Radiograph use in low back pain: a United States Emergency Department database analysis

Utilization of Hip or Knee MRI in Patients 50 Years and Older With Atraumatic Pain: An Analysis of the National Ambulatory Medical Care Survey

PURPOSE

The aim of this study was to use the National Ambulatory Medical Care Survey database to assess MRI utilization in patients 50 years and older with atraumatic hip or knee pain.

METHODS

National Ambulatory Medical Care Survey weighted survey data (2007-2019) were obtained for ambulatory visits in patients 50 years and older with atraumatic hip or knee pain. The outcome variable was MRI ordering status, and analyzed characteristics included patient age, race/ethnicity, payer, physician specialty, metropolitan statistical area, and a coexistent radiography order. Multivariable logistic regressions were conducted to assess the association between MRI ordering status and the analyzed patient characteristics. All tests were two sided, and P values ≤.05 were considered to indicate statistical significance.

RESULTS

In total, 88,978,804 knee pain and 28,675,725 hip pain patient visits (survey weighted) were analyzed, with 4,690,943 (5.3%) and 2,023,226 (7.1%) having knee or hip MRI orders, respectively. Overall, 2,454,433 knee pain visits (2.8%) and 575,155 hip pain visits (2.0%) had orders for both MRI and radiographs. Black patients (P = .03) and patients 80 years and older (P = .04) were less likely to have knee MRI ordered, whereas uninsured patients were less likely to have hip MRI ordered (P = .01). Patients with hip pain were more likely to have hip MRI ordered if seen by a surgical subspecialist (P = .01).

CONCLUSIONS

A low proportion of MRI examinations were ordered for visits in patients 50 years and older with atraumatic hip or knee pain. Groups with lower health care access were less likely to have an MRI order, highlighting known disparities in health care equity.

Improving Access and Decreasing Healthcare Utilization for Patients With Acute Spine Pain: Five-Year Results of a Direct Access Clinic

INTRODUCTION

Spine pain is one of the largest and costliest burdens to our healthcare systems. While evidence-based guidelines for spine pain have been established, and continue to evolve, the actual management of this condition continues to burden the healthcare system. This has led to increased costs due to inefficient entry to healthcare, utilization of treatments unsupported by clinical guidelines, and patient navigation through our healthcare systems. The purpose of this study was to assess the healthcare utilization and related outcomes for Active Duty Service Members (ADSM) receiving healthcare services in a novel acute spine pain clinic (ASPC) during the first 5 years of operation at a large Military Treatment Facility.

MATERIALS AND METHODS

In 2014 the Physical Medicine and Rehabilitation and Physical Therapy (PT) services designed a novel acute spine clinic intended to directly receive ADSM with acute spine symptoms for an initial evaluation by a Physical Therapist. The inclusion criteria into the ASPC were: ADSM, pain less than or equal to 7 days, no more than three prior episodes of acute spine pain in the past 3 years, and not currently receiving care from Chiropractic, Pain Management, or PT services. The exclusion criteria were: significant and/or progressive neurological deficits, bowel or bladder dysfunction, unstable vital signs or fever, hematuria or extensive trauma.

RESULTS

A total of 1,215 patients presented to the ASPC for evaluation between 2014 and 2019. The most common chief complaint was acute pain in the lumbar spine (73%), followed by cervical spine pain (15%), and thoracic spine pain (12%) represented the fewest. The average number of PT visits per patient was 3.5 (range 1-13) with 61.1% utilizing three or fewer visits. Over 95% of cases returned to work the same day as their initial evaluation. Sixty-six percent returned to work without restriction the same day as their initial evaluation. Light duty recommendations were provided to 412 (33.9%) patients ranging from one to 30 days, with greater than 85% of the light duty being less than 14 days. Recommendations to not return to work (sick-in-quarters) were issued to 56 (4.6%) patients. The sick-in-quarters recommendations were for a 24-hour period in 48 cases, 48 hours for seven cases, and 72 hours for one case. All encounters in which the patient first sought care at the ASPC for low back pain met the Healthcare Effectiveness Data Set standard for low back pain care of having no imaging within 28 days of the first encounter for nonspecific low back pain. A medical record review of 100 randomly selected patients within 12 months of the initial evaluation demonstrated decreased utilization of medication, imaging, and referral to surgical services.

CONCLUSIONS

This innovative approach demonstrates the potential benefits of rapid access to treatment and education for patients with acute spine pain by a Physical Therapist. Modeling this approach at Military Treatment Facilities may lead to decreased utilization of medications, radiology services, specialty care referrals, and reduced cost of care provided to individuals with acute spine pain.

Management of patients presenting with low back pain to a private hospital emergency department in Melbourne, Australia

OBJECTIVE

Recent studies suggest many patients with non-specific low back pain presenting to public hospital EDs receive low-value care. The primary aim was to describe management of patients presenting with low back pain to the ED of a private hospital in Melbourne, Australia, and received a final ED diagnosis of non-specific low back pain. We also determined predictors of hospital admission.

