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Bogaert L, Brumagne S, Léonard C, Lauwers A, Peters S. Physiotherapist- and patient-reported barriers to guideline implementation of active physiotherapeutic management of low back pain: A theory-informed qualitative study. Musculoskelet Sci Pract 2024; 73:103129. [PMID: 38943770 DOI: 10.1016/j.msksp.2024.103129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 05/30/2024] [Accepted: 06/24/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND AND OBJECTIVE Adoption of low back pain (LBP) guidelines in physiotherapeutic management is a well-documented problem. Thereby, an in-depth understanding of the barriers to implement an active approach for both patients and physiotherapists is needed. DESIGN Semi-structured interviews were conducted with physiotherapists and patients with non-specific LBP. Interviews, guided by the Theoretical Domains Framework (TDF), were analyzed using the Qualitative Analysis Guide of Leuven. RESULTS A total of 20 participants were interviewed, including ten physiotherapists and ten patients. Our findings reveal that patients and physiotherapists face each 23 barriers spanning 14 TDF domains. The TDF domain "social influences" revealed the most barriers, followed by "beliefs about consequences" and "environmental context" for patients and physiotherapists, respectively. Five barriers did overlap between both groups (lack of guideline awareness, incorrect exercise performance, interdisciplinary communication gaps, time constraints and challenges in patient compliance). CONCLUSIONS Barriers to LBP guideline recommended physiotherapeutic practices span all 14 TDF domains. Consequently, future implementation interventions need to address multiple TDF domains for effective LBP guideline implementation.
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Affiliation(s)
- Liedewij Bogaert
- Department of Physical and Rehabilitation Medicine, University Hospitals Leuven, Leuven, Belgium; REVAL Rehabilitation Research, Hasselt University, Diepenbeek, Belgium.
| | - Simon Brumagne
- Department of Physical and Rehabilitation Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | | | - Amber Lauwers
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Sanne Peters
- School of Health Sciences, University of Melbourne, Australia
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Rezaee M, Nasehi MM, Effatpanah M, Jabbaripour S, Ghamkhar M, Karami H, Mehrizi R, Torabi P, Ghamkhar L. Overutilization of head computed tomography in cases of mild traumatic brain injury: a systematic review and meta-analysis. Emerg Radiol 2024; 31:551-565. [PMID: 38844658 DOI: 10.1007/s10140-024-02247-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 05/23/2024] [Indexed: 07/31/2024]
Abstract
Head computed tomography (CT) is the preferred imaging modality for mild traumatic brain injury (mTBI). The routine use of head CT in low-risk individuals with mild TBI offers no clinical benefit but also causes notable health and financial burden. Despite the availability of related guidelines, studies have reported considerable rate of non-indicated head CT requests. The objectives were to provide an overall estimate for the head CT overutilization rate and to identify the factors contributing to the overuse. A systematic review of PubMed, Scopus, Web of Science, and Embase databases was conducted up to November 2023, following PRISMA and MOOSE guidelines. Two reviewers independently selected eligible articles and extracted data. Quality assessment was performed using a bias risk tool, and a random-effects model was used for data synthesis. Fourteen studies, encompassing 28,612 patients, were included, with 27,809 undergoing head CT scans. Notably, 75% of the included studies exhibited a moderate to high risk of bias. The overutilization rate for pediatric and adult patients was 27% (95% CI: 5-50%) and 32% (95% CI: 21-44%), respectively. An alternative rate, focusing on low-risk pediatric patients, was 54% (95% CI: 20-89%). Overutilization rates showed no significant difference between teaching and non-teaching hospitals. Patients with mTBI from falls or assaults were less likely to receive non-indicated scans. There was no significant association between physician specialty or seniority and overuse, nor between patients' age or sex and the likelihood of receiving a non-indicated scan. Approximately one-third of head CT scans in mTBI cases are avoidable, underscoring the necessity for quality improvement programs to reduce unnecessary imaging and its associated burdens.
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Affiliation(s)
- Mehdi Rezaee
- Department of Orthopedics, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mehdi Nasehi
- Pediatric Neurology Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Pediatric Neurology Department, Mofid Children Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Effatpanah
- Pediatric Department, School of Medicine, Imam Khomeini Hospital, Tehran University of Medical Sciences, National Center for Health Insurance Research, Tehran, Iran
| | - Sama Jabbaripour
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Ghamkhar
- Islamic Azad University Challus Branch, Challus, Mazandaran, Iran
| | - Hossein Karami
- National Center for Health Insurance Research, Tehran, Iran
| | - Reza Mehrizi
- National Center for Health Insurance Research, Tehran, Iran
| | - Pegah Torabi
- Department of Radiology Arak, University of Medical Sciences, Arak, Iran
| | - Leila Ghamkhar
- Physical Therapy, National Center for Health Insurance Research, Tehran, Iran.
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Chilanga CC, Heggelund M, Kjelle E. Assessing MRI referrals' appropriateness for low back pain post a radiology-initiated intervention. Radiography (Lond) 2024; 30:1277-1282. [PMID: 39002178 DOI: 10.1016/j.radi.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/27/2024] [Accepted: 07/02/2024] [Indexed: 07/15/2024]
Abstract
INTRODUCTION This study evaluated a pilot intervention to reduce low-value Magnetic Resonance Imaging (MRI) referrals for Low Back Pain (LBP). METHODS This before-after intervention study analysed MRI referrals for LBP at two private imaging centres in Norway. MRI referrals for LBP obtained before and after an intervention of information campaigns and sending a return letter to clinicians for declined referrals were evaluated on information, quality, and justification rates. Four radiologists and two radiographers assessed the referrals. A point system was used to calculate referral quality. Each referral was given a score 'good' when rated above 5.5 and 'poor' below 2.5. Justification was based on assessors categorised rating as justified, unjustified or need more information. Stata Statistical Software (Release 18) was used for analysis. A mixed model analysed variations of the referrals pre- and post-intervention. A p-value of <.05 in variations was considered statistically significant. RESULTS A total n = 300 patients' referrals (150 referrals pre- and post-intervention) were collected and assessed. Post-intervention, 68% of referrals were justified, up from 63% pre-intervention. The assessment showed a 4% decrease in referrals with poor scores and a 2% increase in those rated as good or intermediate quality post-intervention. These changes were not statistically significant. CONCLUSION It is important to state that it was not possible in our study to identify the subgroup of referrals that are known to be from clinicians who had received a return letter, although the information campaign targeted all referrers. Despite the limitations our findings suggest that providing reasons for declined referrals can serve as an educational tool for clinicians and contribute to the reduction of low value MRI for LBP. IMPLICATIONS FOR PRACTICE Radiology department initiatives that raise awareness and offer referral criteria guidance to clinicians can serve as valuable educational tools, and further emphasize the importance of providing comprehensive information in MRI referrals for LBP.
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Affiliation(s)
- C C Chilanga
- Department of Optometry, Radiography and Lighting Design, Faculty of Health and Social Sciences, University of South-Eastern Norway (USN), Pb 235, 3603 Kongsberg, Norway.
| | - M Heggelund
- Department of Optometry, Radiography and Lighting Design, Faculty of Health and Social Sciences, University of South-Eastern Norway (USN), Pb 235, 3603 Kongsberg, Norway
| | - E Kjelle
- Institute for the Health Sciences, Norwegian University of Science and Technology (NTNU), Gjøvik, Norway
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Alves GS, Vera GEZ, Maher CG, Ferreira GE, Machado GC, Buchbinder R, Pinto RZ, Oliveira CB. Clinical care standards for the management of low back pain: a scoping review. Rheumatol Int 2024; 44:1197-1207. [PMID: 38421427 PMCID: PMC11178557 DOI: 10.1007/s00296-024-05543-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/16/2024] [Indexed: 03/02/2024]
Abstract
The objective of this study is to compare and contrast the quality statements and quality indicators across clinical care standards for low back pain. Searches were performed in Medline, guideline databases, and Google searches to identify clinical care standards for the management of low back pain targeting a multidisciplinary audience. Two independent reviewers reviewed the search results and extracted relevant information from the clinical care standards. We compared the quality statements and indicators of the clinical care standards to identify the consistent messages and the discrepancies between them. Three national clinical care standards from Australia, Canada, and the United Kingdom were included. They provided from 6 to 8 quality statements and from 12 to 18 quality indicators. The three standards provide consistent recommendations in the quality statements related to imaging, and patient education/advice and self-management. In addition, the Canadian and Australian standards also provide consistent recommendations regarding comprehensive assessment, psychological support, and review and patient referral. However, the three clinical care standards differ in the statements related to psychological assessment, opioid analgesics, non-opioid analgesics, and non-pharmacological therapies. The three national clinical care standards provide consistent recommendations on imaging and patient education/advice, self-management of the condition, and two standards (Canadian and Australian) agree on recommendations regarding comprehensive assessment, psychological support, and review and patient referral. The standards differ in the quality statements related to psychological assessment, opioid prescription, non-opioid analgesics, and non-pharmacological therapies.
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Affiliation(s)
- Gabriel S Alves
- Faculty of Medicine, University of Western São Paulo (UNOESTE), Presidente Prudente, Sao Paulo, Brazil
| | - Gustavo E Z Vera
- Faculty of Medicine, University of Western São Paulo (UNOESTE), Presidente Prudente, Sao Paulo, Brazil
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney, Royal Prince Alfred Hospital, Sydney Local Health District, Level 10N, King George V Building, Missenden Road, P. O. Box M179, Camperdown, 2050, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Giovanni E Ferreira
- Institute for Musculoskeletal Health, The University of Sydney, Royal Prince Alfred Hospital, Sydney Local Health District, Level 10N, King George V Building, Missenden Road, P. O. Box M179, Camperdown, 2050, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Gustavo C Machado
- Institute for Musculoskeletal Health, The University of Sydney, Royal Prince Alfred Hospital, Sydney Local Health District, Level 10N, King George V Building, Missenden Road, P. O. Box M179, Camperdown, 2050, Australia
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Rachelle Buchbinder
- Musculoskeletal Health and Wiser Health Care Units, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rafael Z Pinto
- Department of Physical Therapy, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
| | - Crystian B Oliveira
- Faculty of Medicine, University of Western São Paulo (UNOESTE), Presidente Prudente, Sao Paulo, Brazil.
- Institute for Musculoskeletal Health, The University of Sydney, Royal Prince Alfred Hospital, Sydney Local Health District, Level 10N, King George V Building, Missenden Road, P. O. Box M179, Camperdown, 2050, Australia.
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
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Searant I, Brown BT, Jenkins HJ. Chiropractors' perceptions on the use of spinal radiographs in clinical practice: a qualitative study. Chiropr Man Therap 2024; 32:23. [PMID: 38909258 PMCID: PMC11193277 DOI: 10.1186/s12998-024-00547-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 06/18/2024] [Indexed: 06/24/2024] Open
Abstract
BACKGROUND Radiography is commonly used in the assessment of spinal disorders, despite a lack of high-quality evidence demonstrating improved clinical outcomes or additional benefit to the patient. There is disagreement amongst chiropractors regarding the appropriate use of radiography for clinical management. This study aims to qualitatively explore chiropractors' perceptions on the use of spinal radiographs in clinical practice with respect to how they determine when to order radiographs; and how they use radiographs to inform clinical management. METHODS Online qualitative semi-structured interviews were conducted with 17 Australian chiropractors who currently manage patients with spinal disorders. Convienence, snowball, and purposive sampling strategies were used to ensure an appropriate breadth and depth of participant characterisitcs and beliefs. Interview data were recorded, transcribed and analysed using framework analysis. RESULTS Three themes were developed to describe how chiropractors determined when to order radiographs. These themes included specific findings from the clinical encounter that may inform clinical management, their perceptions of radiation risk, and the influence of clinical experience/intuition. Three themes and four subthemes were developed for how chiropractors use radiographs to inform their management. These themes explored the use of radiography for the application of chiropractic technique, as well as the role of radiographs in predicting patient prognosis, and as an educational tool to provide reassurance. CONCLUSION Australian chiropractors' decision-making around spinal radiography is diverse and can be influenced by a number of clinical and external factors. Previously unexplored uses of spinal radiography in clinical practice were highlighted. Some chiropractors reported potential benefits of radiography that are currently not supported by research evidence. Future research should address how radiographic findings are reported to patients with spinal disorders and how this could be optimised to improve patient outcomes.
