Inappropriateness of brain MRI prescriptions and its financial burden

Background Diffusion of diagnostic tests such as (Magnetic Resonance Imaging) MRI is one of the main reasons for increasing growth of health care expenditure. So the current study aimed at estimation of the rate of brain MRI inappropriate prescriptions and their financial burden in Iran. Methods In this cross-sectional study 385 patients were selected by systematic stratified sampling in three public teaching hospitals in Shiraz, Iran. The selected participant's information was collected through data collection form which consisted of patients' demographic information, questions related to prescription and brain MRI prescription indications checklist. The completed indications checklist was compared to the appropriateness status table of indications and scenarios to detect the percent of appropriateness of prescriptions. Results About 21 percent of total brain MRI prescriptions are inappropriate. Previous treatment, number of refers to physician, having other diagnostic tests and the applicant of MRI (P<0.01) had significant relationships with prescriptions appropriateness. The estimated financial burden of inappropriate brain MRIs in Shiraz teaching hospitals was 99988 US dollar in 2017. Conclusions system


Background
Neurological diseases are one of the common causes of death and physical and mental disabilities in different societies (1). Early and precise diagnosis of brain and neurological disorders and damages will assist in better and fast treatment of those illnesses. Para clinic imaging methods have important roles in diagnosing these illnesses (2). In addition to assisting in the early diagnosis of illness, imaging prevents more aggressive measures for treatment (3). In this respect, one application of Magnetic Resonance Imaging (MRI) is diagnosis of brain and neurological illnesses(4).
MRI is one of the expensive diagnostic tests which recently have been increasingly used for diagnosing different illnesses (5). Although MRI has some benefits for patients but unnecessary demand for it have become major challenges in health systems. If MRI services be used wastefully, it will cause some concerns regarding optimum use of resources and it will cause major financial burden for healthcare systems (6) (7).
There is substantial growth in MRI acquisition and utilization in Iran(8) .According to a local research in Iran, about 80% of demanded MRIs by physicians for the patients suffering from headache had normal results and it shows that MRI prescriptions in many cases are illogical and inappropriate(9). Also according to Salari, et al. (2012), 167 lumbar spine prescriptions among 300 prescriptions were inappropriate and the cost of these inappropriate prescriptions was estimated 7178 US dollar(10). So, health economists and policy makers believe that evidence-based and appropriate use of these services is the solutions for reduction of health services costs and promotion of services quality (6).
According to mentioned points, present study aimed to evaluate the level of brain MRI inappropriate prescriptions and their financial burden in public teaching hospitals in Shiraz in 2017.

Methods
This research is a cross-sectional study which was carried out in 2017 to evaluate the level of inappropriate prescriptions of brain MRIs and their financial burden in teaching hospitals of Shiraz University of Medical Sciences.
The research population was the patients who referred to the public teaching hospitals which provide brain MRI services including Chamran Hospital, Namazi Hospital and Faghihi Hospital. Samples (385 patients) were selected by systematic stratified sampling.
In order to collect data, one nurse attended in patients' readiness rooms and examined the prescriptions of the patients who were selected previously through systematic sampling from the waiting list of MRI. The prescriptions which did not have patient history or the reason for MRI prescription was not mentioned were excluded from the study.
The selected participant's information was collected through data collection form. This form consisted of two parts. The first part was about patients' demographic information and the questions related to prescription and the second part was the brain MRI prescription indications checklist. We used the checklist that was developed by Salari etal in 2017 (11).
The data obtained from data collection forms was compared to the appropriateness status table of indications and scenarios to detect the percent of appropriateness of prescriptions. These indications and scenarios appropriateness status table were developed by Salari etal. In that consensus based study, experts in the field of brain disorders (neurosurgeons and neurologists) scored the scenarios according to Rand Appropriateness Method. The scenarios were classified in the categories of appropriate, uncertain and inappropriate (11) Finally, by multiplying the number of inappropriate prescriptions by the tariffs of brain MRI procedure for the patient and insurer in 2017 the overall imposed financial burden was estimated. It should be noted that in current study the financial costs of inappropriate MRI was estimated and comprehensive economic burden of them was not studied. For converting Iranian Rial to United States Dollar (USD) the exchange rate reported by central bank of Iran was used(12). Statistical analysis was performed by Stata 14.

Results
About 60% of patients were female and 96 percent have basic health insurance. Education level of patients were elementary and secondary (33.2), academic (28.7), high school diploma (25.5) and illiterate (13.5), respectively. 37% of patient had complementary health insurance. Table 1 shows descriptive statistics of appropriateness status of brain MRI in studied patients and also the relationship between examined patients' socio-demographic variables with appropriateness of brain MRI descriptions. The results indicate that generally 21.6% of total prescriptions are not appropriate. were with injection and 1260 cases (36%) were with and without injection. The tariffs of doing a brain MRI procedure without injection was 22.7 USD and the tariffs of doing a brain MRI procedure with and without injection was 39 USD in 2017.
So the financial burden of inappropriate brain MRIs in "without injection", "with and without injection" and all MRIs were 50 848, 49140 and 99988 USD, respectively (Table 3).

Discussion
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)  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 sociodemographic 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 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.

Conclusions
About one fourth of brains MRIs were inappropriate. It caused about one hundred thousand USD financial burden which is 17 times of Iran's GDP per capita. In order to better allocation of health system resources for provision of MRI services rationing policies for controlling consumer moral hazard and reducing provider induced demand can be helpful.

Ethics approval and consent to participate
This study was conducted in accordance with the International Declaration of Helsinki. The study protocol was approved by the Ethics Committee of Shiraz University of Medical Sciences. All participants were informed both verbally and through written information of their right to withdraw from the study at any time. All participants gave their written consent to participate in the study.

Consent for publication
The participants gave their written consent to publish findings of the study.

Availability of data and material
The data used in this study are not publicly available because the participants were promised that the raw data would remain confidential. However they are available from the corresponding author on reasonable request.

Competing interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding
This study is financially supported by Shiraz University of Medical Sciences with grant number 13862.