To the best of our knowledge, this is the first study that has used the RAND Appropriateness Method for lumbar spine MRI indications. In our study, lumbar spine MRI was considered in 67 (58%) of the scenarios as appropriate, 45 (39%) as uncertain, and three (2.6%) as inappropriate. After two rounds of consensus development, there were still 67 scenarios in which no agreement was reached or the results remained equivocal. This may demonstrate the ambiguous nature of decision making on whether the MRI is indicated for a patient. It may partly explain why it has been so difficult to curb or slow the growth in unnecessary services provided such as the lumbar spine MRI rate around the world (3
). Our results will help decision makers in identifying appropriate procedures and focusing their efforts on decreasing unnecessary care. In evidence-based medicine, the question arises that what should be done if there is insufficient evidence for a procedure routinely performed in practice (37
). In developed countries, evidence-based clinical guidelines have been helpful, but in middle and low income countries there are serious limitations in preparing these materials (38
). Moreover, evidence-based clinical guidelines often lack flexibility and may not provide enough details for clinicians when making decisions about individual patients (38
). Formal consensus development (including RAM) provides a timely and efficient solution when evidence is insufficient (40
). In our study, we overcame this limitation by developing scenarios representative of the patients seen by clinicians in practice. It should be noted that consensus methods are most widely used in procedures that there is no agreement on. Moreover, no studies were found on using these methods in the lumbar spine MRI. Rashidian (40
) performed a review of the evidence in order to identify the indicators of the lumbar spine MRI. General similarities may be observed between the results of the study carried out by Roudsari and the present study. However, our method was more effective since each of the indicators was divided into detailed and accurate scenarios. Accurate and detailed scenarios can be useful for physicians in practice. In some studies, questions remain about the validity of recommendations based on such methods (39
). Tan et al.(41
) have described the complexities and limitations of using RAM. Many of their criticisms equally apply to other consensus development methods. It should be noted that such methods are useful when there are disagreements or variation in practice and reliable evidence is limited. In these circumstances, formal consensus methods are valuable and their use is inevitable. We spent time on familiarizing the panel members with the method and attracting their valued cooperation. Membership of the panel involves open discussions of personal views and practices and that certain practices might not be supported by evidence or by other panel members. As an advantage of our study, we used the AGREE tool for selection of the evidence sources. This provided a chance for the panel to reach a shared understanding of the evidence before embarking towards consensus building. We also selected the members from different backgrounds and settings to improve comprehensiveness of the views (42
). RAM usually results in a long list of scenarios. To ease the use of its results, it may be possible to develop user-friendly software, or to categorize the scenarios into indications and packages in the format of clinical guidelines. We demonstrated that the RAM is useful for development of scenarios for appropriateness of lumbar spine MRI in a developing country. The method should be used more widely in such settings in other areas of healthcare where controversies exist or the practice varies. It also has the added value of developing a level of ownership by the providers if they see their peers and relevant stakeholders are adequately represented in the process.
The findings of this study can be used for developing national guidelines, conducting research to assess whether the criteria are followed in practice and whether their application can curb the growing rate of unnecessary care in all countries. In Iran, a limited amount of resources are allocated to the health sector. Since MRI is an expensive method of medical diagnosis, doctors have to prescribe it after the easier ways of diagnosis are not useful.