Clinical guidance for MRI referral


Introduction
☰ Table of contents


Background


The Department of Health and Ageing (DoHA) is phasing in new Medicare Benefits Schedule (MBS)–supported referrals for magnetic resonance imaging (MRI) requested by general practitioners (GPs).

From November 2013, GPs will be able to request MRI studies of three anatomical regions with six clinical indications for patients aged 16 years and over. The regions and indications are:

  • head – unexplained seizure(s) and chronic headache with suspected intracranial pathology
  • cervical spine – cervical radiculopathy and cervical spine trauma
  • knee – acute anterior cruciate ligament and acute meniscal tear.

To aid decision making for MRI, The Royal Australian College of General Practitioners (RACGP) has been tasked with producing clinical guidance material for the specific Medicare indications. This guidance has been developed by GPs for GPs, in consultation with radiologists and other specialists as appropriate. The guidance aims to support evidence-based decision making, reduce inappropriate referral and improve patient outcomes.

These new MBS items supplement existing Medicare-eligible requests by GPs for MRI scans for patients under the age of 16, released November 2012.


Aim of guidance


The majority of evidence for medical imaging focuses on lesion detection or diagnostic accuracy. There is sparse evidence regarding the impact of diagnostic imaging on health outcomes. Furthermore, there is emerging evidence of preventable harms and unnecessary interventions.1,2

GPs should be cautious in the decision to use MRI. Clinical history and physical examination are keys to advising patients about appropriate imaging. This guidance focuses on MRI as adjunct to patient management, not as a first-line diagnostic tool.

This guidance is designed to:

  • inform GPs of the indications for MRI referral under new Medicare arrangements
  • guide the appropriate use of MRI in the management process
  • provide key information for decision making at the point of care
  • help determine appropriate and evidence-based use of MRI in general practice
  • inform GPs of the benefits and limitations of MRI in the clinical context
  • educate on the contraindications and safety issues with MRI scanning
  • support GPs to inform patients of the potential negative health impacts.


Development process


DoHA commissioned the RACGP in July 2013 to produce this guidance in time for the introduction of the new MBS-supported MRI referral items in November 2013. Given the limited timeframe, the RACGP took a pragmatic approach to the development of this guidance, but one which is in line with guideline development best practice.

The RACGP convened a GP-led Advisory Group, drawing on GP members with expertise and experience in guideline development and in general and musculoskeletal medicine. A literature search was conducted and key resources were identified. We searched international guidelines and high-grade, evidence-based statements on the specific indications to determine the role and overall benefit of imaging. We documented evidence-based statements, significant issues regarding imaging choice, and any evidence of potential harms.

This guidance provides recommendations based on current, evidence-based guidelines such as those from the Scottish Intercollegiate Guidelines Network (SIGN), the National Institute for Health and Care Excellence (NICE) and the National Health and Medical Research Council (NHMRC). In cases where recommendations specific to the indication were not available, other sources, such as systematic reviews, have been used to inform recommendations.

The guidance was progressively developed under the direction of the Advisory Group. The process was informed by feedback and information received from clinical experts and stakeholders. These include:

  • Arthritis Victoria
  • Australian and New Zealand Association of Neurologists
  • Neurosurgical Society of Australasia
  • Dr Andrew Boyden, Clinical Advisor at National Prescribing Service (NPS) Medicine Wise
  • Mr Tony McBride, Health and Community Consultant
  • Dr Scott Masters, RACGP National Faculty of Specific Interests – Musculoskeletal Network
  • Professor Michele Sterling, Associate Director, Centre of National Research on Disability and Rehabilitation Medicine, University of Queensland.

The RACGP is grateful for information provided by the Royal Australian and New Zealand College of Radiologists (RANZCR) in its Guidance for GP referrals for MRI studies, which is referenced in this guidance.


Evidence for recommendations


Due to the time constraints in the development of this guidance, we have mostly taken recommendations from existing evidence-based guidelines. The Advisory Group did not attempt to re-evaluate the evidence behind these recommendations or convert the recommendation grades to the Australian NHMRC grading levels. Therefore, the recommendations tables include the reference and sources of recommendations, the recommendation grade, and links to further information on the evidence grade where available (refer to Appendix 1). For some recommendations, an evidence grade was not available; therefore, these recommendations should be treated as expert opinion.

As the recommendations have been taken from a number of sources, there is some overlap in their scope that would not normally occur.


Format


The guidance is divided into the three anatomical regions of the MBS item descriptions – head, cervical spine and knee.

For MRI of the head and cervical spine, we have further divided the guidance into the specific indications. For MRI of the knee, both indications have been considered together.

Each section provides key information, evidence-based recommendations, background, imaging choice, imaging issues, benefits and risks as well as optional additional background information.


Scope


This guidance is intended for GPs who are considering referring patients aged 16 years and over with any of the specific Medicare-funded indications for MRI.

The guidance does not cover patients younger than 16 years of age.

The guidance does not give advice on interpreting MRI.

  1. Chou R, Qaseem A, Owens DK, Shekelle P. Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med 2011;154(3):181–89.
  2. Brito JP, Morris JC, Montori VM. Thyroid cancer: zealous imaging has increased detection and treatment of low risk tumours. BMJ 2013;347:f4706.