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Affiliation(s)
- Isaac Searant
- Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.
| | - Benjamin T Brown
- Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Hazel J Jenkins
- Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
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Arnbak BAM, Jensen TS, Lund RA, Hartvigsen J, Søndergaard J, Thomsen JL, Andersen JS, Møller A, Nørgaard B, Rossen CB, Kongsted A. Usual care for low back pain and barriers to best practice: A cross-sectional study in Danish general practice. Musculoskeletal Care 2024; 22:e1911. [PMID: 38923268 DOI: 10.1002/msc.1911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVES To describe the current content of low back pain (LBP) care in Danish general practice, the patients' self-management activities, and the clinicians' experienced barriers to providing best practice care. METHODS This cross-sectional observational study included adults with LBP seeking care in Danish general practice from August 2022 to June 2023. Patient-reported information included demographics, pain intensity, medical history, treatments, and self-management strategies. Clinicians provided data specific to each consultation, detailing the content of these consultations, and barriers to best practice in the specific cases. RESULTS The study involved 71 clinicians from 42 general practice clinics, with patient-reported data from 294 patients, and clinician-reported data from 283 (95%) consultations. The mean age for the included patients was 53 years, 56% were female, and 31% had been on sick leave for LBP during the previous 3 months. Moreover, 44% had seen two or more healthcare professionals in the previous month, 55% had previously undergone diagnostic imaging for LBP, 81% reported using any type of analgesics, and 14% reported using opioids. The majority (91%) reported engaging in self-management activities to alleviate pain. Consultations typically included a physical examination (84%), information about the cause of the pain (74%), and management advice (68%), as reported by clinicians or patients. In general, clinicians reported consultation elements more frequently than patients. Clinicians reported providing best practice care in 84% of cases, with time constraints (23%) and patient expectations (10%) being the most common barriers. CONCLUSIONS This study provides detailed insights into the management of LBP in Danish general practice. It reveals a complex landscape of patient engagement, varying management strategies, and differing perceptions of care content between patients and clinicians. Patients were often engaged in self-management activities and clinicians reported few barriers to providing best practice care.
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Affiliation(s)
- Bodil Al-Mashhadi Arnbak
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
- Department of Radiology, Hospital Lillebaelt, Vejle, Denmark
| | - Tue Secher Jensen
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
- Chiropractic Knowledge Hub, Odense, Denmark
- Department of Diagnostic Imaging & University Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Rikke Arnborg Lund
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
- Chiropractic Knowledge Hub, Odense, Denmark
| | - Jan Hartvigsen
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
- Chiropractic Knowledge Hub, Odense, Denmark
| | - Jens Søndergaard
- Department of Public Health, The Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Janus Laust Thomsen
- Department of Clinical Medicine, Center for General Practice, Aalborg University, Aalborg, Denmark
| | - John Sahl Andersen
- The Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anne Møller
- The Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- The Research Unit of General Practice in Region Zealand and Copenhagen, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Birgitte Nørgaard
- Department of Public Health, The Research Unit of User Perspectives and Community-based Interventions, University of Southern Denmark, Odense, Denmark
| | - Camilla Blach Rossen
- University Clinic for Interdisciplinary Orthopaedic Pathways, Elective Surgery Center, Silkeborg Regional Hospital, Regional Hospital Central Jutland, Silkeborg, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Alice Kongsted
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
- Chiropractic Knowledge Hub, Odense, Denmark
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Tanner L, Saywell NL, Adams T, Niazi IK, Hill J. Factors influencing imaging clinical decision-making in low back pain management. A scoping review. Musculoskeletal Care 2024; 22:e1898. [PMID: 38862275 DOI: 10.1002/msc.1898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND The use of diagnostic imaging in low back pain (LBP) management is often inappropriate, despite recommendations from clinical practice guidelines. There is a limited understanding of factors that influence the imaging clinical decision-making (CDM) process. AIM Explore the literature on factors influencing imaging CDM for people with LBP and consider how these findings could be used to reduce inappropriate use of imaging in LBP management. DESIGN Scoping review. METHOD This review followed the Preferred Reporting Items for Systematic Review extension for scoping reviews. A digital search was conducted in Medline, the Cumulative Index of Nursing and Allied Health Literature, Scopus, and the Cochrane Central Register of Controlled Trials for eligible studies published between January 2010-2023. Data reporting influences on imaging CDM were extracted. Data were then analysed through an inductive process to group the influencing factors into categories. RESULTS After screening, 35 studies (5 qualitative and 30 quantitative) were included in the review, which reported factors influencing imaging CDM. Three categories were developed: clinical features (such as red flags, pain, and neurological deficit), non-modifiable factors (such as age, sex, and ethnicity) and modifiable factors (such as beliefs about consequences and clinical practice). Most studies reported non-modifiable factors. CONCLUSIONS The results of this scoping review challenge the perception that imaging CDM is purely based on clinical history and objective findings. There is a complex interplay between clinical features, patient and clinician characteristics, beliefs, and environment. These findings should be considered when designing strategies to address inappropriate imaging behaviour.
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Affiliation(s)
- Luke Tanner
- Clinical Physiotherapist, Auckland, New Zealand
| | - Nicola L Saywell
- Physiotherapy Department, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
- Research Innovation Centre, Auckland University of Technology, Auckland, New Zealand
| | - Thomas Adams
- Physiotherapy Department, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
- Active Living and Rehabilitation: Aotearoa New Zealand, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Imran Khan Niazi
- Research Innovation Centre, Auckland University of Technology, Auckland, New Zealand
- Centre for Chiropractic Research, New Zealand College of Chiropractic, Auckland, New Zealand
| | - Julia Hill
- Physiotherapy Department, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
- Active Living and Rehabilitation: Aotearoa New Zealand, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
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Al-Ghetaa RK, Alabousi M, You JJ, Emary PC, Riva JJ, Dufton J, Kagoma YK, Rampersaud R, Goytan MJ, Feasby TE, Reed M, Busse JW. Temporal Trends in Spinal Imaging in Ontario (2002-2019) and Manitoba (2001-2011), Canada. Cureus 2024; 16:e63267. [PMID: 39070358 PMCID: PMC11282485 DOI: 10.7759/cureus.63267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2024] [Indexed: 07/30/2024] Open
Abstract
Background Several studies have reported the overuse of spinal imaging, which, in Canada, led to several provincial pathways aimed at optimizing the use of imaging. We assessed temporal trends in spine imaging in two Canadian provinces. Methods We explored the use of X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) examinations of the cervical, thoracic, and lumbar spine regions among adults in Ontario (April 1, 2002, to March 31, 2019) and in Manitoba, Canada (April 1, 2001, to March 31, 2011) using linked Ontario Health Insurance Plan administrative databases and data from Manitoba Health. We calculated the age- and sex-adjusted rates of spinal X-ray, CT, and MRI examinations by dividing the number of imaging studies by the population of each province for each year and estimated the use of each imaging modality per 100,000 persons. Results The total cost of spine imaging in Ontario increased from $45.8 million in 2002/03 to $70.3 million in 2018/19 (a 54% increase), and in Manitoba from $2.2 million in 2001/02 to $5 million in 2010/11 (a 127% increase). In Ontario, rates of spine X-rays decreased by 12% and spine CT scans decreased by 28% over this time period, while in Manitoba, rates of spine X-rays and CT scans remained constant. Age- and sex-adjusted utilization of spinal MRI scans per 100,000 persons markedly increased over time in both Ontario (277%) and Manitoba (350%). Conclusion Despite efforts to reduce the use of inappropriate spinal imaging, both Ontario and Manitoba have greatly increased utilization of spine MRI in the past two decades.
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Affiliation(s)
- Rayeh K Al-Ghetaa
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, CAN
| | | | - John J You
- Medicine, Trillium Health Partners, Mississauga, CAN
| | | | - John J Riva
- Family Medicine, McMaster University, Hamilton, CAN
| | - John Dufton
- Imaging, University Hospital of Northern British Columbia, Prince George, CAN
| | | | | | | | | | - Martin Reed
- Radiology, University of Manitoba, Winnipeg, CAN
| | - Jason W Busse
- Health Research Methodology, McMaster University, Hamilton, CAN
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Vining R, Smith J, Anderson B, Almquist Z, Wong D. Developing an initial set of quality indicators for chiropractic care: a scoping review. BMC Health Serv Res 2024; 24:65. [PMID: 38216977 PMCID: PMC10785553 DOI: 10.1186/s12913-024-10561-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 01/04/2024] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Quality indicators are standardized, evidence-based measures of health care quality. Currently, there is no basic set of quality indicators for chiropractic care published in peer-reviewed literature. The goal of this research is to develop a preliminary set of quality indicators, measurable with administrative data. METHODS We conducted a scoping review searching PubMed/MEDLINE, CINAHL, and Index to Chiropractic Literature databases. Eligible articles were published after 2011, in English, developing/reporting best practices and clinical guidelines specifically developed for, or directly applicable to, chiropractic care. Eligible non-peer-reviewed sources such as quality measures published by the Centers for Medicare and Medicaid Services and the Royal College of Chiropractors quality standards were also included. Following a stepwise eligibility determination process, data abstraction identified specific statements from included sources that can conceivably be measured with administrative data. Once identified, statements were transformed into potential indicators by: 1) Generating a brief title and description; 2) Documenting a source; 3) Developing a metric; and 4) Assigning a Donabedian category (structure, process, outcome). Draft indicators then traversed a 5-step assessment: 1) Describes a narrowly defined structure, process, or outcome; 2) Quantitative data can conceivably be available; 3) Performance is achievable; 4) Metric is relevant; 5) Data are obtainable within reasonable time limits. Indicators meeting all criteria were included in the final set. RESULTS Literature searching revealed 2562 articles. After removing duplicates and conducting eligibility determination, 18 remained. Most were clinical guidelines (n = 10) and best practice recommendations (n = 6), with 1 consensus and 1 clinical standards development study. Data abstraction and transformation produced 204 draft quality indicators. Of those, 57 did not meet 1 or more assessment criteria. After removing duplicates, 70 distinct indicators remained. Most indicators matched the Donabedian category of process (n = 35), with 31 structure and 4 outcome indicators. No sources were identified to support indicator development from patient perspectives. CONCLUSIONS This article proposes a preliminary set of 70 quality indicators for chiropractic care, theoretically measurable with administrative data and largely obtained from electronic health records. Future research should assess feasibility, achieve stakeholder consensus, develop additional indicators including those considering patient perspectives, and study relationships with clinical outcomes. TRIAL REGISTRATION Open Science Framework, https://osf.io/t7kgm.
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Affiliation(s)
- Robert Vining
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, 1000 Brady St, Davenport, IA, USA.
| | - Jennifer Smith
- Palmer College of Chiropractic, 1000 Brady St, Davenport, IA, USA
| | - Brian Anderson
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, 1000 Brady St, Davenport, IA, USA
| | - Zachary Almquist
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, 1000 Brady St, Davenport, IA, USA
| | - Danveshka Wong
- Palmer College of Chiropractic, 1000 Brady St, Davenport, IA, USA
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Reibke PS, Godskesen H, Jensen RK, French SD, Bussières A, Christensen HW, Jensen TS. The effect of clinical guidelines on the utilisation of radiographs in chiropractic clinics in Denmark - an interrupted time series analysis. Chiropr Man Therap 2023; 31:47. [PMID: 37993957 PMCID: PMC10666323 DOI: 10.1186/s12998-023-00518-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 09/28/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND In Denmark, chiropractors have a statutory right to use radiography and the government-funded national Health Insurance provides partial reimbursement. Danish National Clinical Guidelines recommends against routine use of imaging for uncomplicated spinal pain; however, it is not clear if clinical imaging guidelines recommendations have had an effect on the utilisation of spinal radiography. This study aimed to describe the utilisation rate of radiographs in Danish chiropractic clinics in the period from 2010 to 2020 and to assess the impact of clinical guidelines and policy changes on the utilisation of radiographs in Danish chiropractic clinics. METHODS Anonymised data from January 1st, 2010, to December 31st, 2020, were extracted from the Danish Regions register on health contacts in primary care. Data consisted of the total number of patients consulting one of 254 chiropractic clinics and the total number of patients having or being referred for radiography. Data were used to investigate the radiography utilisation per month from 2010 to 2020. An 'interrupted time series' analysis was conducted to determine if two interventions, the dissemination of 1) Danish clinical imaging guidelines recommendations and policy changes related to referral for advanced imaging for chiropractors in 2013 and 2) four Danish clinical guidelines recommendations in 2016, were associated with an immediate change in the level and/or slope of radiography utilisation. RESULTS In total, 336,128 unique patients consulted a chiropractor in 2010 of which 55,449 (15.4%) had radiography. In 2020, the number of patients consulting a chiropractor had increased to 366,732 of which 29,244 (8.0%) had radiography. The pre-intervention utilisation decreased by two radiographs per 10,000 patients per month. Little absolute change, but still statistically significant for Intervention 1, in the utilisation was found after the dissemination of the clinical guidelines and policy changes in 2013 or 2016. CONCLUSIONS The proportion of Danish chiropractic patients undergoing radiography was halved in the period from 2010 to 2020. However, the dissemination of clinical imaging guidelines recommendations and policy changes related to referrals for advanced imaging showed little meaningful change in the monthly utilisation of radiographs in the same period.
