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Letter to the Editor: What Does a Shoulder MRI Cost the Consumer?

Herzog, Richard J. MD, FACR1,2,a; Potter, Hollis G. MD3

Clinical Orthopaedics and Related Research®: June 2017 - Volume 475 - Issue 6 - p 1749–1750
doi: 10.1007/s11999-017-5328-3
Letter to the Editor
Free

1Hospital for Special Surgery, 535 E. 70th Street, 10021, New York, NY, USA

2Spreemo Health Quality Research Institute, New York, NY, USA

3Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA

ae-mail; herzogr@hss.edu; e-mail; natasha.irani@spreemo.com

Received March 3, 2017/Accepted March 17, 2017; previously published online March 23, 2017

(RE; Westermann RW, Schick C, Graves CM, Duchman KR, Weinstein SL. What Does a Shoulder MRI Cost the Consumer? Clin Orthop Relat Res. 2017;475:580-584).

One author (RJH) is an employee of Spreemo Health, New York, NY, USA.

The author (HGP) certifies that neither she, nor any members of her immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

To the Editor,

We read the recently published study by Westermann and colleagues [2] with great interest. In their paper, the authors found that the cost for a MRI shoulder exam was highly variable in the state of Iowa. The authors conclude that improved price transparency may better guide individuals and their referring providers to imaging centers that provide the best value for their healthcare dollar.

The authors did not consider quality in the scope of their study. It is important to note that understanding quality, and not merely cost, is of paramount importance in helping patients and payers identify value.

Key elements of a high-value MRI include the image quality, as well as the accuracy and comprehensiveness of the radiologist's report. From a technical standpoint, details such as in-plane and through-plane resolution, tissue contrast, and artifact reduction pulse sequences (for patients who have had surgery) all affect the diagnostic performance of MRI. Similarly, fellowship-trained musculoskeletal radiologists with an understanding of these technical details, regional anatomy, and current surgical practices provide more-accurate assessment and may obviate the need for diagnostic arthroscopy.

An inaccurate diagnosis may lead to a cascade of unnecessary medical interventions, delay in correct treatment, and increased patient morbidity. Inaccurate diagnoses may also result in increased direct and indirect costs to the patient, as well as to the payer, despite up-front savings of a lower-cost MRI.

If all MRI services were otherwise identical except for price, then certainly obtaining a scan at the lowest price point results in the highest value. However, as in other areas of medicine where additional factors need to be considered, low cost does not always equal high value.

In a clinical study recently completed at Hospital for Special Surgery, a subject underwent a lumbar MRI exam at 10 different regional MRI centers over a 3-week period. Compared to reference exams performed immediately before and after the 10 MRI exams, the study identified meaningful variability in reported diagnostic findings from center to center with an average of 12.5 errors in interpretation and 43.6% false negatives (findings that were not reported) in the MRI reports [1]. Equally alarming is that the variability identified could meaningfully impact the patient's treatment trajectory, and relatedly, the ultimate outcome and total cost of care.

At Hospital for Special Surgery, we frequently repeat outside MRI exams of the shoulder due to both poor technical quality and errors of interpretation. Recognizing that imaging is not merely a commodity based on price can be a meaningful step forward in identifying value for patients and payors in selecting their imaging centers and ultimately, how it impacts the total cost of care.

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References

1. Herzog R, Elgort DR, Flanders A, Moley PJ. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. Spine J. [Published online ahead of print November 17, 2016].
2. Westermann RW, Schick C, Graves CM, Duchman KR, Weinstein SL. What does a shoulder MRI cost the consumer? Clin Orthop Relat Res 2017;475:580-584 10.1007/s11999-016-5181-9.
© 2017 Lippincott Williams & Wilkins LWW