Revised Clinical Guideline Recommendations
for
MRI use in diagnosing soft tissue knee injuries
Information and Consultation Document
Deadline for Feedback
5.00 pm, 10 March 2010
Table of Contents
3. Process used to revise clinical guideline recommendation 4
4. The 2003 MRI recommendation 5
This consultation document sets out the background to: the revision of the clinical guideline recommendations for using MRI for diagnosing internal derangements of the knee; the process used to develop revised recommendations; the current and revised recommendations; and an outline of next steps. Accompanying this consultation document is the evidence-based report underpinning the revised recommendations; it has been supplied for your information.
We want your feedback on the revised recommendations. At the end of this document there is a feedback form, which you can use to share your thoughts with us.
Please email or post your submission to:
Sarah Clark, Research Advisor, Research Group, Strategic Policy and Research, ACC, at Sarah.clark@acc.co.nz
PO Box 242, Wellington
If you have any queries please contact Sarah at the above email address, or by phoning (04) 918 4099.
Please note that all correspondence and submissions on this matter may be the subject of a request under the Official Information Act 1982.
Closing date for feedback
Please send your feedback form to us by 5pm, 10 March 2010.
Next Steps
Activity |
Date |
|---|---|
Consultation Starts |
5 February 2010 |
Closing date for submissions |
10 March 2010 |
Submissions considered by Expert Advisory Group |
March 2010 |
Notification of outcomes/final recommendations |
March-April 2010 |
Endorsement sought |
March-April 2010 |
Dissemination of revised recommendation |
April-May 2010, and onwards |
ACC has sought to revise the clinical guideline MRI recommendations for knees due to concerns that inappropriate and unnecessary MRI investigations are undertaken for the diagnosis of soft-tissue knee injuries. In particular ACC considered the following evidence:
1. A review of ACC’s 2003 guideline ‘The Diagnosis and Management of Soft Tissue Knee Injuries: Internal Derangement’ found that the guideline wording leads to a perceived importance of MRI that is disproportionate to the strength of evidence behind the recommendations; and the wording under-values the benefits of physical diagnostic examinations carried out by skilled and experienced practitioners. The evidence-based review undertaken to investigate the diagnostic efficacy of MRI and clinical examination (and supplied with this consultation)1 identified injury sub-groups which do not benefit from MRI investigation.
2. ACC’s review of High-Tech Imaging costs revealed that claims for MRI of knee injuries have more than doubled over four years and this increase was highly disproportionate to the increase in knee injuries over the same period, indicating that there may be some unnecessary use of MRI.
Whilst the revised recommendations are intended to guide referring physicians about appropriate and necessary MRI use for knee injuries, an equally important role of the recommendations is to inform and educate non-referring physicians, providers and case managers about what imaging-tests clients can reasonably expect. ACC understands that client expectation is a powerful motivator for MRI referral and it is hoped that revised MRI recommendations will assist providers to moderate client expectations about MRI investigations.
The new recommendations will replace the current MRI recommendation on p24 of ACC’s 2003 knee guideline which can be viewed on ACC’s website2. But note that the 2003 knee guideline in its entirety will not be revised.
3. Process used to revise clinical guideline recommendation
The process for revising the MRI recommendations has been based on key principles of guideline development:
1. Evidence-based: an evidence-based review was undertaken to investigate the efficacy of MRI compared with clinical examination for the diagnosis of soft tissue knee injuries. The evidence report was externally peer reviewed by four experts: two orthopaedic surgeons, one District Health Board radiologist and an academic physiotherapist. The evidence report is provided with this consultation document for your information. [Report title: Diagnosing soft-tissue knee injuries: Which injury presentations should be referred for MRI for accurate diagnosis?].
2. Expert Advice: An expert advisory group was established. The group was comprised of knee specialists and radiologists, as nominated by the NZ Orthopaedic Association and the Royal Australian and NZ College of Radiologists, as well as ACC experts/representatives.
Members of the group were:
• Knee specialists: Mark Clatworthy, Andrew Vincent, David Brougham
• Radiologists: Mark Coates, Quentin Reeves, Andrew Kingzett-Taylor
• ACC Representatives: Alastair Wilson (Corporate Medical Advisor) Patrick Medlicott (Medical Advisor, Elective Service Centre), Sarah Clark (Researcher)
The group met in late 2009 and considered the scientific evidence on balance with contextual issues and the expert opinion of group members. Deliberations occurred in late 2009 via email, teleconference and face-to-face meeting. The group agreed on draft revised recommendations which are more detailed than the previous recommendation.
