Reducing unnecessary repeat knee X-rays of osteoarthrosis patients

By Staff News Brief

Knee radiographs are often ordered for patients with moderate to severe knee osteoarthrosis (OA) who return for follow-up visits, but they may not be necessary, especially when patients do not have new symptoms or new trauma. Radiologists at University of Texas Southwestern Medical Center in Dallas conducted a study to determine the percentage of repeat knee radiographs, and then began a campaign to reduce them. They achieved an impressive 50% reduction rate, reported in the May 28, 2019, online edition of Skeletal Radiology.

An estimated 14 million people have symptomatic knee osteoarthrosis in the United States alone, according to the Arthritis Foundation in Atlanta. Most patients undergo an initial knee radiograph and may have them annually thereafter to monitor chronic disease.

Musculoskeletal radiologists at UT Southwestern Medical Center noticed an increasing number of knee radiographs, some of which were being performed within six months of the prior one, Oganes Ashikyan, MD, an assistant professor of radiology and principal investigator of the study told Applied Radiology. They decided to investigate the frequency of repeat radiographs and determine what percentage were unnecessary.

Their study included all knee radiographs performed in 2017 on patients with severe OA.1 They identified 1,227 reports and selected 500 consecutive studies for analysis. Twenty-two percent of the 500 cases, or 112 exams, were knee radiographs that had been performed within six months of the prior one. Of these, 69% were unnecessary based on review of medical records.

The authors summarized their data and estimated the cost savings based on Medicare reimbursement if the unnecessary exams had not been performed. In March 2018, they electronically distributed this data to the hospital’s family medicine and orthopedic surgery departments.

In April 2019, the authors evaluated 500 consecutive cases from the previous 12 months. They determined that only 10%, or 52 exams, represented repeat radiographs performed within six months of the prior. A total of 40 exams were not indicated compared to 77 exams the prior year.

“Based on the total Medicare reimbursement of approximately $60 per knee X-ray, and our initial sample of approximately 1,200 radiographs with severe knee OA obtained during 2017, a 15% reduction in unnecessary expense calculates to $10,800 of savings each year,” they wrote, noting that additional savings could be calculated for patients based on co-pays and costs not covered by their health insurance, transportation costs, and work-related productivity loss.

Dr. Ashikyan said that he and his colleagues are investigating the most effective approaches to reduce unnecessary knee radiographs. “We are considering sending periodic emails, reminding colleagues during joint conferences, and taking advantage of grand rounds to discuss this. We are also considering pop-up messages in a patient’s electronic medical record (EMR) when a physician is ordering a knee radiograph. There are some challenges that will need to be overcome from system administrators’ and programmers’ perspectives, but we remain optimistic that this can be achieved,” he said.

With respect to conducting additional research, Dr. Ashikyan said similar projects on reducing unnecessary knee magnetic resonance imaging (MRI) exams have been conducted.2 His team is considering investigating repeat imaging exam rates of patients with high grades of joint abnormalities in the upper extremity and later of patients with milder disease.


  1. Ashikyan O, Buller DC, Pezeshk P, et al. Reduction of unnecessary repeat knee radiographs during osteoarthrosis follow-up visits in a large teaching medical center. Skeletal Radiol. Published online May 29, 2019. doi: 10.1007/s00256-019-03247-4.
  2. Tornow K, Chlian M, Zert, et al. A quality improvement project to reduce unnecessary knee MRI for chronic degenerative changes. J Am Coll Radiol. Published online April 4, 2019. doi: 10.1016/j.jacr.2018.12.041.
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Reducing unnecessary repeat knee X-rays of osteoarthrosis patients.  Appl Radiol. 

By Staff News Brief| June 25, 2019
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