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Affiliation(s)
| | | | - Rikke Krüger Jensen
- Department of Sport Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Chiropractic Knowledge Hub, Odense, Denmark
| | - Simon D French
- Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - André Bussières
- Département Chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada
| | | | - Tue Secher Jensen
- Department of Sport Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.
- Chiropractic Knowledge Hub, Odense, Denmark.
- Diagnostic Center - Imaging Section, Silkeborg Regional Hospital, Silkeborg, Denmark.
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11
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Özmen E, Biçer O, Meriç E, Circi E, Barış A, Yüksel S. Vertebral bone quality score for opportunistic osteoporosis screening: a correlation and optimal threshold analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3906-3911. [PMID: 37661227 DOI: 10.1007/s00586-023-07912-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/21/2023] [Accepted: 08/19/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE This study investigated the vertebral bone quality (VBQ) score as a potential tool for opportunistic osteoporosis screening and its correlation with dual-energy X-ray absorptiometry (DXA) values. METHODS In a single-center retrospective cohort of 130 patients, VBQ and DXA measures were compared using various statistical analyses. The optimal VBQ threshold for predicting osteoporosis was determined using receiver operating characteristic (ROC) analysis. RESULTS VBQ exhibited a significant negative association with DXA values, suggesting that higher VBQ scores are indicative of lower bone density. Age and VBQ were significant predictors of osteoporosis, with both increasing the log-odds of the condition. An optimal VBQ threshold of 2.7 was determined, demonstrating fair discriminatory power and high negative predictive value. CONCLUSION The study highlighted the potential of VBQ as a diagnostic tool for osteoporosis with high intra- and inter-observer reliability. The optimal VBQ threshold of 2.7 can aid in ruling out osteoporosis and identifying individuals for further evaluation.
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Affiliation(s)
- Emre Özmen
- Orthopedics and Traumatology, Istanbul Physical Therapy and Rehabilitation Training and Research Hospital, Adnan Kahveci Blv. No: 145, 34186, Bahçelievler, Istanbul, Turkey.
| | - Ozancan Biçer
- Orthopedics and Traumatology, SBU Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Emre Meriç
- Orthopedics and Traumatology, Istanbul Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Esra Circi
- Orthopedics and Traumatology, Istanbul Physical Therapy and Rehabilitation Training and Research Hospital, Adnan Kahveci Blv. No: 145, 34186, Bahçelievler, Istanbul, Turkey
| | - Alican Barış
- Orthopedics and Traumatology, Istanbul Physical Therapy and Rehabilitation Training and Research Hospital, Adnan Kahveci Blv. No: 145, 34186, Bahçelievler, Istanbul, Turkey
| | - Serdar Yüksel
- Orthopedics and Traumatology, Istanbul Physical Therapy and Rehabilitation Training and Research Hospital, Adnan Kahveci Blv. No: 145, 34186, Bahçelievler, Istanbul, Turkey
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12
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Orlando JF, Beard M, Guerin M, Kumar S. Systematic review of predictors of hospitalisation for non-specific low back pain with or without referred leg pain. PLoS One 2023; 18:e0292648. [PMID: 37816006 PMCID: PMC10564130 DOI: 10.1371/journal.pone.0292648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/25/2023] [Indexed: 10/12/2023] Open
Abstract
Significant costs and utilisation of healthcare resources are associated with hospitalisations for non-specific low back pain despite clinical guidelines recommending community-based care. The aim of this systematic review was to investigate the predictors of hospitalisation for low back pain. A protocol was registered with PROSPERO international prospective register of systematic reviews (#CRD42021281827) and conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. Database search of Ovid Medline, Emcare, Embase, PsycINFO, Cochrane Library, PEDro and OTSeeker was conducted. Studies were included if they examined a predictor of hospitalisation for non-specific low back pain with or without referred leg pain. Data was extracted and descriptively synthesised. Risk of bias of included studies was assessed using the Critical Appraisal Skills Programme Checklists. There were 23 studies published over 29 articles which identified 52 predictor variables of hospitalisation for low back pain. The risk of hospitalisation was grouped into themes: personal, health and lifestyle, psychology, socioeconomic, occupational, clinical, and health systems and processes. There was moderate level evidence that arrival to an emergency department via ambulance with low back pain, and older age increase the risk of hospitalisations for low back pain. There was low level evidence that high pain intensity, past history of low back pain, opioid use, and occupation type increase the risk of hospitalisation for low back pain. Further research into psychological and social factors is warranted given the paucity of available studies. Hospital avoidance strategies, improved patient screening and resource utilisation in emergency departments are considerations for practice.
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Affiliation(s)
- Joseph F. Orlando
- UniSA Allied Health & Human Performance, University of South Australia, Adelaide, Australia
- Central Adelaide Local Health Network, Adelaide, Australia
| | - Matthew Beard
- Central Adelaide Local Health Network, Adelaide, Australia
| | - Michelle Guerin
- UniSA Allied Health & Human Performance, University of South Australia, Adelaide, Australia
| | - Saravana Kumar
- UniSA Allied Health & Human Performance, University of South Australia, Adelaide, Australia
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Woznica DN, Milligan M, Krymis H, Peters KC, O'Connor MI, Grant RA. Telemedical Interdisciplinary Care Team Evaluation and Treatment of People With Low Back Pain: A Retrospective Observational Study. Arch Rehabil Res Clin Transl 2023; 5:100269. [PMID: 37744196 PMCID: PMC10517362 DOI: 10.1016/j.arrct.2023.100269] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
Objective To evaluate the effects of an interdisciplinary care team (ICT) model delivered by telemedicine on patients with low back pain (LBP). Design Retrospective analysis of deidentified pre-existing data. Setting Retrospective observational study of patients presenting with LBP to a nationwide telemedicine practice using an ICT model. Participants Over a 9-month period all patients with a diagnosis related to LBP and who had an ICT evaluation (medical doctor, advanced practice provider, health coach, and physical therapist) were included in the study (n=36). A minimum of 2 follow-up physical therapy visits were required for inclusion. Interventions Patients were evaluated for LBP, received a diagnosis, and were offered a multidisciplinary treatment plan. Additional real-time audio visual medical, health coaching, registered dietician, and physical therapy services were received as deemed clinically appropriate. Main Outcome Measures Baseline, 30 day, and final pain (mean 81 day) measurements via numerical pain rating scale (NPRS). Baseline and final Patient-Reported Outcomes Measurement Information System (PROMIS)-10 Global Mental/Physical domains. Secondary Outcome Measures Use of prescription medication, referral for imaging, need for injections, or surgery. Results 36 patients met criteria. Pain levels included mild (n=6, 16.7%), moderate (n=19, 52.8%), and severe (n=11, 30.6%). Clinically significant pain improvements were noted in 83.3% (n=25) of those with moderate or severe pain. PROMIS Mental and Physical Health categorization from Fair/Poor to Good/Excellent significantly improved over time. The initial 20% (n=7) in Fair/Poor Mental Health improved to 6.3% (n=2) at finish, while the 80% (n=28) in Good/Excellent Mental Health at start improved to 93.8% (n=30) at finish. Regarding Physical Health, 51.4% (n=18) rated Fair/Poor at start and 31.3% (n=10) at finish, while the 48.6% (n=17) rated Good/Excellent at start improved to 68.8% (n=22) at finish. The need for prescription medication was low (n=6, 16.7%) and spinal imaging orders were negligible (n=1, 2.8%). Injections were warranted in 11.4% (n=4) of patients and surgical referral with operative treatment in 2.8% (n=1). Conclusion Interdisciplinary care delivered through telemedicine can significantly improve pain and support improved health-related quality of life in patients with LBP, with low rates of imaging, prescription, and interventional use.
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Hill J, Kay D, Gordon J, Niazi IK, Saywell N. New Zealanders with low back pain seeking health care: a retrospective descriptive analysis of Accident Compensation Corporation-funded low back pain healthcare service usage. J Prim Health Care 2023; 15:206-214. [PMID: 37756237 DOI: 10.1071/hc23010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/09/2023] [Indexed: 09/29/2023] Open
Abstract
Introduction Most New Zealanders experience low back pain (LBP) at least once throughout their lifetime and many seek help from the large range of health providers in primary care. Accident Compensation Corporation (ACC) funds a significant proportion of those claims, but which services are they funding and what are the costs? Method This was a retrospective audit and descriptive analysis of ACC-funded, non-public hospital healthcare service use by people with LBP in New Zealand (NZ). Outcome measures were the healthcare services accessed by people with ACC-funded LBP,the claims (all occurrences for a service that has generated a payment/year), single contact (with a service), and costs (NZ$) for services between 2009 and 2020. Results The number of claims for services were 129 000 for physiotherapy, 105 000 for general practitioner and 59 000 for radiology services. Per single contact, elective surgery and radiology services were the most expensive. During 2009-2020, there were 3.3 million ACC claims for LBP with a total cost of NZ$4 billion. Over this time, there was an increase in claims, costs and single contacts. Costs decreased slightly during 2010 due to changes in healthcare funding and in 2020 due to the COVID-19 pandemic. Discussion Consumers have considerable choice in where they access health care for ACC-funded LBP services. This study shows the services they use most frequently and the cost to NZ for those services. These data can inform service planning for ACC-funded LBP health care in NZ.
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Affiliation(s)
- Julia Hill
- Department of Physiotherapy, School of Clinical Sciences, Active Living and Rehabilitation: Aotearoa New Zealand, Auckland University of Technology, New Zealand
| | - Dylan Kay
- Clinical Practice, Auckland, New Zealand
| | | | - Imran Khan Niazi
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark; and Centre for Chiropractic Research, New Zealand College of Chiropractic, Auckland, New Zealand; and Research Innovation Centre, Auckland University of Technology, New Zealand
| | - Nicola Saywell
- Department of Physiotherapy, School of Clinical Sciences, Research Innovation Centre, Auckland University of Technology, New Zealand
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15
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Tennant IJ, Yau YH, Yull D, Murphy P, Whittle IR. Imaging incidence and type in primary care patients with low back pain: a cross-sectional study on new referrals to an Australian specialist spinal surgical centre. J Prim Health Care 2023; 15:262-266. [PMID: 37756235 DOI: 10.1071/hc22127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/16/2023] [Indexed: 09/29/2023] Open
Abstract
Introduction Low back pain (LBP) is common and a significant cause of morbidity. Many patients receive inappropriate imaging for LBP in primary care. Aim To explore the incidence and type of spinal imaging conducted for LBP patients referred from general practice for specialist surgical opinion, and evaluate whether imaging conformed to clinical guidelines. Methods Audit of a sequential cohort (n = 100) of new LBP patients referred from primary care for specialist opinion at a suburban Australian capital city independent Spinal Centre. Results In the 6 months before referral, 90% (95% CI 83-95%) of patients underwent spinal imaging. Imaging was performed in 95% of those who did and 79% of those who did not meet guidelines for radiological investigation. 35% of patients were inappropriately imaged and 3% inappropriately not imaged. Spinal computed tomography (CT) imaging was used in 52% of patients, magnetic resonance imaging (MRI) in 42% and image-guided lumbar spinal interventional procedures in 28%. Discussion Most patients with LBP referred for surgical opinion have diagnostic radiological investigations whether or not it is indicated by clinical guidelines. The more frequent use of spinal CT compared to MRI may be due to idiosyncrasies of the Australian Medicare Benefits Schedule (MBS) rebate system. The findings of this pilot study provide support for the changes recommended by the 2016 MBS Review Taskforce on LBP that permit GP access to subsidised lumbar MRI, while constraining access to lumbar CT, and provide novel data about spinal imaging and practice in this cohort of patients.