METHODS

Retrospective review of patients who presented with low back pain and received a final ED diagnosis of non-specific low back pain to Cabrini Malvern ED in 2015. Demographics, lumbar spinal imaging, pathology tests and medications were extracted from hospital records. Multivariate logistic regression was used to determine independent predictors of hospital admission.

RESULTS

Four hundred and fifty presentations were included (60% female); 238 (52.9%) were admitted to hospital. One hundred and seventy-seven (39.3%) patients received lumbar spine imaging. Two hundred and eighty (62.2%) patients had pathology tests and 391 (86.9%) received medications, which included opioids (n = 298, 66.2%), paracetamol (n = 219, 48.7%), NSAIDs (n = 161, 35.8%), benzodiazepines (n = 118, 26.2%) and pregabalin (n = 26, 5.8%). Predictors of hospital admission included older age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.02-1.05), arrival by ambulance (OR 2.03, 95% CI 1.06-3.90) and receipt of pathology tests (OR 3.32, 95% CI 2.01-5.49) or computed tomography scans (OR 1.86, 95% CI 1.12-3.11).

CONCLUSION

We observed high rates of imaging, pathology tests and hospital admissions compared with previous public hospital studies, while medication use was similar. Implementation of strategies to optimise evidence-based ED care is needed to reduce low-value care and improve patient outcomes.

Are Emergency Medicine Provider Characteristics Associated With Diagnostic Imaging for Low Back Pain?

Background

Low back pain (LBP) is one of the most common reasons for presentation to the emergency department (ED). LBP is most commonly non-specific or mechanical in nature yet can be debilitating. Diagnostic imaging (DI) is commonly ordered contrary to guideline recommendations for patients with LBP. This study seeks to determine if physician characteristics are associated with ordering of DI for patients with non-specific or mechanical LBP in the ED. These characteristics include physician sex, age, experience level, location of residency training, and full-time status.

Methodology

We included all patients presenting to the ED of a Canadian tertiary care center with a diagnosis of non-specific or mechanical LBP between January 2015 and June 2018. We tracked the use of DI for physicians caring for patients presenting to the ED over this period. Simple and multivariable logistic regression analyses were performed, controlling for patient characteristics, to identify provider characteristics that were independently associated with DI use.

Results

Internationally trained physicians were less likely to order diagnostic radiographs than Canadian trained physicians (odds ratio [OR], 0.625; 95% confidence interval [CI], 0.48-0.95), while middle-aged physicians ordered more computed tomography scans (OR, 6.34; 95% CI, 1.52-26.52) compared to younger physicians; there was no significant difference between younger and older physicians.

Conclusions

Few physician characteristics were associated with any DI ordering for non-specific or mechanical LBP. The likelihood of receiving DI for non-specific or mechanical LBP may be more strongly related to unmeasured patient characteristics, settings, or logistical factors.

The effect of interventions on appropriate use of lumbar spine radiograph and CT examinations in young adults and children: a three-year follow-up

BACKGROUND

According to international guidelines, radiological examinations of the lumbar spine are of limited value and do not improve clinical outcome unless there are clinical red flags present suggesting serious pathology. Nevertheless, the utilization of lumbar spine imaging remains high.

PURPOSE

To follow up the effects of active referral guideline implementation and education on the number and appropriateness of lumbar spine radiographs and computed tomography (CT) examinations in young patients and to evaluate whether the appropriate radiographs have more significant findings.

MATERIAL AND METHODS

Referral guidelines for spine examinations and info pocket cards on radiation protection were distributed to referring practitioners. Educational lectures were provided annually. The number of lumbar spine radiographs and CT examinations on patients aged <35 years was analyzed before and three years after the interventions. Appropriateness and findings of 313 radiographs and appropriateness of 117 CT scans of the lumbar spine were assessed.

RESULTS

The number of lumbar spine radiographs and CT scans decreased significantly after the interventions and the level remained unchanged during the follow-up (-33% and -72%, respectively, P < 0.001). Appropriateness improved significantly in radiographs from 2005 to 2009 (65% vs. 85%) and in CT scans already from 2005 to 2007 (23% vs. 63%). Radiographs that were in accordance with the guidelines had more significant findings compared to radiographs that were not; in young adults, this was 56% versus 21% (P < 0.001).

CONCLUSION

A combination of interventions can achieve a sustained reduction in the number of lumbar spine examinations and improve appropriateness. Inappropriate lumbar spine radiographs do not seem to contain significant findings that would affect patient care.

Involving end-users in the design of an audit and feedback intervention in the emergency department setting - a mixed methods study

BACKGROUND

Long length of stays (LOS) in emergency departments (ED) negatively affect quality of care. Ordering of inappropriate diagnostic tests contributes to long LOS and reduces quality of care. One strategy to change practice patterns is to use performance feedback dashboards for physicians. While this strategy has proven to be successful in multiple settings, the most effective ways to deliver such interventions remain unknown. Involving end-users in the process is likely important for a successful design and implementation of a performance dashboard within a specific workplace culture. This mixed methods study aimed to develop design requirements for an ED performance dashboard and to understand the role of culture and social networks in the adoption process.

