Low back pain is a significant problem in Veterans. Magnetic Resonance Imaging (MRI) conducted early in an episode of uncomplicated low back pain is not helpful and may lead to unneeded surgeries and medical procedures, greater use of pain medications, and poor outcomes. The percentage of inappropriate lumbar spine LS-MRI orders in VA is similar to Medicare and commercial insurance claims. The VA Choosing Wisely Committee and VA national program offices for pain, diagnostic services, and utilization management are working to reduce rates of inappropriate LS-MRI in VA. Attempts to implement guidelines for advanced imaging with decision support tools generally have modest, short-term effects. Guideline dissemination and audit and feedback have not been effective in improving compliance with guidelines for treatment of low-back pain. New understanding of the barriers and facilitators to guideline adherence is needed to design an effective implementation effort. Inappropriate LS-MRI is associated with downstream costs from low value treatments for back pain, but this has not been studied in VA.
National data on new episodes of uncomplicated low-back pain will be studied to identify providers who consistently order inappropriate scans. Qualitative interviews will identify differences between providers who are concordant and discordant with guidelines. The interviews will identify potential modifiable factors to reduce inappropriate ordering. VA utilization data will evaluate the association of inappropriate LS-MRI with patient pain, and high-cost, potentially low value services: spinal fusion, laminectomy, epidural injections, and prescription opiates.
The appropriateness of LS-MRI orders will be evaluated over 3 years using national VA administrative data to identify de-implementation efforts. A qualitative assessment of guideline concordant and guideline discordant providers will be conducted to identify potential factors associated with inappropriate ordering. The effect of inappropriate orders on outcomes, care, and cost will be studied.
We identified primary care visits for newly diagnosed uncomplicated low-backpain for which imaging guidelines state that MRI is not needed within 6 weeks.
We identified 9,318 primary care providers assigned to patients with index visits for new onset, uncomplicated low back pain and calculated the proportion of visits resulting in inappropriate MRI (i.e. MRI within 42 days of visit). We found 2.85% of index low back pain visits resulted in inappropriate LS-MRI. In multivariate analyses, older providers, those with a higher caseload, and those at satellite clinics were significantly less likely to order inappropriate LS-MRI. Female patients, younger patients, and those with a higher baseline pain score are significantly more likely to receive inappropriate LS-MRI.
We conducted semi-structured telephone interviews with a 54 "low concordant" (34) and "high concordant" (21) providers. Preliminary content analysis was summarized in a matrix. We found diverse environmental, provider, guideline and patient level factors influencing MRI ordering patterns.
Low-back pain is a common problem in VA patients. This study will identify strategies for de-implementation that would target providers who order high volumes of unneeded scans. This would improve care for Veterans with low back pain while lowering cost. Understanding the treatment cascade of inappropriate LS-MRI could bolster de-implementation efforts, ultimately reducing downstream use of opioids and surgical procedures. A VA de-implementation effort could be a model for Medicare, which has so far focused on using decision support and utilization management, implementation tools that have had only modest success in reducing unneeded imaging.
- Barnett PG, Jacobs JC, Jarvik JG, Chou R, Boothroyd D, Lo J, Nevedal A. Assessment of Primary Care Clinician Concordance With Guidelines for Use of Magnetic Resonance Imaging in Patients With Nonspecific Low Back Pain in the Veterans Affairs Health System. JAMA Network Open. 2020 Jul 1; 3(7):e2010343.
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