Health Atlas Radiology - MRI part 1

The Norwegian health atlases look at the geographical variation for the specified health services for residents in the 21 hospital referral areas in Norway (link). In the radiology atlas, we investigate the use of radiology examinations for outpatients. This atlas investigates the use of radiology examinations for residents in the 21 different hospital referral areas in Norway.

The atlas is divided into a number of publications. This is the first part which is for MRI examinations of the head, shoulder, hand, prostate, and knee. We analyze only examinations that were performed at outpatient clinics. Publications of other selected examinations and modalities will be available at a later date.

Note that results from a specific referral area can be highlighted in all figures by clicking on the corresponding referral area on one of the figures.

MRI examinations

Main findings

• Annually, there were 606,000 MRI examinations performed at outpatient clinics and on approximately half a million patients.
• There were 40% more outpatient MRI examinations (per 10,000 population) performed on residents of referral area Fonna compared with referral area Førde.
• 67% of the outpatient MRI examinations were performed at private imaging institutions.

Brain / Head MRI

Main findings

• Brain MRI is the most often performed (19%) of all outpatient MRI during the study period 2018-2022.
• There were 50% more outpatient brain MRI per 10,000 population performed for residents in referral area Østfold compared to referral area Finnmark.
• There were twice as many women than men that received brain MRI in the 15-55 age group.

Shoulder MRI

Main findings

• There was moderate to large geographical variation, with almost twice as many shoulder MRI per 10,000 population for residents in referral area Østfold than in referral area Telemark.
• For those over 50 years old, there was large geographical variation in the proportion who had an X-ray of the shoulder before an MRI.
• There is overuse of shoulder MRI in patients over 50 years of age.

Hand MRI

Main findings

• Use of hand MRI per 10,000 population has increased by 19% from the period 2012–2015 to 2018–2022, and in particular in 2021 and 2022.
• Geographical variation has decreased since 2012–2015 but is still significant. Twice as many hand MRIs were performed per 10,000 population for residents in referral area Møre og Romsdal than for residents in referral area Førde.

Prostate MRI

Main findings

There was large geographical variation in the use of prostate MRI in Norway.

Even though suspicion of prostate cancer is the most important indication for performing a prostate MRI, only a third of the examinations were carried out on patients who were undergoing treatment for prostate cancer.

The findings indicate an overuse of prostate MRI in Norway, in that more than half of the prostate MRI examinations were carried out on patients who were neither in a prostate treatment plan nor had a cancer diagnosis.

Knee MRI

Main findings

• The number of knee MRI pr. 10 000 population has been reduced by 15% since 2012–2015.
• For patients over 50 years old, there was large geographical variation in proportion that received an X-ray prior to an MRI.
• There is overuse of knee MRI for patients over 50 years old.

Definitions and methodology

Patient contacts

We use patient contact, points of contact and examination interchangeably. A point of contact can be one or more examinations reported to take place on the same day at the same institution.

At one patient contact two different diagnostic imaging tests (NCRP codes) can be reported. For instance, for knee MRIs the additional codes provides information that one examination of the right and one of the left knee have been performed. This is counted as one point of contact. If, on the other hand, the additional codes inform that an examination of the same place has been conducted twice at two separate times, this will count as two points of contact.

Secondary examinations

The examinations which include NCRP code ZTX0BC for secondary examinations are excluded from the analyses. Secondary examinations mean that an earlier radiological examination is reconsidered/reexamined. This amounts to 50-63 000 invoices per year in the period between 2018 and 2022. A large proportion of the invoices with this code come from Radiumhospitalet.

Public and private

“Public” refers to radiology departments at hospitals. This includes ideal organizations with long term contracts with regional health trusts.

“Private” refers to private imaging clinics: Aleris/Evidia, Unilabs and Helsehuset røntgen.

Diagnostic imaging for inpatients

Data for bruk av MR-undersøkelser for inneliggende pasienter er ikke tilgjengelig for landet samlet enda. Derfor omhandler dette atlaset kun polikliniske bildeundersøkelser.

MR kolumna (av ryggraden) er en undersøkelse som ofte utføres poliklinisk. For å få en oversikt over undersøkelser som utføres poliklinisk eller som innlagt har SKDE fått tilgang til et aggregert datasett med alle radiologiske bildeundersøkelser for pasienter som ble behandlet i opptaksområdene til Helse Nord. For MR cervikalkolumna og lumbosakralkolumna var det ca. 95 % av aktiviteten utføres poliklinisk.

For alle undersøkelsene er det lite variasjon mellom de fire opptaksområdene i Helse Nord RHF, og andelen er stabil for årene 2018–2022.