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Affiliation(s)
- Isaac J Tennant
- Faculty of Health and Medical Sciences, University of Adelaide, SA, Australia
| | - Yun-Hom Yau
- Faculty of Health and Medical Sciences, University of Adelaide, SA, Australia; and The International Spine Centre, Norwood, SA 5067, Australia; and The Spinal Unit, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Derek Yull
- Faculty of Health and Medical Sciences, University of Adelaide, SA, Australia; and The International Spine Centre, Norwood, SA 5067, Australia
| | - Peter Murphy
- The International Spine Centre, Norwood, SA 5067, Australia
| | - Ian R Whittle
- Faculty of Health and Medical Sciences, University of Adelaide, SA, Australia; and The International Spine Centre, Norwood, SA 5067, Australia; and The Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, Scotland, UK
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Meidinger P, Kéchichian A, Pinsault N. A Model of Triage of Serious Spinal Pathologies and Therapeutic Options Based on a Delphi Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1283. [PMID: 37512094 PMCID: PMC10383224 DOI: 10.3390/medicina59071283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/06/2023] [Accepted: 07/08/2023] [Indexed: 07/30/2023]
Abstract
Background and Objectives: The relevance of red flags in serious spinal pathology (SSP) has evolved throughout the last years. Recently, new considerations have been proposed to expand the consideration of red flags. The purpose of this study was to determine, approve and test a model for the triage and management process of SSPs based on the latest data available in the literature. Materials and Methods: The SSP model was initially built on the basis of a literature review. The model was further determined and approved by an expert panel using a Delphi process. Finally, clinical scenarios were used to test the applicability of the model. Results: After three rounds of the Delphi process, panellists reached a consensus on a final version of the model. The use of clinical scenarios by experts brought about reflexive elements both for the determined model and for the SSPs depicted in the clinical cases. Conclusions: The validation of the model and its implementation in the clinical field could help assess the skills of first-line practitioners managing spinal pain patients. To this end, the development of additional clinical scenarios fitting the determined model should be further considered.
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Affiliation(s)
- Philippe Meidinger
- TIMC-IMAG UMR CNRS 5525, ThEMAS Team, Université Grenoble Alpes, Domaine de la Merci, 5 Avenue du Grand Sablon, 38700 La Tronche, France
| | - Amélie Kéchichian
- TIMC-IMAG UMR CNRS 5525, ThEMAS Team, Université Grenoble Alpes, Domaine de la Merci, 5 Avenue du Grand Sablon, 38700 La Tronche, France
| | - Nicolas Pinsault
- TIMC-IMAG UMR CNRS 5525, ThEMAS Team, Université Grenoble Alpes, Domaine de la Merci, 5 Avenue du Grand Sablon, 38700 La Tronche, France
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17
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Docking S, Gao L, Ademi Z, Bonello C, Buchbinder R. Use of Decision-Analytic Modelling to Assess the Cost-Effectiveness of Diagnostic Imaging of the Spine, Shoulder, and Knee: A Scoping Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:467-475. [PMID: 36940059 PMCID: PMC10119214 DOI: 10.1007/s40258-023-00799-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/23/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Limited evidence is available on the cost-effectiveness of diagnostic imaging for back, neck, knee, and shoulder complaints. Decision analytic modelling may be an appropriate method to synthesise evidence from multiple sources, and overcomes issues with trial-based economic evaluations. OBJECTIVE The aim was to describe the reporting of methods and objectives utilised in existing decision analytic modelling studies that assess the cost-effectiveness of diagnostic imaging for back, neck, knee, and shoulder complaints. METHODS Decision analytic modelling studies investigating the use of any imaging modality for people of any age with back, neck, knee, or shoulder complaints were included. No restrictions on comparators were applied, and included studies were required to estimate both costs and benefits. A systematic search (5 January 2023) of four databases was conducted with no date limits imposed. Methodological and knowledge gaps were identified through a narrative summary. RESULTS Eighteen studies were included. Methodological issues were identified relating to the poor reporting of methods, and measures of effectiveness did not incorporate changes in quantity and/or quality of life (cost-utility analysis in only ten of 18 studies). Included studies, particularly those investigating back or neck complaints, focused on conditions that were of low prevalence but have a serious impact on health (i.e. cervical spine trauma, cancer-related back pain). CONCLUSIONS Future models should pay particular attention to the identified methodological and knowledge gaps. Investment in the health technology assessment of these commonly utilised diagnostic imaging services is needed to justify the current level of utilisation and ensure that these services represent value for money.
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Affiliation(s)
- Sean Docking
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Lan Gao
- Deakin Health Economics, Institute for Health Transformation, School of Health & Social Development, Deakin University, Geelong, VIC, Australia
| | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia
| | - Christian Bonello
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Walther F, Eberlein-Gonska M, Hoffmann RT, Schmitt J, Blum SFU. Measuring appropriateness of diagnostic imaging: a scoping review. Insights Imaging 2023; 14:62. [PMID: 37052758 PMCID: PMC10102275 DOI: 10.1186/s13244-023-01409-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/18/2023] [Indexed: 04/14/2023] Open
Abstract
In radiology, the justification of diagnostic imaging is a key performance indicator. To date, specific recommendations on the measurement of appropriateness in diagnostic imaging are missing. To map the study literature concerning the definition, measures, methods and data used for analyses of appropriateness in research of diagnostic imaging. We conducted a scoping review in Medline, EMBASE, Scopus and the Cochrane Central Register of Controlled Trials. Two independent reviewers undertook screening and data extraction. After screening 6021 records, we included 50 studies. National guidelines (n = 22/50) or American College of Radiology Appropriateness Criteria (n = 23/50) were used to define and rate appropriateness. 22/50 studies did not provide methodological details about the appropriateness assessment. The included studies varied concerning modality, amount of reviewed examinations (88-13,941) and body regions. Computed tomography (27 studies, 27,168 examinations) was the most frequently analyzed modality, followed by magnetic resonance imaging (17 studies, 6559 examinations) and radiography (10 studies, 7095 examinations). Heterogeneous appropriateness rates throughout single studies (0-100%), modalities, and body regions (17-95%) were found. Research on pediatric and outpatient imaging was sparse. Multicentric, methodologically robust and indication-oriented studies would strengthen appropriateness research in diagnostic imaging and help to develop reliable key performance indicators.
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Affiliation(s)
- Felix Walther
- Center for Evidence-Based Healthcare, University Hospital Carl Gustav Carus and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
- Quality and Medical Risk Management, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| | - Maria Eberlein-Gonska
- Quality and Medical Risk Management, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ralf-Thorsten Hoffmann
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jochen Schmitt
- Center for Evidence-Based Healthcare, University Hospital Carl Gustav Carus and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Sophia F U Blum
- Quality and Medical Risk Management, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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To D, De Carvalho D, Pike A, Lawrence R, Etchegary H, Patey AM, Toomey E, Hall A. A qualitative study exploring perceived barriers and enablers to fidelity of training and delivery for an intervention to reduce non-indicated imaging for low back pain. Chiropr Man Therap 2023; 31:6. [PMID: 36721165 PMCID: PMC9890790 DOI: 10.1186/s12998-023-00480-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 01/23/2023] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Non-specific low back pain (LBP) commonly presents to primary care, where inappropriate use of imaging remains common despite guideline recommendations against its routine use. Little is known about strategies to enhance intervention fidelity (i.e., whether interventions were implemented as intended) for interventions developed to reduce non-indicated imaging for LBP. OBJECTIVES We aim to inform the development of an intervention to reduce non-indicated imaging among general practitioners (GPs) and chiropractors in Newfoundland and Labrador (NL), Canada. The study objectives are: [1] To explore perceived barriers and enablers to enhancing fidelity of training of GPs and chiropractors to deliver a proposed intervention to reduce non-indicated imaging for LBP and [2] To explore perceived barriers and enablers to enhancing fidelity of delivery of the proposed intervention. METHODS An exploratory, qualitative study was conducted with GPs and chiropractors in NL. The interview guide was informed by the National Institutes of Health Behavior Change Consortium fidelity checklist; data analysis was guided by the Theoretical Domains Framework (TDF). Participant quotes were coded into TDF domains, belief statements were generated at each domain, and domains relevant to enhancing fidelity of provider training or intervention delivery were identified. RESULTS The study included five GPs and five chiropractors from urban and rural settings. Barriers and enablers to enhancing fidelity to provider training related to seven TDF domains: [1] Beliefs about capabilities, [2] Optimism, [3] Reinforcement, [4] Memory, attention, and decision processes, [5] Environmental context and resources, [6] Emotion, and [7] Behavioural regulation. Barriers and enablers to enhancing fidelity to intervention delivery related to seven TDF domains: [1] Beliefs about capabilities, [2] Optimism, [3] Goals, [4] Memory, attention, and decision processes, [5] Environmental context and resources, [6] Social influences, and [7] Behavioural regulation. CONCLUSION The largest perceived barrier to attending training was time; perceived enablers were incentives and flexible training. Patient pressure, time, and established habits were perceived barriers to delivering the intervention as intended. Participants suggested enhancement strategies to improve their ability to deliver the intervention as intended, including reminders and check-ins with researchers. Most participants perceived intervention fidelity as important. These results may aid in the development of a more feasible and pragmatic intervention to reduce non-indicated imaging for GPs and chiropractors in NL.
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Affiliation(s)
- Daphne To
- Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, Saint John's, NL, A1B 3V6, Canada.
| | - Diana De Carvalho
- grid.25055.370000 0000 9130 6822Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, Saint John’s, NL A1B 3V6 Canada
| | - Andrea Pike
- grid.25055.370000 0000 9130 6822Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, Saint John’s, NL Canada
| | - Rebecca Lawrence
- grid.25055.370000 0000 9130 6822Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, Saint John’s, NL Canada
| | - Holly Etchegary
- grid.25055.370000 0000 9130 6822Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, Saint John’s, NL A1B 3V6 Canada
| | - Andrea M. Patey
- grid.412687.e0000 0000 9606 5108Centre for Implementation Research, Ottawa Hospital Research Institute – General Campus, Ottawa, ON Canada
| | - Elaine Toomey
- grid.10049.3c0000 0004 1936 9692School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Amanda Hall
- grid.25055.370000 0000 9130 6822Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, Saint John’s, NL Canada
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Feasibility of testing the effectiveness of a theory-informed intervention to reduce imaging for low back pain: a pilot cluster randomised controlled trial. Pilot Feasibility Stud 2022; 8:249. [PMID: 36494716 PMCID: PMC9733261 DOI: 10.1186/s40814-022-01216-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 11/29/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND General medical practitioner (GP) recruitment and subsequent data collection in clinical practice are challenging and may limit successful completion of a large-scale trial. The aim of this study was to assess the feasibility of undertaking a cluster randomised controlled trial to test an intervention to reduce non-indicated imaging for low back pain in general medical practice. METHODS A pilot cluster randomised controlled trial was performed, with recruitment of GPs and randomisation of GP clinics. All GPs attended a training session and were asked to record low back pain codes in electronic medical records for any low back pain presentations. Intervention group GPs were trained in the use of a patient education booklet to be used during low back pain patient visits. Control group GPs provided usual care. Outcomes for the proposed trial were collected to determine feasibility. GP recruitment was assessed as the proportion of GPs approached who consented to participate. Low back pain imaging outcomes were collected from electronic medical records (counts of patients presenting with low back pain) and from Australian healthcare administrative (Medicare) data (counts of imaging use). GP compliance with study procedures was assessed and qualitative data reported. RESULTS Thirty-four GP clinics were approached, with four participating (12%). At these clinics, 13/19 (68%) GPs consented to participate, and 10/19 (53%) started the study. Outcome data were collected from medical records for all GPs. Three GPs (30%) withdrew consent to access Medicare data, limiting reporting of imaging outcome measures. Three GPs (30%) self-reported low compliance entering low back pain codes. CONCLUSIONS This pilot cluster randomised controlled trial demonstrated the feasibility of many aspects of a full-scale effectiveness study, while also identifying a number of challenges that need to be resolved. Recommendations related to GP recruitment, study compliance, data collection, and outcome measures were made to increase the success of a future trial. TRIAL REGISTRATION Australia and New Zealand Clinical Trials Register (ANZCTR), Trial ID: ACTRN12619000991112; Registered 11 July 2019, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376973.