METHODS

We performed 13 semi-structured interviews with attending physicians in different roles within a single public ED in the U.S. to get an in-depth understanding of physicians' needs and concerns. Principles of human-centered design were used to translate these interviews into design requirements and to iteratively develop a front-end performance feedback dashboard. Pre- and post- surveys were used to evaluate the effect of the dashboard on physicians' motivation and to measure their perception of the usefulness of the dashboard. Data on the ED culture and underlying social network were collected. Outcomes were compared between physicians involved in the human-centered design process, those with exposure to the design process through the ED social network, and those with limited exposure.

RESULTS

Key design requirements obtained from the interviews were ease of access, drilldown functionality, customization, and a visual data display including monthly time-trends and blinded peer-comparisons. Identified barriers included concerns about unintended consequences and the veracity of underlying data. The surveys revealed that the ED culture and social network are associated with reported usefulness of the dashboard. Additionally, physicians' motivation was differentially affected by the dashboard based on their position in the social network.

CONCLUSIONS

This study demonstrates the feasibility of designing a performance feedback dashboard using a human-centered design approach in the ED setting. Additionally, we show preliminary evidence that the culture and underlying social network are of key importance for successful adoption of a dashboard.

Effect of Clinical Decision Support on Appropriateness of Advanced Imaging Use Among Physicians-in-Training

OBJECTIVE

Clinical decision support (CDS) tools have been shown to reduce inappropriate imaging orders. We hypothesized that CDS may be especially effective for house staff physicians who are prone to overuse of resources.

MATERIALS AND METHODS

Our hospital implemented CDS for CT and MRI orders in the emergency department with scores based on the American College of Radiology's Appropriateness Criteria (range, 1-9; higher scores represent more-appropriate orders). Data on CT and MRI orders from April 2013 through June 2016 were categorized as pre-CDS or baseline, post-CDS period 1 (i.e., intervention with active feedback for scores of ≤ 4), and post-CDS period 2 (i.e., intervention with active feedback for scores of ≤ 6). Segmented regression analysis with interrupted time series data estimated changes in scores stratified by house staff and non-house staff. Generalized linear models further estimated the modifying effect of the house staff variable.

RESULTS

Mean scores were 6.2, 6.2, and 6.7 in the pre-CDS, post-CDS 1, and post-CDS 2 periods, respectively (p < 0.05). In the segmented regression analysis, mean scores significantly (p < 0.05) increased when comparing pre-CDS versus post-CDS 2 periods for both house staff (baseline increase, 0.41; 95% CI, 0.17-0.64) and non-house staff (baseline increase, 0.58; 95% CI, 0.34-0.81), showing no differences in effect between the cohorts. The generalized linear model showed significantly higher scores, particularly in the post-CDS 2 period compared with the pre-CDS period (0.44 increase in scores; p < 0.05). The house staff variable did not significantly change estimates in the post-CDS 2 period.

CONCLUSION

Implementation of active CDS increased overall scores of CT and MRI orders. However, there was no significant difference in effect on scores between house staff and non-house staff.

How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years

Objectives

To (1) estimate the proportion of patients seeking care for low back pain (LBP) who are imaged and (2) explore trends in the proportion of patients who received diagnostic imaging over time. We also examined the effect of study-level factors on estimates of imaging proportion.

Data sources

Electronic searches of MEDLINE, Embase and CINAHL databases from January 1995 to December 2017.

Eligibility criteria for selecting studies

Observational designs and controlled trials that reported imaging for patients presenting to primary care or emergency care for LBP. We assessed study quality and calculated pooled proportions by care setting and imaging type, with strength of evidence assessed using the GRADE system.

Results

45 studies were included. They represented 19 451 749 consultations for LBP that had resulted in 4 343 919 imaging requests/events over 21 years. Primary care: moderate quality evidence that simple imaging proportion was 16.3% (95% CI 12.6% to 21.1%) and complex imaging was 9.2% (95% CI 6.2% to 13.5%). For any imaging, the pooled proportion was 24.8% (95% CI 19.3%to 31.1%). Emergency care: moderate quality evidence that simple imaging proportion was 26.1% (95% CI 18.2% to 35.8%) and high-quality evidence that complex imaging proportion was 8.2% (95% CI 4.4% to 15.6%). For any imaging, the pooled proportion was 35.6% (95% CI 29.8% to 41.8%). Complex imaging increased from 7.4% (95% CI 5.7% to 9.6%) for imaging requested in 1995 to 11.4% (95% CI 9.6% to 13.5%) in 2015 (relative increase of 53.5%). Between-study variability in imaging proportions was only partially explained by study-level characteristics; there were insufficient data to comment on some prespecified study-level factors.

Summary/conclusion

One in four patients who presented to primary care with LBP received imaging as did one in three who presented to the emergency department. The rate of complex imaging appears to have increased over 21 years despite guideline advice and education campaigns.

Trial registration number

CRD42016041987.

