Imaging Wisely Campaign: Initiative to Reduce Imaging for Low Back Pain Across a Large Safety Net System

Implementing appropriateness criteria for use of imaging technology (Project ACUITY) in magnetic resonance imaging of the lumbar spine: a Singapore experience

INTRODUCTION

Uncomplicated acute low back pain is usually self-limiting and does not warrant imaging. However, despite current recommendations, many patients continue to receive spinal imaging, increasing healthcare costs. The Ministry of Health, Singapore, convened a multidisciplinary workgroup to develop a consensus guideline on magnetic resonance imaging (MRI) of the lumbar spine (Agency for Care Effectiveness [ACE] guideline) for low back pain that was incorporated into electronic radiology order forms. We analysed the MRI orders following implementation of the guideline.

METHODS

A list of 'appropriate' and 'inappropriate' indications was developed based on existing literature. These indications were inserted into the MRI of the lumbar spine request form within the electronic system. It was mandatory for clinicians to specify on a drop-down list of indications. For 'inappropriate' indications, clinicians are required to fill out a free-text 'pop up' elaborating on their clinical reasoning for the MRI request.

RESULTS

Baseline pre-intervention data were collected over 3 months. A total of 492 MRI scans were performed with 64 (13.0%) inappropriate orders. Post-intervention, we retrospectively analysed two sets of data over 3 months each in 2021 and 2022. In 2021, there were 86 (9.1%) inappropriate orders out of 940 scans performed. In 2022, there were 38 (7.3%) inappropriate studies out of 521 scans performed. There was a statistically significant overall decrease in inappropriate scans from 13.0% pre-intervention to 7.3% post-intervention ( P = 0.01). Among all the 124 inappropriate studies post-intervention, only one patient eventually required surgery.

CONCLUSION

Our study demonstrates the positive impact of implementing a local guideline through electronic medical records in reducing inappropriate MRI of the lumbar spine for low back pain. Further studies on the impact of other behavioural nudges are recommended.

Behavioural 'nudging' interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial

INTRODUCTION

Opioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and two in three will receive an opioid. NUDG-ED aims to determine the effectiveness of two different behavioural 'nudge' interventions on low-value care for ED patients with low back pain.

METHODS AND ANALYSIS

NUDG-ED is a 2×2 factorial, open-label, before-after, cluster randomised controlled trial. The trial includes 8 ED sites in Sydney, Australia. Participants will be ED clinicians who manage back pain, and patients who are 18 years or over presenting to ED with musculoskeletal back pain. EDs will be randomly assigned to receive (i) patient nudges, (ii) clinician nudges, (iii) both interventions or (iv) no nudge control. The primary outcome will be the proportion of encounters in ED for musculoskeletal back pain where a person received a non-indicated lumbar imaging test, an opioid at discharge or both. We will require 2416 encounters over a 9-month study period (3-month before period and 6-month after period) to detect an absolute difference of 10% in use of low-value care due to either nudge, with 80% power, alpha set at 0.05 and assuming an intra-class correlation coefficient of 0.10, and an intraperiod correlation of 0.09. Patient-reported outcome measures will be collected in a subsample of patients (n≥456) 1 week after their initial ED visit. To estimate effects, we will use a multilevel regression model, with a random effect for cluster and patient, a fixed effect indicating the group assignment of each cluster and a fixed effect of time.

ETHICS AND DISSEMINATION

This study has ethical approval from Southwestern Sydney Local Health District Human Research Ethics Committee (2023/ETH00472). We will disseminate the results of this trial via media, presenting at conferences and scientific publications.

TRIAL REGISTRATION NUMBER

ACTRN12623001000695.