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Avoiding nocebo and other undesirable effects in chiropractic, osteopathy and physiotherapy: An invitation to reflect. Musculoskelet Sci Pract 2022; 62:102677. [PMID: 36368170 DOI: 10.1016/j.msksp.2022.102677] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/12/2022] [Accepted: 10/16/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION While the placebo effect is increasingly recognised as a contributor to treatment effects in clinical practice, the nocebo and other undesirable effects are less well explored and likely underestimated. In the chiropractic, osteopathy and physiotherapy professions, some aspects of historical models of care may arguably increase the risk of nocebo effects. PURPOSE In this masterclass article, clinicians, researchers, and educators are invited to reflect on such possibilities, in an attempt to stimulate research and raise awareness for the mitigation of such undesirable effects. IMPLICATIONS This masterclass briefly introduces the nocebo effect and its underlying mechanisms. It then traces the historical development of chiropractic, osteopathy, and physiotherapy, arguing that there was and continues to be an excessive focus on the patient's body. Next, aspects of clinical practice, including communication, the therapeutic relationship, clinical rituals, and the wider social and economic context of practice are examined for their potential to generate nocebo and other undesirable effects. To aid reflection, a model to reflect on clinical practice and individual professions through the 'prism' of nocebo and other undesirable effects is introduced and illustrated. Finally, steps are proposed for how researchers, educators, and practitioners can maximise positive and minimise negative clinical context.
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Jenkins HJ, Moloney NA, French SD, Maher CG, Dear BF, Magnussen JS, Hancock MJ. General practitioner experiences using a low back pain management booklet aiming to decrease non-indicated imaging for low back pain. Implement Sci Commun 2022; 3:71. [PMID: 35765064 PMCID: PMC9238090 DOI: 10.1186/s43058-022-00317-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/05/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Imaging is overused in the management of low back pain, resulting in overdiagnosis, increased healthcare utilisation, and increased costs. Few effective interventions to decrease inappropriate use have been developed and have typically not been developed using behaviour change theory. An intervention to reduce non-indicated imaging for low back pain was developed using behavioural change theory, incorporating a novel low back pain management booklet to facilitate patient education and reassurance. The aim of this study was to assess the adoption and feasibility of use of the developed intervention within clinical practice and to determine appropriate implementation strategies to address identified barriers to use.
Methods
Fourteen general medical practitioners were recruited and trained to use the booklet with low back pain patients over a minimum 5-month period. Quantitative data on use of the booklet were collected and analysed descriptively. Qualitative data on use of the booklet and training session were collected in general medical practitioner interviews and thematically analysed. Barriers to use were identified and mapped to suitable implementation strategies using the Behaviour Change Wheel.
Results
Practitioners used the booklet with 73 patients. The booklet was used with 63% of patients presenting with low back pain. Facilitators for using the booklet included patient’s requesting imaging and lower practitioner confidence in managing low back pain. Barriers included accessible storage and remembering to use the booklet. Implementation strategies were identified to increase adoption and feasibility of use, including development of a digital version of the booklet.
Conclusions
General medical practitioners reported that the low back pain management booklet and training were useful for clinical practice, particularly with patients requesting imaging. Barriers to use were identified and implementation strategies to address these barriers will be incorporated into future effectiveness studies. This study forms one of a series of studies to thoroughly develop and test an intervention to reduce non-indicated imaging for low back pain; a successful intervention would decrease healthcare costs and improve patient management.
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Jakimovski D, Bergsland N. Editorial for "Paraspinal Muscle in Chronic Low Back Pain: Comparison Between Standard Parameters and Chemical Shift Encoding-Based Water-Fat MRI". J Magn Reson Imaging 2022; 56:1609-1610. [PMID: 35253949 DOI: 10.1002/jmri.28144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 01/28/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Dejan Jakimovski
- Department of Neurology, Buffalo Neuroimaging Analysis Center (BNAC), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Niels Bergsland
- Department of Neurology, Buffalo Neuroimaging Analysis Center (BNAC), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA.,IRCCS, Fondazione Don Carlo Gnocchi, Milan, Italy
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Kühn L, Lindert L, Choi KE. Research designs and instruments to detect physiotherapy overuse of low-value care services in low back pain management: a scoping review protocol. Syst Rev 2022; 11:212. [PMID: 36199151 PMCID: PMC9536019 DOI: 10.1186/s13643-022-02083-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 09/28/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The provision of low-value care services in low back pain management is a problem of global scope. Inappropriate imaging, overmedication, and overused invasive therapies are prevalent in physician services. Yet, little is known about overused low-value physiotherapy services. Most studies addressing physiotherapy overuse in low back pain management arose from countries in which physiotherapy is established in primary care. However, measures and instruments addressing physiotherapy overuse limitedly fit legislative conditions of health systems in which physiotherapy is a service of secondary care. Thus, this scoping review's purpose is to map existing research designs and instruments aiming to detect overused low-value physiotherapy services taking specific healthcare settings and aspects of medical overuse into account. METHODS The development of this scoping review is guided by the Arksey and O'Malley framework. A two-step, peer-reviewed search strategy in accordance with the PRESS checklist will be conducted on MEDLINE (PubMed), Web of Science, and CINHAL. Additionally, gray literature will be searched on Google Scholar. Preprints of empirical studies will be included. Initially, two reviewers will independently screen articles for eligibility by title and abstract. A third reviewer will mediate discrepancies. Uncertainties will be eliminated by a full-text analysis or by contacting the corresponding authors. A four-step analytical process will guide result reporting focusing on major research questions outlined in this protocol. Numerical and narrative tables, graphics, and narrative summaries will be the methods to summarize and collate results. In the final step, the German health system will serve as an exemplary setting and frame to practically apply results. DISCUSSION Results of this scoping review will help researchers to systematically select overuse measures referring to aspects of the overuse typology, specific healthcare settings, and physiotherapy services. It will further provide information on the limitations of present studies and will give advice on how to address them. Moreover, this review will illustrate to what degree existing studies succeed to comprehensively cover the concept of the overuse typology. SYSTEMATIC REVIEW REGISTRATION This protocol has been registered on the open science framework ( https://doi.org/10.17605/OSF.IO/PMF2G ).
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Affiliation(s)
- Lukas Kühn
- Brandenburg Medical School Theodor Fontane, Center for Health Services Research, Seebad 82/83, 15562 Rüdersdorf bei Berlin, Neuruppin, Germany.
| | - Lara Lindert
- Brandenburg Medical School Theodor Fontane, Center for Health Services Research, Seebad 82/83, 15562 Rüdersdorf bei Berlin, Neuruppin, Germany
| | - Kyung-Eun Choi
- Brandenburg Medical School Theodor Fontane, Center for Health Services Research, Seebad 82/83, 15562 Rüdersdorf bei Berlin, Neuruppin, Germany
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Mabry LM, Severin R, Gisselman AS, Ross MD, Davenport TE, Young BA, Keil AP, Goss DL. Physical Therapists Are Routinely Performing the Requisite Skills to Directly Refer for Musculoskeletal Imaging: An Observational Study. J Man Manip Ther 2022; 30:261-272. [PMID: 35968741 PMCID: PMC9487956 DOI: 10.1080/10669817.2022.2106729] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
OBJECTIVES To explore if physical therapists are practicing skills necessary to refer patients for musculoskeletal imaging. METHODS An expert panel established a list of nine requisite skills to refer for musculoskeletal imaging. A blinded expert panel validated the list using a 5-point Likert scale. The skills list was examined via an electronic survey distributed to United States physical therapists. RESULTS 4,796 respondents were included. Each of the nine skills were routinely performed by a majority of the respondents (range: 54.52-94.72%). Respondents routinely performed 6.95 (± 0.06) skills, with 67.41% routinely performing seven or more skills. Doctors of physical therapy routinely performed more imaging skills (7.15 ± 0.06) compared to their masters- (6.44 ± 0.19) and bachelors-trained (5.95 ± 0.21) counterparts (p < 0.001). Residency/fellowship-trained physical therapists were more likely to routinely perform more imaging skills (7.60 ± 0.11 vs. 6.79 ± 0.07, p < 0.001). Imaging skill performance was greater among board-certified physical therapists (7.39 ± 0.09 vs. 6.71 ± 0.08, p < 0.001) and APTA members (7.06 ± 0.07 vs. 6.65 ± 0.12, p < 0.001). CONCLUSION Physical therapists are routinely practicing the requisite imaging skills to directly refer to a radiologist for musculoskeletal imaging.
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Affiliation(s)
- Lance M. Mabry
- Department of Physical Therapy, Congdon School of Health Sciences, High Point University, One University Parkway, High Point, NCUSA
| | - Richard Severin
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
- Department of Physical Therapy, Robbins College of Health and Human Sciences, Baylor University , Waco, TX, USA
| | - Angela S. Gisselman
- Doctor of Physical Therapy Program, Department of Public Health and Community Medicine, School of Medicine, Tufts University, Phoenix, AZ, USA
| | - Michael D. Ross
- Department of Physical Therapy, Daemen University, Amherst, NY, USA
| | - Todd E. Davenport
- Department of Physical Therapy, School of Health Sciences, University of the Pacific, Stockton, CA, USA
| | - Brian A. Young
- Department of Physical Therapy, Robbins College of Health and Human Sciences, Baylor University , Waco, TX, USA
| | - Aaron P. Keil
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Don L. Goss
- Department of Physical Therapy, Congdon School of Health Sciences, High Point University, One University Parkway, High Point, NCUSA
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Smith A, Kumar V, Cooley J, Ammendolia C, Lee J, Hogg-Johnson S, Mior S. Adherence to spinal imaging guidelines and utilization of lumbar spine diagnostic imaging for low back pain at a Canadian Chiropractic College: a historical clinical cohort study. Chiropr Man Therap 2022; 30:39. [PMID: 36114583 PMCID: PMC9479444 DOI: 10.1186/s12998-022-00447-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 08/28/2022] [Indexed: 11/10/2022] Open
Abstract
Background Diagnostic imaging is useful for assessing low back pain (LBP) when a clinician suspects a specific underlying pathology. Evidence-based imaging guidelines assist clinicians in appropriately determining the need for imaging when assessing LBP. A previous study reported high adherence to three clinical guidelines, with utilization rate of 12.3% in imaging of LBP patients attending a chiropractic teaching clinic. A new imaging guideline for spinal disorders has been published and used in teaching. Thus, the aims of our study were to assess the adherence to the new guideline and X-ray utilization in new episodes of LBP. Methods We conducted a historical clinical cohort study using patient electronic health record audits at seven teaching clinics over a period of 20 months. Records of patients who were at least 18 years of age, presented with a new onset of LBP, and consented to data collection were included. Abstracted data included patient demographics, the number and type of red flags, and the decision to image. Rate of guideline adherence (proportion of those not recommended for imaging, given no red flags) and rate of image utilization were descriptively analyzed. Results We included 498 patients in this study. At least 81% of included patients had one or more red flags reported. The most commonly reported individual red flag was age ≥ 50 (43.8%) followed by pain at rest (15.7%). In those referred for imaging, age ≥ 50 (93.3%) was the most frequently reported red flag. No red flag(s) were identified in 93 patient records, and none were referred for imaging of their LBP, yielding an adherence rate of 100% (95% CI 96, 100%). A total of 17 of 498 patients were recommended for imaging for their low back pain, resulting in an imaging utilization rate of 3.4% (95% CI 1.8, 5.0%). Conclusion The imaging utilization rate was 3.4%, lower than 12.3% previously reported at a chiropractic teaching clinic. None without red flags were referred for imaging, yielding a 100%, adherence rate to current LBP imaging guidelines. Future research should consider currency of guideline, accuracy of red flags and factors influencing clinicians’ decision, when assessing imaging adherence rates.