Clinician, patient and general public beliefs about diagnostic imaging for low back pain: protocol for a qualitative evidence synthesis

INTRODUCTION

Little is known about how to reduce unnecessary imaging for low back pain. Understanding clinician, patient and general public beliefs about imaging is critical to developing strategies to reduce overuse.

OBJECTIVE

To synthesise qualitative research that has explored clinician, patient or general public beliefs about diagnostic imaging for low back pain.

METHODS AND ANALYSIS

We will perform a qualitative evidence synthesis of relevant qualitative research exploring clinician, patient and general public beliefs about diagnostic imaging for low back pain. Exclusions will be studies not using qualitative methods and studies not published in English. Studies will be identified using sensitive search strategies in MEDLINE, EMBASE, CINAHL, AMED and PsycINFO. Two reviewers will independently apply inclusion and exclusion criteria, extract data, and use the Critical Appraisal Skills Programme quality assessment tool to assess the quality of included studies. To synthesise the data we will use a narrative synthesis approach that involves developing a theoretical model, conducting a preliminary synthesis, exploring relations in the data, and providing a structured summary. We will code the data using NVivo. At least two reviewers will independently apply the thematic framework to extracted data. Confidence in synthesis findings will be evaluated using the GRADE Confidence in the Evidence from Reviews of Qualitative Research tool.

ETHICS AND DISSEMINATION

Ethical approval is not required to conduct this review. We will publish the results in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42017076047.

Clinical predictors of the medical interventions provided to patients with low back pain in the emergency department

BACKGROUND

Low back pain is a common complaint in emergency departments (ED), where deviations from standard of care have been noted.

OBJECTIVE

To relate the ordering of advanced imaging and opioid prescriptions with the presentation of low back pain in ED.

METHODS

Six hundred adults with low back pain from three centers were prospectively analyzed for history, examination, diagnosis, and the ordering of tests and treatments.

RESULTS

Of 559 cases the onset of pain was less than one week in 79.2%; however, most had prior low back pain, 63.5% having warning signs of a potential serious condition, and 83.9% had psychosocial risk factors. Computer tomography (CT) or magnetic resonance imaging (MRI) were ordered in 16.6%, opioids were prescribed in 52.6%, and hospital admission in 4.5%. A one-year follow-up of 158 patients found 40.8% received subsequent spine care and 5.1% had a medically serious condition. Caucasian race, age 50 years or older, warning signs, and radicular findings were associated with advanced imaging. Severe pain and psychosocial factors were associated with opioid prescribing.

CONCLUSIONS

Most patients present to the ED with acute exacerbations of chronic low back pain. Risk factors for a serious condition are common, but rarely do they develop. Racial disparities and psychosocial factors had concerning relationships with clinical decision-making.

Drivers of poor medical care

The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting harms necessitate an investigation of drivers to inform potential solutions. We describe the network of influences that contribute to poor care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. In each domain the drivers operate at the global, national, regional, and individual level, and are modulated by the specific contexts within which they act. We discuss in detail drivers of poor care in each domain.

Justification and active guideline implementation for spine radiography referrals in primary care

Background Spinal disorders are a major public health problem. Appropriate diagnostic imaging is an essential part in the management of back complaints. Nevertheless, inappropriate imaging increases population collective dose and health costs without improving outcome. Purpose To determine the effects of active implementation of referral guidelines on the number and justification of spine radiography in primary care in one city. Material and Methods Specified guidelines for spine radiography were distributed to referring practitioners altogether three times during the study period. Educational lectures were provided before the guidelines were taken into use. The guidelines were also made available via the intranet. The number of spine radiography referrals during similar 6-month periods in the year preceding the interventions and the following 2 years was analyzed. Justification of 448 spine radiographs was assessed similarly. Results After interventions, the total number of spine radiography examinations decreased by 48% (P < 0.001) and that of cervical spine radiography by 46% ( P < 0.001), thoracic spine by 53% ( P < 0.001), and lumbar spine by 47% ( P < 0.001). The results persisted after 1-year follow-up. Before interventions, 24% of the cervical, 46% of the thoracic, and 32% of the lumbar spine radiography referrals were justified. After interventions, only justification of lumbar spine radiography improved significantly, 64% being justified ( P = 0.005). Conclusion Spine radiography in primary care can be reduced significantly by active referral guideline implementation. The proportion of inappropriate radiography was unexpectedly high. Thus, further education and studies concerning the appropriate use of spinal radiography seems to be needed.

Another Pill, Another Test, and Another Procedure: One Resident's Reflection on Healthcare Cost Containment

In the United States, healthcare expenditures have continued to rise at alarming rates despite numerous strategies to contain costs. One area of focus that is underappreciated is doctor-patient communication about expectations of treatment. Studies have shown that clinicians' misperceptions of assumptions about patients' expectations are an essential component to our nation's healthcare overuse problem. Strategies to address these misperceptions and assumptions as a method of reducing costs and providing higher-quality care to our patients are warranted.

