervous system MRI will not give us the quality we expect or patients deserve.

Further, each test in a diagnostic testing program plays its own separate role in the evaluation of a patient.  No test is simply a substitute for another, since each test gives critical and unique information necessary for patient diagnosis and treatment. 

In the end, the treating physician must be able to trust the results from each test and must correlate all test results with the patient being examined, in order to design an optimal treatment plan for each patient.  Delayed evaluation for any reason squanders the most valuable assets in patients' lives, namely, their time and their health.  The subsequent effects on their lives and the lives of the organizations they serve, is incalculable. - by Vernon Rowe, MD