Inappropriate prescriptions for MRI services can lead to an adverse outcome for patients and imposes an excessive cost on the patients and health systems. So the appropriateness of brain MRI prescriptions, its related factors and financial burden were investigated in this study.
Findings show that 21.6 percentage of brain MRI prescriptions were without indication (inappropriate). Researches that mainly assessed the brain MRI appropriateness are few, so other MRI services are also compared with our findings. Piersson et al.  reported that about 19 percentage of brain MRIs in a single center in Ghana were inappropriate. It seems the use of MRI procedure in Iran is similar to that of the United States of America (USA), which has a very costly health system; because Lehnert & Bree (2010) found that 26 percentage of MRI and Computerized Tomography (CT) scan prescriptions in the USA are inappropriate . Oikarinen et al.  indicated that 7 percentage of MRIs done in an academic hospital in Finland were inappropriate. Saadat et al.  found that 17.2 percentage of conducted MRIs in private centers in Tehran were normal that 9.8 percentage of them were for headache examinations. Barzin et al. demonstrated that 81 percentage of requested MRIs by physicians for patients suffering from headaches in an educational hospital in Sari city had normal results . Sheehan et al.  reported that 45 percentage (106 cases) out of 237 prescribed MRIs for shoulder in a department of veterans affairs tertiary care hospital were inappropriate. In recent research in Ontario, the inappropriate rate of hip MRI is estimated at 32.1 percentage .
The 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 settings associated 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 instruments 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 a significant relationship with the appropriateness of brain MRI.
We found that having previous treatment and other diagnostic tests are related to brain MRI’s appropriateness. Manta  showed that having no previous radiographic examination was the most predictor of inappropriate prescription of hip MRI in Ontario.
Also, Sheehan et al.  showed that ultrasound could be a cost-saving substitution for 66 percentage of shoulder MRIs.
Finding also indicates that 27.74 percentage of 191 patients at the first visit to the physicians were without indication for brain MRI. We also found the more number of times a patient visits a physician, the less likely the inappropriateness of brain MRI. Patients with more visits to doctors likely have chronic and severe symptoms , so their MRIs probably are necessary and appropriate. It also can be explained by defensive medicine. In the first visit, physicians reduce and compensate for malpractice liability risk and apply more tests and treatments, which may be unnecessary .
One of the main results is that the primary applicant of MRI has a significant relationship with brain MRI’s appropriateness. About 19 percentage of prescriptions requested primarily by physicians were inappropriate, but on the contrary, more than 60 percentage of brain MRIs requested primarily by patients were inappropriate. Patients usually appeal diagnostic tests e.g., MRI from their physician; however, many times, their request is unnecessary. Although it likely increases patients’ satisfaction and health outcomes, it wastes health system resources and maybe increases the side effects of these tests . It is also related to the consumer moral hazard concept, resulting from information asymmetry between purchasers and patients .
Some macro factors which can affect on volume of unnecessary diagnostic tests and interventions that we could not 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 . This phenomenon can be explained by provider induced demand or more accessibility to these services.
The present study showed that the financial burden resulting from inappropriate brain MRI prescriptions in 2017 was 99,988 USD in Shiraz public hospitals, which is about 17 times of Iran's GDP per capita in that year (5680 USD) . This financial burden is related to one type of MRI services (brain MRI), in one city and only public centers. Considering all the mentioned factors, there is a 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) .
There are few studies with a focus on Brain MRI. Moreover, different studies have utilized different tools for checking the appropriateness of MRI services, and finally, there are different approaches to estimate the financial/economic burden. As we estimated only the direct financial burden of inappropriate brain MRI services, it is not compared with other areas.
A major limitation of the current study is that there are not clear statistics about the utilization of brain MRI in Iran, so we cannot estimate the overall financial burden of brain MRI in Iran. We only estimated the financial burden of brain MRI in public hospitals in Shiraz. Another main limitation is that we calculated the only direct medical financial costs of inappropriate brain MRI and comprehensive economic burden of them (such as transportation cost, food cost, productivity loss and intangible cost) was not studied. Moreover, the lack of similar studies on brain MRI, relevant factors and its financial burden was another limitation.