Race/Ethnicity and overuse of care: a systematic review

POLICY POINTS: Racial/ethnic differences in the overuse of care (specifically, unneeded care that does not improve patients' outcomes) have received little scholarly attention. Our systematic review of the literature (59 studies) found that the overuse of care is not invariably associated with race/ethnicity, but when it was, a substantial proportion of studies found greater overuse of care among white patients. The absence of established subject terms in PubMed for the overuse of care or inappropriate care impedes the ability of researchers or policymakers to synthesize prior scientific or policy efforts.

CONTEXT

The literature on disparities in health care has examined the contrast between white patients receiving needed care, compared with racial/ethnic minority patients not receiving needed care. Racial/ethnic differences in the overuse of care, that is, unneeded care that does not improve patients' outcomes, have received less attention. We systematically reviewed the literature regarding race/ethnicity and the overuse of care.

METHODS

We searched the Medline database for US studies that included at least 2 racial/ethnic groups and that examined the association between race/ethnicity and the overuse of procedures, diagnostic (care) or therapeutic care. In a recent review, we identified studies of overuse by race/ethnicity, and we also examined reference lists of retrieved articles. We then abstracted and evaluated this information, including the population studied, data source, sample size and assembly, type of care, guideline or appropriateness standard, controls for clinical confounding and financing of care, and findings.

FINDINGS

We identified 59 unique studies, of which 11 had a low risk of methodological bias. Studies with multiple outcomes were counted more than once; collectively they assessed 74 different outcomes. Thirty-two studies, 6 with low risks of bias (LRoB), provided evidence that whites received more inappropriate or nonrecommended care than racial/ethnic minorities did. Nine studies (2 LRoB) found evidence of more overuse of care by minorities than by whites. Thirty-three studies (6 LRoB) found no relationship between race/ethnicity and overuse.

CONCLUSIONS

Although the overuse of care is not invariably associated with race/ethnicity, when it was, a substantial proportion of studies found greater overuse of care among white patients. Clinicians and researchers should try to understand how and why race/ethnicity might be associated with overuse and to intervene to reduce it.

Gimme that old time religion: the influence of the healthcare belief system of chiropractic's early leaders on the development of x-ray imaging in the profession

Background

Chiropractic technique systems have been historically documented to advocate overutilization of radiography. Various rationales for this have been explored in the literature. However, little consideration has been given to the possibility that the healthcare belief system of prominent early chiropractors may have influenced the use of the diagnostic modality through the years. The original rationale was the visualisation of chiropractic subluxations, defined as bones slightly out of place, pressing on nerves, and ultimately causing disease. This paradigm of radiography has survived in parts of the chiropractic profession, despite lacking evidence of clinical validity. The purpose of this paper is to compare the characteristics of the chiropractic technique systems that have utilised radiography for subluxation detection with the characteristics of religion, and to discover potential historical links that may have facilitated the development of those characteristics.

Discussion

Twenty-three currently or previously existing technique systems requiring radiography for subluxation analysis were found using a search of the internet, books and consultation with experts. Evidence of religiosity from the early founders’ writings was compared with textbooks, published papers, and websites of subsequently developed systems. Six criteria denoting religious thinking were developed using definitions from various sources. They are: supernatural concepts, claims of supremacy, rules and rituals, sacred artefacts, sacred stories, and special language. All of these were found to a greater or lesser degree in the publicly available documents of all the subluxation-based chiropractic x-ray systems.

Summary

The founders and early pioneers of chiropractic did not benefit from the current understanding of science and research, and therefore substituted deductive and inductive reasoning to arrive at conclusions about health and disease in the human body. Some of this thinking and rationalisation demonstrably followed a religion-like pattern, including BJ Palmer’s use of radiography. Although access to scientific methods and research education became much advanced and more accessible during the past few decades, the publicly available documents of technique systems that used radiography for chiropractic subluxation detection examined in this paper employed a historically derived paradigm for radiography that displayed characteristics in common with religion.

Electronic supplementary material

The online version of this article (doi:10.1186/s12998-014-0036-5) contains supplementary material, which is available to authorized users.

A systematic review of diagnostic imaging use for low back pain in the United States

BACKGROUND CONTEXT

Various studies have reported on the increasing use and costs of diagnostic imaging for low back pain (LBP) in the United States. However, it is unclear whether the methods used in these studies allowed for meaningful comparisons or whether the reported use data can be used to develop evidence-based use benchmarks.

PURPOSE

The primary purpose of this study was to review previous estimates of the use of diagnostic imaging for LBP in the United States.

STUDY DESIGN/SETTING

The study design is a systematic review of published literature.

METHODS

A search through May 2012 was conducted using keywords and free text terms related to health services and LBP in Medline and Health Policy Reference; results were screened for relevance independently, and full-text studies were assessed for eligibility. Only studies published in English since the year 2000 reporting on use of diagnostic imaging for LBP using claims data from the United States were included. Reporting quality was assessed using a modified Downs and Black tool for observational studies.