3. Consultative: ACC is now consulting with interested stakeholders to hear your views on the accuracy and appropriateness of the revised recommendations.
4. The 2003 MRI recommendation
The current MRI recommendation on p24 of ACC’s 2003 knee guideline (‘The Diagnosis and Management of Soft Tissue Knee Injuries: Internal Derangement’) is as follows:
• MRI may be considered by specialists where further information is required to make a diagnosis and decide appropriate subsequent management. [Grade of recommendation = C].
5. Proposed revision of MRI Recommendations (for knees)
Clinical Presentation |
Recommendations |
Grade of Recommendation |
|---|---|---|
• Undertake a thorough history-taking and clinical examination in the first instance and before considering an MRI referral. • Weight bearing X-rays must be evaluated prior to MRI. |
C* C* | |
ACL Injuries: |
• If a clear clinical diagnosis of ACL injury has been made, MRI is not usually necessary. • If there is clinical doubt about diagnosis or patient management use MRI. |
B B |
Meniscus & Chondral Injuries: |
MRI is not indicated for all meniscal tears: • If a clear clinical diagnosis of meniscal tear has been made, MRI is not always necessary. • Use MRI in situations where there is doubt about diagnosis or patient management. • MRI is useful to diagnose chondral damage. |
B B C* |
MCL Injuries: |
• Do not use MRI for the diagnosis of isolated MCL injuries, except where there is concern about alternative pathology or if symptoms fail to settle after 6-8 weeks. |
C |
PCL injuries and posterior-lateral complex injuries: |
• Use MRI for patients suspected of acute PCL and/or posterior-lateral complex injuries. |
C |
Grades of Recommendation:
A The recommendation is supported by good evidence (multiple high quality studies with low risk of bias).
B The recommendation is supported by fair evidence (consistent results from multiple studies, but with some risk of bias).
C The recommendation is supported by expert opinion only, based on level 4 evidence in the text, and the expertise within the multidisciplinary team.
I No recommendation can be made because the evidence is insufficient (ie, evidence is lacking, of poor quality or conflicting and the balance of benefits and harms cannot be determined).
Note on C*: the expertise within the expert advisory group was relied on because these specific issues were not addressed within the scope of the evidence review.
6. Next Steps
After the submissions have been received, the expert advisory group will reconvene in March 2010 to consider all submissions and make changes to the recommendations where appropriate.
Professional/stakeholder groups will be notified of the outcome of the consultation process, deliberations of the expert advisory group and the final recommendations. ACC will seek official endorsement of the recommendations from those professional groups.
As a point of clarification, the 2003 knee guideline will not be updated because all other recommendations about the diagnosis and management of knee injuries remain accurate and relevant (according to expert opinion sought during a review in late 2007). This consultation pertains only to a revision of the MRI recommendation in the 2003 guideline.
ACC will disseminate the final recommendations in its publication “ACC Reviews” and via other mechanisms.
Please email or post your submission to:
Sarah Clark, Research Advisor, Research Group, Strategic Policy and Research, ACC, at Sarah.clark@acc.co.nz
PO Box 242, Wellington
Respondent Name |
Respondent Organisation and Address |
|---|---|
Feedback Areas |
Response |
1. The revised clinical guideline recommendation. Please comment on whether you agree with the revised recommendations, and provide reasons for your response. |
|
2. Any other feedback on the revised recommendation. |
|
3. Which of the following resources would assist you to implement the revised recommendations and/or moderate client expectations? • a quick reference guide • an internet-based resource • an electronic decision support tool • client information sheets • workshops/case studies • other? |
Please note that all correspondence and submissions on this matter may be the subject of a request under the Official Information Act 1982.
1 Diagnosing soft-tissue knee injuries: Which injury presentations should be referred for MRI for accurate diagnosis?.
2 http://www.acc.co.nz/about-acc/research-sponsorship-and-projects/research-and-development/evidence-based-healthcare-reports/index.htm#Clinical_Guidelines