Data for use of MRIs for inpatients is not available collectively for the whole country yet. This atlas therefore only pertains to outpatient diagnostic imaging.

MRI of the vertebral column (the spine) is an examination typically performed in outpatient clinics. To get an overview of examinations carried out for outpatients and inpatients, SKDE has received access to an aggregated data set containing all radiological diagnostic imaging tests for patients treated in referral area Helse Nord. For MRIs of the cervical and lumbar spine, 95% of the activity was carried out in outpatient clinics.

For all examinations, there was little variation between the four referral areas in Helse Nord health trust, and the proportion remains stable for the period 2018-2022.

Reimbursements of expenditure

Reimbursements of expenditure are defined in the current atlas as “payments from the National Insurance scheme to healthcare provides for patient treatment and performed health services” (sources: Helfo).

All NCRP codes are connected to reimbursements categories and rates specified by HELFO (https://www.helfo.no/Sykehus-poliklinikk/regelverk-og-takster-for-sykehus-poliklinikk/regelverk-og-refusjon-for-sjukehus-og-poliklinikk). The actual reimbursement might be higher for a patient contact than the rate as additional examinations might be carried out at the same patient contact.

In the calculations of the financial effects, the average actual reimbursements in 2022 for the diagnostic test under consideration is used.

About the atlas

Data set

The atlas uses data delivered by KUHR (Kontroll og utbetaling av helserefusjoner) on outpatient radiology funded by the public health care system from 2018 to 2022. Radiological examinations that are not funded by the public health care system (e.g., the patients pay themselves, private health insurance) are not included in this atlas. The Norwegian Directorate of Health indicates that 9% of the activity at private imaging clinics in 2017 was paid for privately.

In addition, we have activity data for patients undergoing MRIs of the whole or parts of the vertebral column for the period of one year before and one year after the MRI. This includes data from KUHR containing activity in the primary healthcare service and data from NRP (Norwegian Patient Registry) with activity in the specialist healthcare service.

Information about indications and referrals is not available or of poor quality in the data from KUHR.

Number of residents is collected from Statistics Norway.

Responsibilities: The health atlas uses data from KUHR and NPR, but the authors/SKDE are solely responsible for the interpretation and presentation of the data. KUHR/NRP do not have any responsibility for the analyses or interpretations of the data set.

Selection of types of MRI:

1. Mostly outpatient
2. Of a certain volume
3. Of low value

Division of referral areas

The regional health trusts have a responsibility to ensure good, equal and timely specialist health services for anyone who needs it, regardless of their place of residence, cf. the Health Trust Act section 1. In practice, it is the individual health trusts and private providers under a contract with a regional health authority that provide and perform the public health services. Each health trust has a hospital referral area that includes specific municipalities or city districts. Different disciplines can have different hospital referral areas, and for some services, functions are divided between different health trusts and/or private providers. In the health atlases from SKDE, it is the hospital referral areas for specialist health services for medical emergency care that are used.

The size of the healthcare institutions' referral areas varies considerably, as shown in the figure.

There are also differences in the composition of the population in these referral areas, particularly when it comes to the age of the population. The median age varies from 44 years for residents in the referral areas Innlandet and Helgeland to 32 years for residents in the referral area Lovisenberg. All rates and proportions calculated in the atlas are therefore sex- and age-adjusted so that they are comparable (standardised against Norway's population in 2020).

The list below shows the health trusts or hospitals for which hospital referral areas have been defined and the short versions of the names used in this healthcare atlas.

How the work is grounded the medical community

Working with the atlas we have benefited greatly from discussing sample definitions and analyses with the reference group; Panchakulasingam Kandiah (assistant Director of Medical Strategy and Development Helse Vest RHF), Aslak Bjarne Aslaksen (Clinical Executive of Helse Bergen and head of the Radiology Network in Helse Vest), Bjørn Hofman (professor at the Department of Health Sciences, NTNU Gjøvik), Elin Kjelle (Post doc at the Department of Health Sciences, NTNU Gjøvik) and Fredrik Nomme (head of the Radiological Society and medical director of Unilabs).

In addition, we have received valuable comments and feedback from Peder A. Halvorsen (general practice specialist and professor at the Research group for General Practice, UiT), Gisle Roksund (general practice and community medicine specialist), Marit Herder (radiology specialist, UNN), Cato Kjærvik (orthopedic surgery specialist, Nordland Hospital Trust), Jeroen Reinen (Sørlandet Hospital Trust), Erik Skaaheim Haug (Vestfold Hospital Trust).

Questions?

Questions?

Do you have questions, comments or feedback? Please get in touch!

You can contact us by sending an email to helseatlas@skde.no.