RESULTS

The search strategy yielded 1,102 citations, seven of which met the criteria for eligibility. Studies reported use from commercial health plans (N=4) and Medicare (N=3), with sample sizes ranging from 13,760 to 740,467 members with LBP from specific states or across the United States. The number of diagnostic codes used to identify nonspecific LBP ranged from 2 to 66; other heterogeneity was noted in the methods used across these studies. In commercial health plans, use of radiography occurred in 12.0% to 32.2% of patients with LBP, magnetic resonance imaging (MRI) was used in 16.0% to 21.0%, computed tomography (CT) was used in 1.4% to 3.0%, and MRI and/or CT was used in 10.9% to 16.1%. Findings in Medicare populations were 22.9% to 48.2% for radiography, 11.6% for MRI, and 10.4% to 16.3% for MRI and/or CT.

CONCLUSIONS

The reported use of diagnostic imaging for LBP varied across the studies reviewed; differences in methodology made meaningful comparisons difficult. Standardizing methods for performing and reporting analyses of claims data related to use could facilitate efforts by third-party payers, health care providers, and researchers to identify and address the perceived overuse of diagnostic imaging for LBP.

Practice patterns in spine radiograph utilization among doctors of chiropractic enrolled in a provider network offering complementary care in the United States

OBJECTIVE

Nonspecific back pain is associated with high use of diagnostic imaging in primary care, yet current evidence suggests that routine imaging of the spine is unnecessary. The objective of this study is to describe current practice patterns in spine radiograph utilization among doctors of chiropractic enrolled in an American provider network.

METHODS

A cross-sectional analysis of administrative claims data from one of the largest providers of complementary health care networks for health plans in the United States was performed. Survey data containing provider demographics were linked with routinely collected data on spine radiograph utilization and patient characteristics aggregated at the provider level. We calculated rates and variations of spine radiographs over 12 months. Negative binomial regression was performed to identify significant predictors of high radiograph utilization and to estimate the associated incidence risk ratio.

RESULTS

Complete data for 6946 doctors of chiropractic and 249193 adult patients were available for analyses. In 2010, claims were paid for a total of 91542 new patient examinations and 23369 spine radiographs (including 17511 ordered within 5 days of initial patient examination). The rate of spine radiographs within 5 days of an initial patient visit was 204 per 1000 new patient examinations. Significant predictors of higher radiograph utilization rates included the following: practicing in the Midwest or South US census regions, practicing in an urban or suburban setting, chiropractic school attended, and being a male provider in full-time practice with more than 20 years of experience.

CONCLUSION

Chiropractic school attended and practice location were the most influential predictors of spine radiograph utilization among network chiropractors. This information may help to inform the development and evaluation of a tailored intervention to address overuse of radiograph utilization.

The role of MRI in musculoskeletal practice: a clinical perspective

This clinical perspective presents an overview of current and potential uses for magnetic resonance imaging (MRI) in musculoskeletal practice. Clinical practice guidelines and current evidence for improved outcomes will help providers determine the situations when an MRI is indicated. The advanced competency standard of examination used by physical therapists will be helpful to prevent overuse of musculoskeletal imaging, reduce diagnostic errors, and provide the appropriate clinical context to pathology revealed on MRI. Physical therapists are diagnostically accurate and appropriately conservative in their use of MRI consistent with evidence-based principles of diagnosis and screening.

Identifying factors likely to influence compliance with diagnostic imaging guideline recommendations for spine disorders among chiropractors in North America: a focus group study using the Theoretical Domains Framework

Background

The Theoretical Domains Framework (TDF) was developed to investigate determinants of specific clinical behaviors and inform the design of interventions to change professional behavior. This framework was used to explore the beliefs of chiropractors in an American Provider Network and two Canadian provinces about their adherence to evidence-based recommendations for spine radiography for uncomplicated back pain. The primary objective of the study was to identify chiropractors’ beliefs about managing uncomplicated back pain without x-rays and to explore barriers and facilitators to implementing evidence-based recommendations on lumbar spine x-rays. A secondary objective was to compare chiropractors in the United States and Canada on their beliefs regarding the use of spine x-rays.

Methods

Six focus groups exploring beliefs about managing back pain without x-rays were conducted with a purposive sample. The interview guide was based upon the TDF. Focus groups were digitally recorded, transcribed verbatim, and analyzed by two independent assessors using thematic content analysis based on the TDF.

Results

Five domains were identified as likely relevant. Key beliefs within these domains included the following: conflicting comments about the potential consequences of not ordering x-rays (risk of missing a pathology, avoiding adverse treatment effects, risks of litigation, determining the treatment plan, and using x-ray-driven techniques contrasted with perceived benefits of minimizing patient radiation exposure and reducing costs; beliefs about consequences); beliefs regarding professional autonomy, professional credibility, lack of standardization, and agreement with guidelines widely varied ( social/professional role & identity); the influence of formal training, colleagues, and patients also appeared to be important factors ( social influences); conflicting comments regarding levels of confidence and comfort in managing patients without x-rays ( belief about capabilities); and guideline awareness and agreements ( knowledge).

Conclusions

Chiropractors’ use of diagnostic imaging appears to be influenced by a number of factors. Five key domains may be important considering the presence of conflicting beliefs, evidence of strong beliefs likely to impact the behavior of interest, and high frequency of beliefs. The results will inform the development of a theory-based survey to help identify potential targets for behavioral-change strategies.

