Appropriate use of services is an important component of quality health care. VHA operations partners are considering deploying new computer order templates to discourage overuse of radiology services. Although preliminary evidence suggests there is overuse of radiology services at the VA, little is known about reasons for overuse and strategies to decrease it. As a case study, this project will examine overuse of lumbar spine (LS) MRI. Low back pain is common among Veterans; in FY 2011, 18% of VHA health system users had at least one health care encounter associated with a diagnosis of low back pain.
The objectives of this study are to: a) Measure the appropriate use of LS MRI in VA by two methods: chart review, using InterQual criteria, the current VA standard; and administrative data review, using the National Quality Forum/CMS endorsed measure. 2) Compare findings from the two methods in a select group of cases to determine usability of administrative data review algorithms for decision support tools. 3) Advise national partners and VHA "Choosing Wisely" task force on recommendations for developing decision support tools based on study findings.
We identified 252 patients at VA Palo Alto Health Care System (VAPAHCS) who received LS MRI in FY2012 and assessed inappropriateness of referral by chart review based on the InterQual criteria. To assess inappropriate use by administrative data review we first identified all VA patients who received an outpatient LS-MRI in VA FY2012 DSS outpatient radiology data using CPT codes 721.48, 721.49, and 721.58. We linked these data to VA utilization data, to identify care which preceded the referral for LS-MRI. We compared the care received, as described in the administrative data, to the measure of overuse of MRI for low back pain endorsed by the National Quality Forum and the Centers for Medicare and Medicaid Services (NQF/CMS) (NQF#0514). We compared the findings of inappropriateness using chart review with the assessments using administrative data for the 252 outpatient cases at VAPAHCS. Based on the findings, we are developing recommendations for VHA Operations partners and the "Choosing Wisely Task Force" for implementation of a program to improve decision support for providers when ordering MRIs for patients with low back pain.
Chart Review Findings
-Of the 252 scans reviewed, approximately 66% of LS MRIs ordered in FY2012 were assessed as inappropriate by chart review. Scans ordered for Veterans under 35 years were more likely to be inappropriate (89%) than those for Veterans 35 years and older (53-65% inappropriate), but no differences by age group were statistically significant.
-There were no significant differences by sex or race/ethnicity in the assessment of inappropriateness. Nearly half of all LS MRIs included in the chart review were ordered in primary care settings and 73% of those MRIs were assessed as inappropriate. However, the differences in the proportion of inappropriate scans was not significant for any clinic type pairs.
Administrative Measure findings
-110,661 LS MRIs ordered by 16,273 unique providers in FY2012 were evaluated using the NQF/CMS administrative data measure: overall, 31% of these scans were assessed as inappropriate.
-69% (76,425) of scans were ordered by doctors of medicine or doctors of osteopathic medicine (MD/DOs) and 31% of these scans were assessed as inappropriate. Advanced practice registered nurses and nurse practitioners (APRN/NP) ordered 13% (14,982) of the LS MRIs, of which 32.8% were assessed as inappropriate.
-The majority of scans were ordered in primary care/internal medicine clinics (68,315 or 62%) and 33.9% (23,162) of these scans were assessed as inappropriate.
-Scans ordered in Emergency and Urgent Care clinical settings were more likely to be assessed as inappropriate compared to scans ordered in Primary Care/Internal Medicine. Scans ordered in physical medicine & rehabilitation services, pain clinic, neurology, orthopedics, neurosurgery, "other medicine services" and "miscellaneous other services" were less likely to be assessed as inappropriate compared to scans ordered in Primary Care/Internal Medicine.
-Only scans ordered by allopathic and osteopathic residents were significantly less likely to be assessed as inappropriate compared to scans ordered by MD/DOs. Scans ordered by all other providers were not significantly more likely to be assessed as inappropriate than those ordered by MD/DOs.
-The highest ordering 10% (1,768) of providers ordered approximately 50% (17,029) of all inappropriate scans.
Comparison of chart review and administrative data review findings at VAPAHCS
-66% of scans were deemed inappropriate by chart review using InterQual criteria, and 27% of the same charts were deemed inappropriate by administrative data review using the NQF/CMS endorsed measure.
-The positive predictive value of administrative data review to chart review on identification of inappropriate scans was = 51/69 = 73.9%
-The negative predictive value of administrative data review to chart review on identification of inappropriate scans was = 69/183=37.7%
The finding that a small number of providers are responsible for more than half of the scans that are not guideline compliant, suggests that a widespread intervention, for example a nationally adopted decision tool or order set for LS MRI, would not be an efficient or effective use of resources. A more in-depth evaluation of this small number ofclinicians would provide the needed information to design an appropriate intervention. Anecdotally, we have observed that providers are generally unaware of best practices and are uncertain what to do for these patients. Additionally, we understand that there are administrative rules at some medical centers that require referring providers to order an MRI prior to referral for specialist care for low back pain. Next steps in this research are to complete the needed in-depth evaluation of the providers responsible for the majority of scans assessed as inappropriate; to determine if the small number of providers who are responsible for the majority of scans deemed inappropriate are consistent over two or more years; to assess the impact of administrative rules on ordering practices in a subset of VA medical centers.
- Avoundjian T, Gidwani R, Yao D, Lo J, Sinnott P, Thakur N, Barnett PG. Evaluating Two Measures of Lumbar Spine MRI Overuse: Administrative Data Versus Chart Review. Journal of the American College of Radiology : JACR. 2016 Sep 1; 13(9):1057-66.
- Gidwani R, Sinnott P, Avoundjian T, Lo J, Asch SM, Barnett PG. Inappropriate ordering of lumbar spine magnetic resonance imaging: are providers Choosing Wisely? The American journal of managed care. 2016 Feb 1; 22(2):e68-76.