What aspects of magnetic resonance imaging reports of the lumbo-sacral spine do general practitioners find the most useful? A scoping review

Step 1: Identifying the research question

The main research question using the Population-Concept-Context (PCC) framework recommended by the Joanna Briggs Institute (JBI) for scoping reviews was: What is the available evidence regarding the preparation of radiological reports (concept) to GPs (population) of LSS MRIs (context)? The sub-questions included the following.

1.  What are the findings of studies evaluating MRI LSS reports to GPs (e.g., effectiveness, acceptability, barriers, and facilitators)?

2.  What aspects of reports do GPs find most useful?

Eligibility criteria

Published full-text quantitative and mixed-methods studies were included. Case reports, letters, book chapters, comments, discussions, editorials, conference abstracts, and theses were also excluded. Participants focused on GPs and excluded other healthcare professionals. The articles were limited to English because of the time and resources required for translation and interpretation. The inclusion and exclusion criteria are presented in Table 1.

Step 2: Identifying relevant studies

A comprehensive search strategy was developed using a medical librarian to identify relevant literature in the main electronic databases. These included MEDLINE (Ovid), EMBASE, Web of Science, Scopus, and CINAHL Plus. Keywords and index terms were identified using the Ovid MEDLINE strategy (Appendix 1).

Step 3: Study selection

After database searches, citations were deduplicated and titles and abstracts were screened for inclusion by a single reviewer (WS). The remaining studies were subjected to a full-text review. The selection process is summarized in a PRISMA-ScR flow diagram⁷ (Figure 1).

Figure 1. PRIMSA flow diagram.

Step 4: Data charting

Data were charted using a standardized form with the following headings: author(s), year, journal, location, aims, methodology, and findings. A second reviewer assisted with disagreements resolved by a third reviewer. The Oxford Centre of Evidence-Based Medicine Levels of Evidence framework⁹ categorizes the study design. No formal critical appraisal tool was used because of the exploratory nature of the study.

Step 5: Collating, summarising and presenting the results

The results were summarized according to the review questions and eligibility criteria. The literature search and screening results are shown in the PRISMA-ScR flow diagram (Figure 1). Charted data were synthesized quantitatively in tables, and key themes were summarized. Suggestions for future research were also presented.

Characteristics of included studies

The years of publication of the included articles ranged from 2009 to 2020. Five of the twelve included studies were published between 2018 and 2020. Studies originated in seven countries: the UK and the USA (three each), two from Canada, and one each from Australia, Norway, Belgium, and Switzerland.

The main study design was a cross-sectional survey (N =6). Four of these six surveys included a combination of qualitative and quantitative questions, whereas the remaining two were solely quantitative. The remaining articles employed various methods, such as retrospective chart review, interview/thematic analysis, literature review, before and after comparative review, retrospective feedback review, and scoping review.

Thematic results

Five overarching themes emerged as the most useful themes for GPs in interpreting MRI LSS reports. To provide actionable evidence, these themes were presented as recommendations for practice (Figure 2).

Figure 2. Recommendations for MRI Lumbosacral Spine Reports.

Theme 1: Use of technical information in reports

Three of the 12 studies found that GPs considered some technical information in MRI reports to be unnecessary or confusing⁵. Technical information, such as patient demographics and procedural details, is recommended in the guidelines⁵, yet two studies highlight that GPs find some elements unhelpful^10,11.

Theme 2: Content of reports

Six studies addressed the content of this report. International guidelines recommend clinical history, findings, and treatment⁵. GPs prefer explanations of terminology, normal anatomical sizes, and relevance of the findings^5,11,12. Currie et al. highlight the importance of clear conclusions and qualifiers like “clinically insignificant.”¹¹ Eskander et al. suggested that reports should include patient history and pertinent negative results³. Three studies indicated that GPs value specific management advice within reports^3,10,11. Modic changes linked to prognosis may influence MRI use in LBP patients¹³.

Theme 3: Format of reports

Four studies discussed the format of their reports. International guidelines often favour structured reports, but UK guidelines do not mandate them⁵. The RANZCR guidelines advocate standardized templates¹⁴. Structured reporting improved consistency and completeness, with 84.5% of clinicians favouring it¹⁵. The advantages of a structured reporting style include completeness, consistency, and uniformity of the reports¹². However, routine use is rare, although tools, such as audible prompts, may enhance efficiency^15,16. Surveys show mixed preferences for prose or itemized formats, but structured text is often favoured^3,12.

Theme 4: Report language / comprehensibility

Four studies focused on language clarity. Standardized and unambiguous languages are recommended¹⁵. GPs prefer concise conclusions because descriptive or ambiguous reports can create uncertainty¹¹.

