Rational use of shoulder MRI in the private setting: specialist-ordered MRIs influence clinical management significantly more often than primary care physicians.

The aim of this study was to determine the difference in proportion of shoulder MRIs that influence the management plan of shoulder patients based on whether MRI was ordered by a shoulder specialist, orthopaedic surgeon or primary care provider prior to referral to a specialist. This observational analytical study was conducted in a private practice setting. Data were obtained from 153 MRIs performed on 151 patients. Seventy-seven MRIs were ordered by a specialist shoulder surgeon and 76 by a primary care provider (general practitioner, non-operative sports medicine physician or physiotherapist). Specialist-ordered MRIs influenced patient management significantly more often than primary care-ordered MRIs (82% vs. 22%, p < 0.001). Fifty-four percent of referral letters from primary care providers to the specialist did not have documentation of a physical examination, yet an MRI had been ordered. The most common diagnoses for primary care-ordered MRIs which did not have influence on patient management were subacromial bursitis and adhesive capsulitis. With less than 25% of primary care-ordered shoulder MRIs influencing clinical management, questions must be raised about the indications for MRI. Greater than 50% of referrals contained no documented physical examination, suggesting that MRI is being relied upon for assessment. If access to private MRI was to be rationalized, perhaps shoulder specialist-ordered CT and X-ray could be covered by insurance providers. Currently, they are not covered in our system, yet are more likely to influence clinical management than primary care-ordered MRIs, which are currently covered by insurance without restriction on indications.