Diagnostic imaging for spinal disorders in the elderly: a narrative review

The high prevalence of neck and low back pain in the rapidly aging population is associated with significant increases in health care expenditure. While spinal imaging can be useful to identify less common causes of neck and back pain, overuse and misuse of imaging services has been widely reported. This narrative review aims to provide primary care providers with an overview of available imaging studies with associated potential benefits, adverse effects, and costs for the evaluation of neck and back pain disorders in the elderly population. While the prevalence of arthritis and degenerative disc disease increase with age, fracture, infection, and tumor remain uncommon. Prevalence of other conditions such as spinal stenosis and abdominal aortic aneurysm (AAA) also increase with age and demand special considerations. Radiography of the lumbar spine is not recommended for the early management of non-specific low back pain in adults under the age of 65. Aside from conventional radiography for suspected fracture or arthritis, magnetic resonance imaging (MRI) and computed tomography (CT) offer better characterization of most musculoskeletal diseases. If available, MRI is usually preferred over CT because it involves less radiation exposure and has better soft-tissue visualization. Use of subspecialty radiologists to interpret diagnostic imaging studies is recommended.

Physical therapy in the emergency department: development of a novel practice venue

BACKGROUND AND PURPOSE

The American Physical Therapy Association's Vision 2020 advocates that physical therapists be integral members of health care teams responsible for diagnosing and managing movement and functional disorders. This report details the design and early implementation of a physical therapist service in the emergency department (ED) of a large, urban hospital and presents recommendations for assessing the effectiveness of physical therapists in this setting.

CASE DESCRIPTION

Emergency departments serve multiple purposes in the American health care system, including care of patients with non-life-threatening illnesses. Physical therapists have expertise in screening for problems that are not amenable to physical therapy and in addressing a wide range of acute and chronic musculoskeletal pain problems. This expertise invites inclusion into the culture of ED practice. This administrative case report describes planning and early implementation of a physical therapist practice in an ED, shares preliminary outcomes, and provides suggestions for expansion and effectiveness testing of practice in this novel venue.

OUTCOMES

Referrals have increased and length of stay has decreased for patients receiving physical therapy. Preliminary surveys suggest high patient and practitioner satisfaction with physical therapy services. Outpatient physical therapy follow-up options were developed. Educating ED personnel to triage patients who show deficits in pain and functional mobility to physical therapy has challenged the usual culture of ED processes.

DISCUSSION

Practice in the hospital ED enables physical therapists to fully use their knowledge, diagnostic skills, and ability to manage acute pain and musculoskeletal injury. Recommendations for future action are made to encourage more institutions across the country to incorporate physical therapy in EDs to enhance the process and outcome of nonemergent care.

Interventions for improving the appropriate use of imaging in people with musculoskeletal conditions

BACKGROUND

Imaging is commonly performed for musculoskeletal conditions. Identifying interventions to improve the appropriate use of imaging for musculoskeletal conditions could potentially result in improved health outcomes for patients and reduced health care costs.

OBJECTIVES

To determine the effects of interventions that aim to improve the appropriate use of imaging for people with musculoskeletal conditions.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group Specialised Register (June 2007), The Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 2), MEDLINE (January 1966 to June 2007), EMBASE (January 1980 to June 2007) and CINAHL (January 1982 to June 2007). We also searched reference lists of included studies and relevant reviews. We undertook citation searches of all included studies, contacted authors of included studies, and contacted other experts in the field of effective professional practice.

SELECTION CRITERIA

Randomised controlled trials, non-randomised controlled clinical trials and interrupted time-series analyses that evaluated interventions designed to improve the use of imaging for musculoskeletal symptoms.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data. We contacted study authors for additional information.

MAIN RESULTS

Twenty eight studies met our inclusion criteria. The majority of the studies were for the management of osteoporosis or low back pain, and most evaluated interventions aimed at health professionals. To improve the use of imaging in the management of osteoporosis, the effect of any type of intervention compared to no-intervention controls was modest (absolute improvement in bone mineral density test ordering +10%, IQR 0.0 to +27.7). Patient mediated, reminder, and organisational interventions appeared to have most potential for improving imaging use in osteoporosis. For low back pain studies, the most common intervention evaluated was distribution of educational materials and this showed varying effects. Other interventions in low back pain studies also showed variable effects. For other musculoskeletal conditions, distribution of educational materials, educational meetings and audit and feedback were not shown to be effective for changing imaging ordering behaviour. Across all conditions, increasing the number of intervention components did not increase effect.

AUTHORS' CONCLUSIONS

For improving the use of imaging in osteoporosis, most professional interventions demonstrated benefit, and patient mediated, reminder, and organisational interventions appeared to have most potential for benefit. For low back pain studies interventions showed varying effects. For other musculoskeletal conditions, no firm conclusions can be drawn.