Theme 5: Addendums to reports

Two studies examined the impact of epidemiological factors. Fried et al. found fewer specialist referrals and repeated imaging¹⁷. McCullough et al. highlighted that patients are less likely to receive narcotics by primary care if the imaging report includes an epidemiological statement¹⁸.

Two points of interest, which were not key themes but were considered valuable to the review, were identified as follows:

Radiologist training

One study found that 92.4% of clinicians and 94.7% of radiologists supported mandatory training in report writing, with 23.9% feeling unprepared¹⁵.

Technological aids

Studies have highlighted the benefits of PACS and electronic consultation platforms for communication and for reducing unnecessary imaging^19,20

Quality of the evidence

There was a scarcity of highly relevant evidence identified by this scoping review process, with only six of the 12 included studies directly addressing the research question. Most of the included studies were quantitative. The Oxford Centre of Evidence-Based Medicine Levels of Evidence⁹ was used to categorize the study designs in the included articles. As there was little qualitative evidence, no outcomes-based research, and no randomized control trials, the highest level of evidence of any of the studies according to the scale was a relatively low level of 3. The low certainty and relevance of the evidence included in this scoping review indicate the need for better quality research in this area.

The geographical spread of the included papers may be influenced by healthcare policy in the respective countries of origin, with the majority derived from countries with higher levels of accessibility of MRI services and potentially more emphasis on improving transitions of care between secondary and primary levels. Notably, none of the included studies was conducted in developing countries. This may be due to the exclusion of unpublished and non-English literature in this review and the comparatively low levels of MRI availability and/or accessibility²¹.

Strengths and limitations

This is the first review to collate evidence specific to MRI LSS reports, with the review methodology allowing rapid collection of evidence across several databases. It was decided that a scoping review would be the most appropriate form of investigation for the research question because preliminary searches identified only a small number of articles that specifically addressed the research topic. Therefore, it was determined that the broad nature of a scoping review would provide flexibility to include many different types of relevant articles and could form the basis for further investigation, such as a systematic review.

The lack of critical appraisal of the quality of the included literature is a limitation, as evidence is weighted according to relevance and correlation to the review question, as opposed to the quality of the findings²².

The search strategy employed in conducting this scoping review had several limitations, including the lack of investigation of the radiology viewpoint, exclusion of grey and non-English language literature, limited range of databases searched, and lack of a fully independent second. However, a skilled academic librarian was engaged to ensure that the search strategy was performed appropriately to identify the most relevant articles.

Context of existing research

An existing scoping review assessed whether the guidelines considered the preferences of the ordering clinician or not⁵. Farmer et al. found that most radiology guidelines recommend the inclusion of technical information in radiology reports, such as technique, examination quality, comparison with prior studies, and procedural details⁵. This contrasts with the findings in our review, which showed that GPs do not want detailed anatomy and acronyms, and they did not find the radiological terminology helpful¹¹, supported by Grieve et al., who found that 70% of GPs did not value the inclusion of exam techniques¹⁰.

The findings of this scoping review showed broad agreement with the recommended reporting format for most radiological guidance⁵. The inclusion of the patient’s history is deemed important³, as are the inclusion of normal findings^11,12, relevant abnormal findings³, differential diagnoses¹², clear conclusions¹¹, and treatment recommendations^3,11,12.

Our review showed a clear preference for structured reporting by GPs and other clinicians^12,15. However, structured reporting is not mentioned in-depth in most international radiology guidelines⁵. This may be because it is not routinely performed by radiologists, is time-consuming, and distracts from image interpretation¹⁵.

The inclusion of epidemiological and prevalence statements resulted in a significant reduction in patient referral to a spine specialist, further imaging, and narcotic prescription^17,18. Jarvik et al. showed that inclusion of an epidemiological statement did not reduce spine-related interventions²³. However, they also identified a reduction in further imaging and opioid prescriptions for pain management²³. Witherow et al. also investigated the addition of a prevalence statement to reports, concluding that it may result in decreased opioid prescription, which is consistent with our findings²⁴.

Implications for research/practice/policy

The findings of this review highlight the lack of high-quality evidence on the topic and diverse methodologies used to arrive at the current findings. These insights provide a compelling rationale for further examining this topic.

The identification of the five themes that contribute to the usefulness of MRI LSS reports for GPs, highlighting that reports should answer the clinical question clearly, avoid jargon, use standardized language, and comment on the significance of observations. This also provides a helpful steer towards specific questions that can be examined through a systematic review as a next step. This scoping review further indicates that there is scope for improvement in terms of the training provided on radiology reporting writing, and the necessity to tailor reports appropriately for the intended audience.

The evidence presented in this review may assist healthcare professionals, regulators, and service providers in undertaking improvement projects, such as the development of guidance on MRI LSS report writing for primary care settings.