Effect of governmental intervention on appropriateness of lumbar MRI referrals: A canadian experience

In 2012, the Ontario government attempted to reduce inappropriate lumbar MRI referrals through guideline and decision-aid distributions to physicians as well as threats of financial penalties. The goals of this study were to determine if any change in lumbar MRI referral appropriateness occurred after this policy change at a tertiary care hospital in Ontario and to determine if any change in the number of new lumbar MRI referrals occurred after the policy change.


Six hundred lumbar MRI referral forms were randomly selected; 300 before and 300 after the policy change. The ACR Appropriateness Criteria for low back pain imaging were used to evaluate the appropriateness of each referral and assign it a score from 1 to 9. The numbers of new referrals during 3-month periods both before and after the policy change were recorded. Student's t test was performed to test for significant differences after the policy change.


Before the policy change, 50.4% of lumbar MRI referrals were appropriate, and 47.9% were not appropriate. After the policy change, appropriateness increased, with 62.6% of referrals being appropriate and 37.1% not appropriate. The mean appropriateness score before the policy change was 5.08 (95% confidence interval, 4.74-5.42) and increased significantly after the policy change to 5.79 (95% confidence interval, 5.46-6.12) (P = .004). No significant difference in the number of new lumbar MRI referrals before (246 ± 20.1 per month) and after (232.7 ± 38.3 per month) the policy change was noted (P > .05).


The Ontario government's interventions have significantly increased the appropriateness of lumbar MRI referrals. However, many referrals remain inappropriate, and no change in the number of new referrals has occurred.


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Kennedy SA
Fung W
Malik A
Farrokhyar F
Midia M