Identifying and educating physicians who classify as "super-referrers" may be the key to reducing low-value imaging services that provide little to no benefit for patients and create expensive, unnecessary costs.

Using recommendations from the Choosing Wisely (CW) campaign, researchers in Norway assessed nearly 238,000 exams referred by 3,700 physicians and found that 42% of MR scans were not recommended by CW. These exams were specific for the head, knee, or lower back, and all were identified in the Norwegian CW guidelines as low-value.

About 2.3% (86) of the doctors were labeled as high-referrers and responsible for 33% of these assessments. Ten percent of exams were set up by 0.5% of super-referrers, which amounted to 17, each of whom ordered 87 or more low-value exams in 2019. Most had over 10 years of experience.

“Our findings of variation in referral practice may indicate flaws in the GPs' role as gatekeepers,” wrote the authors in their study.

All exams were ordered across four public and two private imaging facilities, with private ones performing the most, at 74%. Data from the Norwegian Health Economics Administration and directly from private imaging centers in 2019 was used in the study, which defined high-referrers as those within the 95th percentile of exams that went against CW-recommendations and super-referrers, within the 99th percentile.

Avoiding wasteful imaging
Reasons for the high rate of low-value exam referrals included time pressures, patient-related factors, unfamiliarity with guidelines and difficulties handling uncertainty. Decision support tools, education, providing feedback to referrers, or creating handouts may be useful for addressing them, say the authors.

High- and super-referrers consisted of general practitioners, those without a specialization, neurologists, orthopedic surgeons, and ear, nose and/or throat doctors. The majority were male, with all in the super-referrer portion typically working within 30 miles of an MR scanner.

Imaging utilization was not associated with referrers’ experience and distance to services, indicating that healthcare entities may facilitate equal access to care and that rural residents are traveling for care.

“Our main analysis focused on high-volume MRs, as reducing such resource-intensive examinations provides a high potential to free resources for high-value examinations. Further research should include examinations using ionizing radiation due to their implications for radio protection,” wrote the authors.

The findings were published in Insights into Imaging.