Fiscal analysis of emergency admissions for chronic back pain: a pilot study from a Maine hospital

OBJECTIVE

Our study was designed to document fiscal data for emergency department admissions for acute exacerbation of chronic back pain.

DESIGN

This was a 12-month retrospective, descriptive study.

SETTING

The two emergency facilities operated by the Maine General Medical Center in central Maine provided the study data.

PATIENTS

We collected fiscal data for patients with emergency admissions for acute exacerbation of chronic nonmalignant back pain (International Classification of Disease code 724.1). Data were limited to patients with the top three of five Current Procedural Terminology (CPT) codes visits (99283-99285) for emergency department, indicating problems of moderate to high complexity. Records with event codes (E codes) for trauma and/or malignant disease were excluded.

OUTCOME MEASURES

We totaled charges for physician and provider services, laboratory tests, imaging studies, medications, and other billable items.

RESULTS

Of 1,397 emergency department visits for acute exacerbation of chronic back pain logged over the 12-month study for all five CPT codes, 1,039 visits were tagged with the three highest codes; 30% were multiple visits. Mean charges per visit ranged from $399 for CPT code 99283 to $1,943 for code 99285. While only 3% of the patients (N=46) were seen three or more times, they accounted for 12.4% of the total charges.

CONCLUSIONS

Emergency department care may be a costly venue for the management of chronic back pain. Because most patients obtain only short-term relief, they are likely to continue seeking urgent care intermittently until effective long-term pain management is widely available and reimbursable on an outpatient basis.

Radiological examination in low back pain patients: Anxiety of the patient? Anxiety of the therapist?

A review of the recent literature shows that guidelines on the management of low back pain (LBP) have little impact on the use of radiological imagery. Among the factors which might account for the use of radiological examination, a review of the literature points to some that refer to the patient, others to the clinician and still others to the therapeutic interaction. This leads one to question the importance of radiological examination for both the patient and the physician. The matter at stake in this review is the relationship that may exist between this type of examination and the patient's and/or the physician's anxiety. If these aspects are associated or causally related, this relationship can be two-sided and is thus susceptible to affect the patient, the physician, or both. Some possible keys which emphasize the central role of the therapeutic relationship in this predicament are also reviewed.

Survey of Acute Low Back Pain Management by Specialty Group and Practice Experience

OBJECTIVE

The objective of this study was to explore concurrence with evidence-based management of acute back pain by primary care specialty and years in practice groups.

METHODS

Participants randomly selected from five American Medical Association physician groups were surveyed asking their initial care recommendations for case scenarios with and without sciatica. Response differences were compared among groups and with the Agency for Health Research Quality's guideline.

RESULTS

Response rate was 25%. Emergency physicians were least likely to order diagnostic studies for both cases but more often made recommendations likely to promote inactivity. Occupational physicians were less likely to order diagnostic studies and more likely choose treatments conducive to increasing activity. The longer physicians were in practice, the less likely they were to follow recommendations. All specialty groups selected more nonevidence-based interventions for the patient with sciatica. General practitioners were least likely to follow the guidelines in either case.

CONCLUSIONS

Despite widespread dissemination of acute low back pain guidelines, the study suggests a lack of adherence by certain primary care groups, physicians with more practice experience, and in specific areas of management.

Can you diagnose for vertebral fracture correctly by plain X-ray?

INTRODUCTION

A wrong diagnosis of latent vertebral fracture is often made when it is based on plain X-ray imaging. Magnetic resonance imaging (MRI) has a high degree of accuracy for the definite diagnosis. This study was designed to identify ways to support improvements in the diagnostic accuracy of plain X-ray (X-P).

METHODS

We studied X-P and MRI images of 120 women and men (age range: 50-96 years). Five orthopedists and two radiologists interpreted front and lateral thoracolumbar X-Ps and MRI images. The correct diagnosis rate for the presence and location of incident vertebral fractures and the correct diagnosis rate according to morphological classifications were analyzed.

RESULTS

A correct diagnosis of incident fractures was made in 51.5% of cases overall. Diagnoses of non-incident fracture based on X-P in those cases with incident fracture based on MRI (false positive) occurred in 24.8% of the patients, while diagnoses of incident fracture based on X-P in those cases without incident fracture based on MRI (false negative) occurred in 6.5% of the patients. The application of morphological classifications (the primary osteoporosis diagnostic criteria and Yoshida's classification) resulted in the correct diagnosis rate being significantly higher in the group without prevalent fracture even when there were morphological changes (wedge, indented, protruding type) in the anterior bone cortex. Odds ratios were investigated for factors that would affect the correct diagnosis rate, including age, body weight, lumbar vertebrae bone mineral density, and examiner ability. In an overall investigation, age (OR=0.660), body weight (OR=2.082), and examiner ability (p=0.0205) affected the correct diagnosis rate.

CONCLUSION

The correct diagnosis rate for incident vertebral fractures with X-Ps was low (24.8%) and in cases with prevalent fractures, the rate was even lower (16.8%), but the number of prevalent fractures and BMD did not exert an effect. One key improving the correct diagnosis rate may be to pay attention to morphological changes in the anterior bone cortex.