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O’Connor DA, Glasziou P, Maher CG, McCaffery KJ, Schram D, Maguire B, Ma R, Billot L, Gorelik A, Traeger AC, Albarqouni L, Checketts J, Vyas P, Clark B, Buchbinder R. Effect of an Individualized Audit and Feedback Intervention on Rates of Musculoskeletal Diagnostic Imaging Requests by Australian General Practitioners: A Randomized Clinical Trial. JAMA 2022; 328:850-860. [PMID: 36066518 PMCID: PMC9449798 DOI: 10.1001/jama.2022.14587] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE Audit and feedback can improve professional practice, but few trials have evaluated its effectiveness in reducing potential overuse of musculoskeletal diagnostic imaging in general practice. OBJECTIVE To evaluate the effectiveness of audit and feedback for reducing musculoskeletal imaging by high-requesting Australian general practitioners (GPs). DESIGN, SETTING, AND PARTICIPANTS This factorial cluster-randomized clinical trial included 2271 general practices with at least 1 GP who was in the top 20% of referrers for 11 imaging tests (of the lumbosacral or cervical spine, shoulder, hip, knee, and ankle/hind foot) and for at least 4 individual tests between January and December 2018. Only high-requesting GPs within participating practices were included. The trial was conducted between November 2019 and May 2021, with final follow-up on May 8, 2021. INTERVENTIONS Eligible practices were randomized in a 1:1:1:1:1 ratio to 1 of 4 different individualized written audit and feedback interventions (n = 3055 GPs) that varied factorially by (1) frequency of feedback (once vs twice) and (2) visual display (standard vs enhanced display highlighting highly requested tests) or to a control condition of no intervention (n = 764 GPs). Participants were not masked. MAIN OUTCOMES AND MEASURES The primary outcome was the overall rate of requests for the 11 targeted imaging tests per 1000 patient consultations over 12 months, assessed using routinely collected administrative data. Primary analyses included all randomized GPs who had at least 1 patient consultation during the study period and were performed by statisticians masked to group allocation. RESULTS A total of 3819 high-requesting GPs from 2271 practices were randomized, and 3660 GPs (95.8%; n = 727 control, n = 2933 intervention) were included in the primary analysis. Audit and feedback led to a statistically significant reduction in the overall rate of imaging requests per 1000 consultations compared with control over 12 months (adjusted mean, 27.7 [95% CI, 27.5-28.0] vs 30.4 [95% CI, 29.8-30.9], respectively; adjusted mean difference, -2.66 [95% CI, -3.24 to -2.07]; P < .001). CONCLUSIONS AND RELEVANCE Among Australian general practitioners known to frequently request musculoskeletal diagnostic imaging, an individualized audit and feedback intervention, compared with no intervention, significantly decreased the rate of targeted musculoskeletal imaging tests ordered over 12 months. TRIAL REGISTRATION ANZCTR Identifier: ACTRN12619001503112.
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Affiliation(s)
- Denise A. O’Connor
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
| | - Christopher G. Maher
- Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, Camperdown, New South Wales, Australia
| | - Kirsten J. McCaffery
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Dina Schram
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Brigit Maguire
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Robert Ma
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Newtown, New South Wales, Australia
| | - Alexandra Gorelik
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia
| | - Adrian C. Traeger
- Institute for Musculoskeletal Health, Sydney Local Health District and The University of Sydney, Camperdown, New South Wales, Australia
| | - Loai Albarqouni
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
| | - Juliet Checketts
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Parima Vyas
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Brett Clark
- Australian Government Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Victoria, Australia
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Di Gangi S, Bagnoud C, Pichierri G, Rosemann T, Plate A. Characteristics and health care costs in patients with a diagnostic imaging for low back pain in Switzerland. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:823-835. [PMID: 34718899 PMCID: PMC9170616 DOI: 10.1007/s10198-021-01397-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 10/21/2021] [Indexed: 06/13/2023]
Abstract
Low back pain (LBP) is one of the most common musculoskeletal disorders worldwide and a frequent cause for health care utilization with a high economic burden. A large proportion of diagnostic imaging in patients with LBP is inappropriate and can cause more harm than good, which in turn can lead to higher health care costs. The aim of this study was to determine characteristics and health care costs for patients with a diagnostic imaging for LBP in Switzerland. Groupe Mutuel, one of the biggest health care insurance companies in Switzerland and covering approximately 12% of the population, provided data for this analysis. Patients were identified by diagnostic imaging for the lumbar spine in 2016 or 2017. The study period was 2015-2019, that is one year before and two years after the year of imaging. Regression analysis models were used to identify patient variables associated with higher health care costs. A total of 75,296 patients (57% female, mean age: 54.5 years) were included into the study. Magnetic resonance imaging was the most commonly used diagnostic method (44.3%). Patients generated annual mean health care costs of 518,488,470 CHF (466,639,621 Euro) in the whole observation period; 640 million CHF (576 million Euro) in the index year. Overall, costs for LBP patients were 72% higher compared with the costs of no LBP patients. Our findings confirm the economic burden of LBP and highlight the importance of ongoing efforts to improve prevention, diagnostics and patient care in patients with LBP.
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Affiliation(s)
- Stefania Di Gangi
- Institute of Primary Care, University and University Hospital Zürich, Pestalozzistrasse 24, 8091, Zürich, Switzerland.
| | | | - Giuseppe Pichierri
- Institute of Primary Care, University and University Hospital Zürich, Pestalozzistrasse 24, 8091, Zürich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University and University Hospital Zürich, Pestalozzistrasse 24, 8091, Zürich, Switzerland
| | - Andreas Plate
- Institute of Primary Care, University and University Hospital Zürich, Pestalozzistrasse 24, 8091, Zürich, Switzerland
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Ruiz Santiago F, Láinez Ramos-Bossini AJ, Wáng YXJ, Martínez Barbero JP, García Espinosa J, Martínez Martínez A. The value of magnetic resonance imaging and computed tomography in the study of spinal disorders. Quant Imaging Med Surg 2022; 12:3947-3986. [PMID: 35782254 PMCID: PMC9246762 DOI: 10.21037/qims-2022-04] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/13/2022] [Indexed: 08/15/2023]
Abstract
Computed tomography (CT) and magnetic resonance imaging (MRI) have replaced conventional radiography in the study of many spinal conditions, it is essential to know when these techniques are indicated instead of or as complementary tests to radiography, which findings can be expected in different clinical settings, and their significance in the diagnosis of different spinal conditions. Proper use of CT and MRI in spinal disorders may facilitate diagnosis and management of spinal conditions. An adequate clinical approach, a good understanding of the pathological manifestations demonstrated by these imaging techniques and a comprehensive report based on a universally accepted nomenclature represent the indispensable tools to improve the diagnostic approach and the decision-making process in patients with spinal pain. Several guidelines are available to assist clinicians in ordering appropriate imaging techniques to achieve an accurate diagnosis and to ensure appropriate medical care that meets the efficacy and safety needs of patients. This article reviews the clinical indications of CT and MRI in different pathologic conditions affecting the spine, including congenital, traumatic, degenerative, inflammatory, infectious and tumor disorders, as well as their main imaging features. It is intended to be a pictorial guide to clinicians involved in the diagnosis and treatment of spinal disorders.
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Affiliation(s)
| | | | - Yì Xiáng J. Wáng
- Department of Imaging and Interventional Radiology, the Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - José Pablo Martínez Barbero
- Department of Radiology and Physical Medicine, Hospital Virgen de las Nieves, University of Granada, Granada, Spain
| | - Jade García Espinosa
- Department of Radiology and Physical Medicine, Hospital Virgen de las Nieves, University of Granada, Granada, Spain
| | - Alberto Martínez Martínez
- Department of Radiology and Physical Medicine, Hospital Virgen de las Nieves, University of Granada, Granada, Spain
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de Zoete A, de Boer MR, van Tulder MW, Rubinstein SM, Ostelo R. Diagnostic Imaging in Chiropractic Practice: A Survey of Opinions and Self-Reported Guideline Adherence of Dutch and Belgian Chiropractors. J Manipulative Physiol Ther 2022; 45:57-72. [PMID: 35753875 DOI: 10.1016/j.jmpt.2022.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 02/23/2022] [Accepted: 03/08/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The purpose of this study was (1) to describe diagnostic imaging in Dutch and Belgian chiropractic practice in general, (2) to estimate adherence to the diagnostic imaging guidelines for patients with low back pain (LBP) via vignettes, and (3) to evaluate factors associated with diagnostic imaging and adherence to the guidelines. METHODS We used a web-based survey to collect sociodemographic data, practice characteristics, amount of imaging, opinions, and indications for requesting imaging from registered Dutch and Belgian chiropractors in 2013. Additionally, adherence to imaging guidelines for LBP was assessed by 6 vignettes in patients with LBP. Multivariable regression analyses were conducted to explore associations between characteristics of chiropractors and the use of imaging. Generalized mixed models were used to explore guidelines adherence and their relationship with chiropractor's characteristics. RESULTS The overall response rate was 60% (n = 203 out of 340). In total, 83% of chiropractors viewed diagnostic imaging in general as an important part of their practice. It is important to note that Dutch and Belgian chiropractors are not allowed to refer directly for imaging. Chiropractors reported that they would like to have imaging in 42% of their patients. Imaging had already been performed in 37% of patients before the first visit and was ordered by another health care provider (ie, general practitioner or medical specialist). The most common indication for ordering imaging was exclusion of contraindications (73%). The most common reason against imaging was the perceived limited value (45%). Many chiropractors (71%) were familiar with imaging guidelines. Adherence to the imaging guidelines for LBP based upon the vignettes was 66%. Dutch chiropractors and chiropractors with less than 10 years in practice demonstrated better adherence to guidelines and imaging use as compared with Belgian and those with more than 10 years of experience. CONCLUSIONS Most Dutch and Belgian chiropractors reported that imaging in general was important in chiropractic practice. Self-reported indications for ordering diagnostic imaging were in line with the imaging guidelines in the majority of cases. We found some variances between Belgian and Dutch chiropractors and years of experience related to guideline adherence.
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Affiliation(s)
- Annemarie de Zoete
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Michiel R de Boer
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands; Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands; Department Physiotherapy & Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Sidney M Rubinstein
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - Raymond Ostelo
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
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To D, Hall A, Bussières A, French SD, Lawrence R, Pike A, Patey AM, Brake-Patten D, O'Keefe L, Elliott B, De Carvalho D. Exploring factors influencing chiropractors' adherence to radiographic guidelines for low back pain using the Theoretical Domains Framework. Chiropr Man Therap 2022; 30:23. [PMID: 35534902 PMCID: PMC9082849 DOI: 10.1186/s12998-022-00433-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background The inappropriate use of lumbar spine imaging remains common in primary care despite recommendations from evidence-based clinical practice guidelines to avoid imaging in the absence of red flags. This study aimed to explore factors influencing ordering behaviours and adherence to radiographic guidelines for low back pain (LBP) in chiropractors in Newfoundland and Labrador (NL), Canada. Methods We conducted two focus groups in December 2018 with chiropractors in different regions of NL (eastern, n = 8; western, n = 4). An interview guide based on the Theoretical Domains Framework (TDF) served to identify perceived barriers to, and enablers of, target behaviours of guideline adherence and managing LBP without X-rays. We conducted thematic analysis of chiropractors’ statements into relevant theoretical domains, followed by grouping of similar statements into specific beliefs. Domains key to changing radiographic guideline adherence, LBP imaging behaviours, and/or informing intervention design were identified by noting conflicting beliefs and their reported influence on the target behaviours. Results Six of the 14 TDF domains were perceived to be important for adherence to radiographic guidelines and managing non-specific LBP without imaging. Participating chiropractors reported varying levels of knowledge and awareness of guidelines for LBP imaging (Knowledge). Many chiropractors based their decision for imaging on clinical presentation, but some relied on “gut feeling” (Memory, attention, and decision processes). While chiropractors thought it was their role to manage LBP without imaging, others believed ordering imaging was the responsibility of other healthcare providers (Social/professional role and identity). Contrasting views were found regarding the negative consequences of imaging or not imaging LBP patients (Beliefs about consequences). Communication was identified as a skill required to manage LBP without imaging (Skills) and a strategy to enable appropriate imaging ordering behaviours (Behavioural regulation). Chiropractors suggested that access to patients’ previous imaging and a system that facilitated better interprofessional communication would likely improve their LBP imaging behaviours (Behavioural regulation). Conclusion We identified potential influences, in six theoretical domains, on participating chiropractors’ LBP imaging behaviours and adherence to radiographic guidelines. These beliefs may be targets for theory-informed behaviour change interventions aimed at improving these target behaviours for chiropractors in NL. Supplementary Information The online version contains supplementary material available at 10.1186/s12998-022-00433-5.
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Affiliation(s)
- Daphne To
- Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, A1B 3V6, Canada
| | - Amanda Hall
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - André Bussières
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada.,Département chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Simon D French
- Department of Chiropractic, Macquarie University, Sydney, NSW, Australia
| | - Rebecca Lawrence
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Andrea Pike
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Andrea M Patey
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, ON, Canada
| | | | | | - Barbara Elliott
- Patient Engagement Partner, North Bay, ON, Canada.,Faculty of Education and Professional Studies - School of Nursing, Nipissing University, North Bay, ON, Canada
| | - Diana De Carvalho
- Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, A1B 3V6, Canada.
