Given the high importance of doing MRI in diagnosis and treatment procedure, high cost of purchasing and maintaining MRI machines for centers and also high cost of using MRI for patients and health insurers(13), the appropriateness of brain MRI prescriptions and its related factors were investigated in this study.
Findings show that 21.6 % of brain MRI prescriptions were without indication (inappropriate). Researches which especially assessed the brain MRI appropriateness are few, so other MRI services are also compared with our findings. Piersson etal (2017) reported that about 19 percent of brain MRIs in a single center in Ghana were inappropriate(14). It seems the use of MRI procedure in Iran is similar to that of USA which has a very costly health system; because Lehnert & Bree (2010) found that 26% of MRI and CT prescriptions in USA are inappropriate(15). Oikarinen et al (2013) indicated that 7% of MRIs done in an academic hospital in Finland were inappropriate(16). Saadat et al (2008) found that 17.2% of conducted MRIs in private centers in Tehran were normal that 9.8%of them were for headache examinations(17). Barzin et.al demonstrated that 81% of requested MRIs by physicians for patients suffering from headache in an educational hospital in Sari city had normal results(9). Sheehan et al (2016) reported that 45% (106 cases) out of 237 prescribed MRIs for shoulder in a department of veterans affairs tertiary care hospital were inappropriate(18). In a recent research in Ontario, the inappropriate rate of hip MRI is estimated at 32.1%(19).
Comparison also shows that there are different results on different MRI services (all MRI, brain, shoulder, hip, … ). There are also different inappropriate rate of MRI prescriptions across different countries and setting which associate with their health system structure and policies to control physician and patient behavior. However, it seems these differences should be mainly explained by different methodology, indications criteria and instrument which are used by different researchers.
Analytic findings show that there are no significant relationships between socio-demographic variables and brain MRI appropriateness. However, several clinical factors have significant relationship with appropriateness of brain MRI.
We found that having previous treatment and also other diagnostic tests are related to appropriateness of brain MRI. Manta (2019) showed that having no previous radiographic examination was the most predictor of inappropriate prescription of hip MRI in Ontario(19)
Also Sheehan et al (2016) showed that ultrasound could be a cost saving substitution for 66 percentage of shoulder MRIs(18).
Finding also indicates that 27.74% of 191 patients at first visit to the physicians were without indication for brain MRI. We found also the more number of times a patient visits a physician, the less likelihood of inappropriateness of brain MRI. Patients with more visits to doctors likely have chronic and severe symptoms(20), so their MRIs probably are necessary and appropriate. It also can be explained by defensive medicine. Physician in first visit in order to reduce and compensate the risk of malpractice
liability apply more tests and treatments which may be unnecessary(21).
One of the main results is that the primary applicant of MRI has significant relationship with the appropriateness of brain MRI. About 19 percent of prescriptions requested primarily by physicians were inappropriate, but on the contrary more than 60 percent of brain MRIs which requested primarily by patients were inappropriate. Patients usually appeal diagnostic tests e.g. MRI from their physician; however in many times their request is unnecessary. Although it likely increases satisfaction of patient and health outcome, it waste health system resources and maybe increases the side effects of these tests(22). It is also related to consumer moral hazard concept which itself results from information asymmetry between purchasers and patients(23).
There are some macro factors which can effect on volume of unnecessary diagnostic tests and interventions which we couldn't assess their effect. For example Andrade et al. found that more supply of imaging services (imaging centers, MRI machines, radiologists) by itself increase the demand for such services(24). This phenomenon can be explained by provider induced demand or more accessibility of these services.
The present study showed that the financial burden resulted from inappropriate prescriptions of brain MRIs in 2017 was 99988 USD in Shiraz teaching hospitals which is about 17 times of Iran's Gross Domestic Product (GDP) per capita in that year (5680 USD)(25). This financial burden is related only to one MRI services (brain MRI), in one city and in only public centers. So with considering all mentioned factors there are noticeable financial burden of inappropriate MRI services in Iran. It should be asserted that according to a national study in 2018, there were 276 MRI machines in Iran (about 3.5 per one million population)(26)
A major limitations of current study is that there are not clear statistics about utilization of brain MRI in Iran, so we cannot estimate overall financial burden of brain MRI in Iran. Another limitation was lack of similar studies on brain MRI with respect to relevant factors to inappropriate prescriptions of brain MRI.