Abstract
Magnetic responance imaging (MRI) of the lumbar spine that is not concordant with treatment guidelines for low back pain represents an unnecessary cost for US health plans and may be associated with adverse effects. Use of MRI in the US Department of Veterans Affairs (VA) primary care clinics remains unknown. To assess the use of MRI scans during the first 6 weeks (early MRI scans) of episodes of nonspecific low back pain in VA primary care sites and to determine if historical concordance can identify clinicians and sites that are the least concordant with guidelines. Retrospective cohort study of electronic health records from 944 VA primary care sites from the 3 years ending in 2016. Data were analyzed between January 2017 and August 2019. Participants were patients with new episodes of nonspecific low back pain and the primary care clinicians responsible for their care. MRI scans. The proportion of early MRI scans at VA primary care clinics was assessed. Clinician concordance with published guidelines over 2 years was used to select clinicians expected to have low concordance in a third year. A total of 1 285 405 new episodes of nonspecific low back pain from 920 547 patients (mean [SD] age, 56.7 [15.8] years; 93.6% men) were attributed to 9098 clinicians (mean [SD] age, 52.1 [10.1] years; 55.7% women). An early MRI scan of the lumbar spine was performed in 31 132 of the episodes (2.42%; 95% CI, 2.40%-2.45%). Historical concordance was better than a random draw in selecting the 10% of clinicians who were subsequently the least concordant with published guidelines. For primary care clinicians, the area under the receiver operating characteristic curve was 0.683 (95% CI, 0.658-0.701). For primary care sites, the area was under this curve was 0.8035 (95% CI, 0.754-0.855). The 10% of clinicians with the least historical concordance were responsible for just 19.2% of the early MRI scans performed in the follow-up year. VA primary care clinics had low rates of use of early MRI scans. A history of low concordance with imaging guidelines was associated with subsequent low concordance but with limited potential to select clinicians most in need of interventions to implement guidelines.
Highlights
Low back pain has been reported to be the second most common reason for physician office visits[1] and its associated health care costs have been reported to be increasing.[2,3] Magnetic resonance imaging (MRI) is used routinely, with 8% to 21% of patients with low back pain in US health plans receiving a scan.[4,5,6] The Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society suggests that clinicians should not routinely perform MRI imaging during the first 6 weeks of an episode of nonspecific low back pain without indications that serve as a red flag.[7]
An early MRI scan of the lumbar spine was performed in 31 132 of the episodes (2.42%; 95% CI, 2.40%-2.45%)
The goals of this study were to determine if a program to implement guidelines is needed in the Veterans Affairs (VA) health care system and, if so, assess whether particular clinicians or clinics could reliably be identified as having low concordance
Summary
Low back pain has been reported to be the second most common reason for physician office visits[1] and its associated health care costs have been reported to be increasing.[2,3] Magnetic resonance imaging (MRI) is used routinely, with 8% to 21% of patients with low back pain in US health plans receiving a scan.[4,5,6] The Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society suggests that clinicians should not routinely perform MRI imaging during the first 6 weeks of an episode of nonspecific low back pain without indications that serve as a red flag.[7]. The goals of this study were to determine if a program to implement guidelines is needed in the Veterans Affairs (VA) health care system and, if so, assess whether particular clinicians or clinics could reliably be identified as having low concordance. We hypothesized that historical concordance is better than a random draw in selecting clinicians and clinics for a program to improve concordance with guidelines. A selective approach that focuses on the least concordant clinicians could spare the time of those who are concordant with imaging guidelines. The Medicare mandate to use computerized decision support for certain advanced imaging orders[17] represents an estimated annual cost of $123 million of clinician time.[18] A selective approach has implications for patient safety. Important alerts may be missed when clinicians receive too many unneeded notifications.[17,19,20]
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