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Kjelle E, Andersen ER, Krokeide AM, Soril LJJ, van Bodegom-Vos L, Clement FM, Hofmann BM. Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review. BMC Med Imaging 2022; 22:73. [PMID: 35448987 PMCID: PMC9022417 DOI: 10.1186/s12880-022-00798-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 04/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children. METHODS A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included. RESULTS A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations. CONCLUSIONS A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally. SYSTEMATIC REVIEW REGISTRATION PROSPERO: CRD42020208072.
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Affiliation(s)
- Elin Kjelle
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway.
| | - Eivind Richter Andersen
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway
| | - Arne Magnus Krokeide
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway
| | - Lesley J J Soril
- Department of Community Health Sciences and The Health Technology Assessment Unit, O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
| | - Leti van Bodegom-Vos
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Fiona M Clement
- Department of Community Health Sciences and The Health Technology Assessment Unit, O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
| | - Bjørn Morten Hofmann
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway
- Centre of Medical Ethics, The University of Oslo, Blindern, Postbox 1130, 0318, Oslo, Norway
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Duarte ST, Nunes C, Costa D, Donato H, Cruz EB. Models of care for low back pain patients in primary healthcare: a scoping review protocol. BMJ Open 2022; 12:e053848. [PMID: 35379620 PMCID: PMC8981342 DOI: 10.1136/bmjopen-2021-053848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Low back pain (LBP) is the most prevalent musculoskeletal condition worldwide and it is responsible for high healthcare costs and resources consumption. It represents a challenge for primary care services that struggle to implement evidence-based practice. Models of care (MoCs) are arising as effective solutions to overcome this problem, leading to better health outcomes. Although there is growing evidence regarding MoCs for the management of LBP patients, an analysis of the existing body of evidence has not yet been carried out. Therefore, this scoping review aims to identify and map the current evidence about the implementation of MoCs for LBP in primary healthcare. Findings from this study will inform policy makers, health professionals and researchers about their characteristics and outcomes, guiding future research and best practice models. METHODS AND ANALYSIS This protocol will follow the Joanna Briggs Institute methodological guidelines for scoping reviews. Studies that implemented an MoC for LBP patients in primary healthcare will be included. Searches will be conducted on PubMed, EMBASE, Cochrane Central Register of Controlled Trials, PEDro, Scopus, Web of Science, grey literature databases and relevant organisations websites. This review will consider records from 2000, written in English, Portuguese or Spanish. Two researchers will independently screen all citations and full-text articles and abstract data. Data extracted will include the identification of the MoC, key elements of the intervention, organisational components, context-specific factors and patient-related, system-related and implementation-related outcomes. ETHICS AND DISSEMINATION As a secondary analysis, this study does not require ethical approval. It will provide a comprehensive understanding on existing MoCs for LBP, outcomes and context-related challenges that may influence implementation in primary healthcare, which is meaningful knowledge to inform future research in this field. Findings will be disseminated through research papers in peer-reviewed journals, presentations at relevant conferences and documentation for professional organisations and stakeholders.
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Affiliation(s)
- Susana Tinoco Duarte
- Comprehensive Health Research Center, NOVA University of Lisbon, Lisboa, Portugal
- National School of Public Health, NOVA University of Lisbon, Lisboa, Portugal
| | - Carla Nunes
- Comprehensive Health Research Center, NOVA University of Lisbon, Lisboa, Portugal
- National School of Public Health, NOVA University of Lisbon, Lisboa, Portugal
| | - Daniela Costa
- Comprehensive Health Research Center, NOVA University of Lisbon, Lisboa, Portugal
- National School of Public Health, NOVA University of Lisbon, Lisboa, Portugal
| | - Helena Donato
- Documentation and Scientific Information Service, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Eduardo B Cruz
- Comprehensive Health Research Center, NOVA University of Lisbon, Lisboa, Portugal
- Physical Therapy Department, Polytechnic Institute of Setúbal, Setubal, Portugal
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Jenkins HJ, Kongsted A, French SD, Jensen TS, Doktor K, Hartvigsen J, Hancock M. Patients with low back pain presenting for chiropractic care who want diagnostic imaging are more likely to receive referral for imaging: a cross-sectional study. Chiropr Man Therap 2022; 30:16. [PMID: 35379281 PMCID: PMC8978373 DOI: 10.1186/s12998-022-00425-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is unclear if the use of imaging for low back pain (LBP) is impacted by patient beliefs. This study aimed to: (1) describe beliefs about the importance of imaging and whether patients wanted imaging when presenting for chiropractic care for LBP; (2) describe associations between baseline patient characteristics and imaging beliefs and whether patients wanted imaging; and (3) determine whether patients who believed imaging to be important in the management of LBP, or who wanted to receive imaging, were more likely to receive an imaging referral. METHODS Cross-sectional observational data was collected between November 2016 to December 2019 from 10 primary care chiropractic clinics in Denmark. Consecutive patients aged 18 or older and presenting with a new episode of LBP were included (N = 2818). Beliefs about the importance of imaging (two questions) and whether imaging was wanted (one question) were collected at the initial visit, together with baseline participant characteristics and whether an imaging referral was provided. Associations between imaging beliefs/desire to receive imaging and participant characteristics were explored using multivariable logistic regression analysis. The relationships between imaging beliefs and desire to receive imaging with subsequent imaging referral were assessed using multivariable logistic regression analysis adjusted for pre-selected confounder variables. RESULTS Approximately one third of participants believed imaging to be important for the management of LBP (29.5% (95%CI 27.8, 31.3) or 41.5% (95%CI 39.6, 43.3) depending on the two imaging beliefs questions). Approximately one quarter (26.1%, 95%CI 24.5, 27.7) of participants wanted to receive an imaging referral. Participants were more likely to believe in the importance of imaging or want an imaging referral if they had a longer duration of LBP, history of previous imaging for LBP, or a lower completed education level. Participants who wanted imaging at the initial consult were more likely to receive an imaging referral (Odds ratio; 95%CI 1.6; 1.2, 2.1). CONCLUSIONS Approximately one third of patients presenting for chiropractic care in Denmark believed imaging to be important in the management of LBP. One quarter wanted imaging at the initial consult. Patients' desire for imaging appeared to impact the use of diagnostic imaging.
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Affiliation(s)
- Hazel J Jenkins
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.
| | - Alice Kongsted
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Chiropractic Knowledge Hub, Odense, Denmark
| | - Simon D French
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Tue Secher Jensen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Chiropractic Knowledge Hub, Odense, Denmark.,Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Klaus Doktor
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Chiropractic Knowledge Hub, Odense, Denmark
| | - Jan Hartvigsen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Chiropractic Knowledge Hub, Odense, Denmark
| | - Mark Hancock
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
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Abstract
OBJECTIVE To examine the effectiveness of implementing interventions to improve guideline-recommended imaging referrals in low back pain. DESIGN Systematic review with meta-analysis. LITERATURE SEARCH We searched MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature, Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials from inception to June 14, 2021, as well as Google Scholar and reference lists of relevant systematic reviews published in the last 10 years. We conducted forward and backward citation tracking. STUDY SELECTION CRITERIA Randomized controlled or clinical trials in adults with low back pain to improve imaging referrals. DATA SYNTHESIS Bias was assessed using the Cochrane Risk of Bias 2 tool. Data were synthesized using narrative synthesis and random-effects meta-analysis (Hartung-Knapp-Sidik-Jonkman method). We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS Of the 2719 identified records, 8 trials were included, with 6 studies eligible for meta-analysis (participants: N = 170 460). All trials incorporated clinician education; 4 included audit and/or feedback components. Comparators were no-intervention control and passive dissemination of guidelines. Five trials were rated as low risk of bias, and 2 trials were rated as having some concerns. There was low-certainty evidence that implementing interventions to improve guideline-recommended imaging referrals had no effect (odds ratio [95% confidence interval]: 0.87 [0.72, 1.05]; I2 = 0%; studies: n = 6). The main finding was robust to sensitivity analyses. CONCLUSION We found low-certainty evidence that interventions to reduce imaging referrals or use in low back pain had no effect. Education interventions are unlikely to be effective. Organizational- and policy-level interventions are more likely to be effective. J Orthop Sports Phys Ther 2022;52(4):175-191. Epub 05 Feb 2022. doi:10.2519/jospt.2022.10731.
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Appropriateness of referrals from primary care for lumbar MRI. Chiropr Man Therap 2022; 30:9. [PMID: 35193634 PMCID: PMC8862387 DOI: 10.1186/s12998-022-00418-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 02/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background International guidelines do not recommend routine imaging, including magnetic resonance imaging (MRI), and seek to guide clinicians only to refer for imaging based on specific indications. Despite this, several studies show an increase in the use of MRI among patients with low back pain (LBP) and an imbalance between appropriate versus inappropriate use of MRI for LBP. This study aimed to investigate to what extent referrals from general practice for lumbar MRI complied with clinical guideline recommendations in a Danish setting, contributing to the understanding and approaches to lumbar MRI for all clinicians managing LBP in the primary sector. Materials and methods From 2014 to 2018, all referrals for lumbar MRI were included from general practitioners in the Central Denmark Region for diagnostic imaging at a public regional hospital. A modified version of the American College of Radiology Imaging Appropriateness Criteria for LBP was used to classify referrals as appropriate or inappropriate, based on the unstructured text in the GPs’ referrals. Appropriate referrals included fractures, cancer, symptoms persisting for more than 6 weeks of non-surgical treatment, previous surgery, candidate for surgery or suspicion of cauda equina. Inappropriate referrals were sub-classified as lacking information about previous non-surgical treatment and duration. Results Of the 3772 retrieved referrals for MRI of the lumbar spine, 55% were selected and a total of 2051 referrals were categorised. Approximately one quarter (24.5%) were categorised as appropriate, and 75.5% were deemed inappropriate. 51% of the inappropriate referrals lacked information about previous non-surgical treatment, and 49% had no information about the duration of non-surgical treatment. Apart from minor yearly fluctuations, there was no change in the distribution of appropriate and inappropriate MRI referrals from 2014 to 2018. Conclusion The majority of lumbar MRI referrals (75.5%) from general practitioners for lumbar MRI did not fulfil the ACR Imaging Appropriateness Criteria for LBP based on the unstructured text of their referrals. There is a need for referrers to include all guideline-relevant information in referrals for imaging. More research is needed to determine whether this is due to patients not fulfilling guideline recommendations or simply the content of the referrals.
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French SD, O’Connor DA, Green SE, Page MJ, Mortimer DS, Turner SL, Walker BF, Keating JL, Grimshaw JM, Michie S, Francis JJ, McKenzie JE. Improving adherence to acute low back pain guideline recommendations with chiropractors and physiotherapists: the ALIGN cluster randomised controlled trial. Trials 2022; 23:142. [PMID: 35164841 PMCID: PMC8842895 DOI: 10.1186/s13063-022-06053-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 01/27/2022] [Indexed: 12/29/2022] Open
Abstract
Background Acute low back pain is a common condition, has high burden, and there are evidence-to-practice gaps in the chiropractic and physiotherapy setting for imaging and giving advice to stay active. The aim of this cluster randomised trial was to estimate the effects of a theory- and evidence-based implementation intervention to increase chiropractors’ and physiotherapists’ adherence to a guideline for acute low back pain compared with the comparator (passive dissemination of the guideline). In particular, the primary aim of the intervention was to reduce inappropriate imaging referral and improve patient low back pain outcomes, and to determine whether this intervention was cost-effective. Methods Physiotherapy and chiropractic practices in the state of Victoria, Australia, comprising at least one practising clinician who provided care to patients with acute low back pain, were invited to participate. Patients attending these practices were included if they had acute non-specific low back pain (duration less than 3 months), were 18 years of age or older, and were able to understand and read English. Practices were randomly assigned either to a tailored, multi-faceted intervention based on the guideline (interactive educational symposium plus academic detailing) or passive dissemination of the guideline (comparator). A statistician independent of the study team undertook stratified randomisation using computer-generated random numbers; four strata were defined by professional group and the rural or metropolitan location of the practice. Investigators not involved in intervention delivery were blinded to allocation. Primary outcomes were X-ray referral self-reported by clinicians using a checklist and patient low back pain-specific disability (at 3 months). Results A total of 104 practices (43 chiropractors, 85 physiotherapists; 755 patients) were assigned to the intervention and 106 practices (45 chiropractors, 97 physiotherapists; 603 patients) to the comparator; 449 patients were available for the patient-level primary outcome. There was no important difference in the odds of patients being referred for X-ray (adjusted (Adj) OR: 1.40; 95% CI 0.51, 3.87; Adj risk difference (RD): 0.01; 95% CI − 0.02, 0.04) or patient low back pain-specific disability (Adj mean difference: 0.37; 95% CI − 0.48, 1.21, scale 0–24). The intervention did lead to improvement for some key secondary outcomes, including giving advice to stay active (Adj OR: 1.96; 95% CI 1.20, 3.22; Adj RD: 0.10; 95% CI 0.01, 0.19) and intending to adhere to the guideline recommendations (e.g. intention to refer for X-ray: Adj OR: 0.27; 95% CI 0.17, 0.44; intention to give advice to stay active: Adj OR: 2.37; 95% CI 1.51, 3.74). Conclusions Intervention group clinicians were more likely to give advice to stay active and to intend to adhere to the guideline recommendations about X-ray referral. The intervention did not change the primary study outcomes, with no important differences in X-ray referral and patient disability between groups, implying that hypothesised reductions in health service utilisation and/or productivity gains are unlikely to offset the direct costs of the intervention. We report these results with the caveat that we enrolled less patients into the trial than our determined sample size. We cannot recommend this intervention as a cost-effective use of resources. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12609001022257. Retrospectively registered on 25 November 2009 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06053-x.
