Abstract
BackgroundClinical practice guidelines suggest that magnetic resonance imaging of the lumbar spine (LS-MRI) is unneeded during the first 6 weeks of acute, uncomplicated low-back pain. Unneeded LS-MRIs do not improve patient outcomes, lead to unnecessary surgeries and procedures, and cost the US healthcare system about $300 million dollars per year. However, why primary care providers (PCPs) order unneeded LS-MRI for acute, uncomplicated low-back pain is poorly understood.ObjectiveTo characterize and explain the factors contributing to PCPs ordering unneeded LS-MRI for acute, uncomplicated low-back pain.DesignQualitative study using semi-structured interviews.ParticipantsVeterans Affairs PCPs identified from administrative data as having high or low rates of guideline-concordant LS-MRI ordering in 2016.ApproachProviders were interviewed about their use of LS-MRI for acute, uncomplicated low-back pain and factors contributing to their decision-making. Directed content analysis of transcripts was conducted to identify and compare environmental-, patient-, and provider-level factors contributing to unneeded LS-MRI.Key ResultsFifty-five PCPs participated (8.6% response rate). Both low (n = 33) and high (n = 22) guideline-concordant providers reported that LS-MRIs were required for specialty care referrals, but they differed in how other environmental factors (stringency of radiology utilization review, management of patient travel burden, and time constraints) contributed to LS-MRI ordering patterns. Low- and high-guideline-concordant providers reported similar patient factors (beliefs in value of imaging and pressure on providers). However, provider groups differed in how provider-level factors (guideline familiarity and agreement, the extent to which they acquiesced to patients, and belief in the value of LS-MRI) contributed to LS-MRI ordering patterns.ConclusionsResults describe how diverse environmental, patient, and provider factors contribute to unneeded LS-MRI for acute, uncomplicated low-back pain. Prior research using a single intervention to reduce unneeded LS-MRI has been ineffective. Results suggest that multifaceted de-implementation strategies may be required to reduce unneeded LS-MRI.
Highlights
Unneeded LS-MRI may be a particular concern for patients seen by the Veterans Health Administration (VA), as more than 10% of patients seen in VA are diagnosed with low-back pain (LBP) each year,[16] and studies using different methods[17, 18] have found between 30 and 66% of LS-MRI ordered by VA providers were unneeded
LS-MRI is not recommended for acute, uncomplicated lowback pain prior to 6 weeks of conservative therapy
We identified and characterized environmental, patient, and provider factors contributing to unneeded LS-MRI, many of which differed between low and high-concordant PCP groups
Summary
Magnetic resonance imaging of the lumbar spine (LS-MRI) for acute, uncomplicated low-back pain (LBP)[1] does not improve pain, back function, quality of life, or mental health; providers may order imaging anyway.[2,3,4] Unneeded LS-MRIs cost the US healthcare system $300 million annually and reveal incidental abnormalities resulting in anxiety,[5] belief in presence of disease,[2, 6] and unnecessary procedures.[7,8,9] Clinical guidelines suggest acute, uncomplicated LBP should be treated with conservative therapy instead of LS-MRI in the first 6 weeks.[7, 10] Reducing use of low-value LS-MRI is an important challenge for primary care because LBP is common among adults in the USA.[11]. Clinical practice guidelines suggest that magnetic resonance imaging of the lumbar spine (LS-MRI) is unneeded during the first 6 weeks of acute, uncomplicated low-back pain. Why primary care providers (PCPs) order unneeded LS-MRI for acute, uncomplicated low-back pain is poorly understood. OBJECTIVE: To characterize and explain the factors contributing to PCPs ordering unneeded LS-MRI for acute, uncomplicated low-back pain. APPROACH: Providers were interviewed about their use of LS-MRI for acute, uncomplicated low-back pain and factors contributing to their decision-making. KEY RESULTS: Fifty-five PCPs participated (8.6% response rate) Both low (n = 33) and high (n = 22) guideline-concordant providers reported that LS-MRIs were required for specialty care referrals, but they differed in how other environmental factors (stringency of radiology utilization review, management of patient travel burden, and time constraints) contributed to LS-MRI ordering patterns.
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