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Beales D, Kent P, Birkrem MB, Man Chow C, Li LK, Tan RLJ, Kendell M, Straker L, O'Sullivan P, Smith A. Only one fifth of young Australian adults have beliefs about medical imaging for low back pain that align with current evidence: A cross-sectional study. Musculoskelet Sci Pract 2021; 56:102460. [PMID: 34547611 DOI: 10.1016/j.msksp.2021.102460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/31/2021] [Accepted: 09/09/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Patients' perceptions/expectations may be a factor behind medical imaging referral rates. Few studies have investigated the beliefs that might drive expectations of medical imaging. OBJECTIVES This study examined whether beliefs of young Australian adults with and without impactful low back pain (LBP) concerning medical scans for LBP align with current evidence. It also investigated if these beliefs were associated with clinical factors (history of impactful LBP, history of previous medical scans, LBP-related disability and the presence of leg pain) or sociodemographic factors (sex, education, income). DESIGN Cross-sectional observational study. METHODS 78 participants from the Raine Study with a history of impactful LBP and 85 participants with no history of impactful LBP completed a study-specific questionnaire with five statements concerning beliefs about medical imaging for LBP. All statements were not aligned with current evidence about the use of medical imaging in LBP management. RESULTS Only 15-21% (n = 24-34) of the participants held beliefs that were aligned with current evidence. Participants with a university education had slightly more aligned beliefs compared to those whose highest education was completing secondary school. There was no difference in the beliefs of participants based on their history of impactful LBP, or other clinical or sociodemographic factors. CONCLUSION As beliefs are likely to drive care-seeking behavior, it is notable that most participants' views about the role of medical imaging for LBP were not aligned with current evidence. Therefore, this suggests a need for community education, especially for those with lower education.
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Affiliation(s)
- Darren Beales
- Curtin EnAble Institute and Curtin School of Allied Health, Curtin University, Perth, Australia.
| | - Peter Kent
- Curtin EnAble Institute and Curtin School of Allied Health, Curtin University, Perth, Australia; Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark.
| | - Magnus B Birkrem
- Curtin EnAble Institute and Curtin School of Allied Health, Curtin University, Perth, Australia.
| | - Cheuk Man Chow
- Curtin EnAble Institute and Curtin School of Allied Health, Curtin University, Perth, Australia.
| | - Lap Kiu Li
- Curtin EnAble Institute and Curtin School of Allied Health, Curtin University, Perth, Australia.
| | - Rui Ling Joleen Tan
- Curtin EnAble Institute and Curtin School of Allied Health, Curtin University, Perth, Australia.
| | - Michelle Kendell
- Curtin EnAble Institute and Curtin School of Allied Health, Curtin University, Perth, Australia.
| | - Leon Straker
- Curtin EnAble Institute and Curtin School of Allied Health, Curtin University, Perth, Australia.
| | - Peter O'Sullivan
- Curtin EnAble Institute and Curtin School of Allied Health, Curtin University, Perth, Australia.
| | - Anne Smith
- Curtin EnAble Institute and Curtin School of Allied Health, Curtin University, Perth, Australia.
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Shraim BA, Shraim MA, Ibrahim AR, Elgamal ME, Al-Omari B, Shraim M. The association between early MRI and length of disability in acute lower back pain: a systematic review and narrative synthesis. BMC Musculoskelet Disord 2021; 22:983. [PMID: 34819061 PMCID: PMC8614033 DOI: 10.1186/s12891-021-04863-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/08/2021] [Indexed: 01/07/2023] Open
Abstract
Background Clinical guideline recommendations are against early magnetic resonance imaging (eMRI) within the first 4 to 6 weeks of conservative management of acute low back pain (LBP) without “clinical suspicion” of serious underlying conditions (red flags). There is some limited evidence that a significant proportion of patients with LBP receive eMRI non- indicated by clinical guidelines, which could be associated with increased length of disability (LOD). The aim of this systematic review was to investigate whether eMRI for acute LBP without red flags is associated with increased LOD. The LOD was defined as the number of disability days (absence from work). Methods Medline, EMBASE, and CINAHL bibliographic databases were searched from inception until June 5, 2021. Two reviewers independently assessed the methodological quality of included studies using the Newcastle–Ottawa scale and extracted data for the review. The search identified 324 records, in which seven studies met the inclusion criteria. Three of the included studies used the same study population. Owing to between-study heterogeneity, a narrative synthesis of results was used. Results All included studies were of good methodological quality and consistently reported that patients with acute LBP without red flags who received eMRI had increased LOD compared to those who did not receive eMRI. Three retrospective cohort studies reported that the eMRI groups had a higher mean LOD than the no eMRI groups ranging from 9.4 days (95% CI 8.5, 10.2) to 13.7 days (95% CI 13.0, 14.5) at the end of 1-year follow-up period. The remaining studies reported that the eMRI groups had a higher hazard ratio of work disability ranging between 1.75 (95% CI 1.23, 2.50) and 3.57 (95% CI 2.33, 5.56) as compared to the no eMRI groups. Conclusion eMRI is associated with increased LOD in patients with acute LBP without red flags. Identifying reasons for performing non-indicated eMRI and addressing them with quality improvement interventions may improve adherence to clinical guidelines and improve disability outcomes among patients with LBP. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04863-9.
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Affiliation(s)
- Bara A Shraim
- College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Muath A Shraim
- NHMRC Centre of Clinical Research Excellence in Spinal Pain, Injury & Health, School of Health & Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, 4072, Australia
| | - Ayman R Ibrahim
- College of Medicine, QU Health, Qatar University, Doha, Qatar
| | | | - Basem Al-Omari
- College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates.,KU Research and Data Intelligence Support Center (RDISC) AW 8474000331, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
| | - Mujahed Shraim
- Department of Public Health, College of Health Sciences, Qatar University, QU Health, Doha, Qatar.
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Jenkins HJ, Kongsted A, French SD, Jensen TS, Doktor K, Hartvigsen J, Hancock M. What are the effects of diagnostic imaging on clinical outcomes in patients with low back pain presenting for chiropractic care: a matched observational study. Chiropr Man Therap 2021; 29:46. [PMID: 34814923 PMCID: PMC8611826 DOI: 10.1186/s12998-021-00403-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/11/2021] [Indexed: 12/29/2022] Open
Abstract
Background Evidence suggests that diagnostic imaging for low back pain does not improve care in the absence of suspicion of serious pathology. However, the effect of imaging use on clinical outcomes has not been investigated in patients presenting to chiropractors. The aim of this study was to determine if diagnostic imaging affects clinical outcomes in patients with low back pain presenting for chiropractic care. Methods A matched observational study using prospective longitudinal observational data with one year follow up was performed in primary care chiropractic clinics in Denmark. Data was collected from November 2016 to December 2019. Participants included low back pain patients presenting for chiropractic care, who were either referred or not referred for diagnostic imaging during their initial visit. Patients were excluded if they were less than 18 years old, had a diagnosis of underlying pathology, or had previous imaging relevant to their current clinical presentation. Coarsened exact matching was used to match participants referred for diagnostic imaging with participants not referred for diagnostic imaging on baseline variables including participant demographics, pain characteristics, and clinical history. Mixed linear and logistic regression models were used to assess the effect of imaging on back pain intensity and disability at two-weeks, three-months, and one-year, and on global perceived effect and satisfaction with care at two-weeks. Results 2162 patients were included, with 24.1% referred for imaging. Near perfect balance between matched groups was achieved for baseline variables except age and leg pain. Participants referred for imaging had slightly higher back pain intensity at two-weeks (0.4, 95%CI: 0.1, 0.8) and one-year (0.4, 95%CI: 0.0, 0.7), and disability at two-weeks (5.7, 95%CI: 1.4, 10.0), but the changes are unlikely to be clinically meaningful. No difference between groups was found for the other outcome measures. Similar results were found when sensitivity analysis, adjusted for age and leg pain intensity, was performed. Conclusions Diagnostic imaging did not result in better clinical outcomes in patients with low back pain presenting for chiropractic care. These results support that current guideline recommendations against routine imaging apply equally to chiropractic practice.
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Affiliation(s)
- Hazel J Jenkins
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Rm 347, 17 Wally's Walk, Sydney, 2109, Australia.
| | - Alice Kongsted
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Chiropractic Knowledge Hub, Odense, Denmark
| | - Simon D French
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Rm 347, 17 Wally's Walk, Sydney, 2109, Australia
| | - Tue Secher Jensen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Chiropractic Knowledge Hub, Odense, Denmark.,Diagnostic Centre - Imaging Section, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Klaus Doktor
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Chiropractic Knowledge Hub, Odense, Denmark
| | - Jan Hartvigsen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Chiropractic Knowledge Hub, Odense, Denmark
| | - Mark Hancock
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Rm 347, 17 Wally's Walk, Sydney, 2109, Australia
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Di Gangi S, Bagnoud C, Pichierri G, Rosemann T, Plate A. Treatment Patterns in Patients with Diagnostic Imaging for Low Back Pain: A Retrospective Observational Study. J Pain Res 2021; 14:3109-3120. [PMID: 34675640 PMCID: PMC8504656 DOI: 10.2147/jpr.s328033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/22/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Low back pain (LBP) is one of the most frequent reasons for medical consultations. Literature suggests a large evidence-performance gap, especially regarding pain management. Therefore, the monitoring of treatment patterns is important to ensure high quality of treatment. This study aimed to describe treatment patterns specific to patients with diagnostic imaging of the spine for LBP. Patients and Methods The study was retrospective observational and based on health claims data from 2015 to 2019 provided by a Swiss health insurance company covering around 12% of the population. Patients, ≥18 years of age, with diagnostic imaging of the spine were included and observed 12 months before and after imaging. Patients with back surgery or comorbidities associated with the use of pain medications were excluded. Results In total, 60,822 patients (mean age: 53.5 y, 56.1% female) were included and 85% received at least one pain medication. Of these, non-steroidal anti-inflammatory drugs, paracetamol, or opioids were prescribed in 88.6%, 70.7%, and 40.3% of patients, respectively. Strong opioids were used in 17% of patients given opioids. Patients with combinations of diagnostic imaging methods had the highest odds of receiving pain medication prescriptions (1.81, 95% CI: 1.66, 1.96, P < 0.001). Prescribed defined daily doses corresponded to short-term therapies. Conclusion Although the majority of patients received non-opioid short-term therapies, we found a substantial use of opioids, and in particular, a relative high usage of strong opioids. Our results highlighted the importance of both patient and healthcare provider awareness regarding the prudent treatment of LBP.
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Affiliation(s)
- Stefania Di Gangi
- Institute of Primary Care, University and University Hospital Zurich, Zürich, Switzerland
| | | | - Giuseppe Pichierri
- Institute of Primary Care, University and University Hospital Zurich, Zürich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University and University Hospital Zurich, Zürich, Switzerland
| | - Andreas Plate
- Institute of Primary Care, University and University Hospital Zurich, Zürich, Switzerland
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Simula AS, Jenkins HJ, Hancock MJ, Malmivaara A, Booth N, Karppinen J. Patient education booklet to support evidence-based low back pain care in primary care - a cluster randomized controlled trial. BMC FAMILY PRACTICE 2021; 22:178. [PMID: 34493219 PMCID: PMC8422671 DOI: 10.1186/s12875-021-01529-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 08/19/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Inappropriate imaging and low-value care for low back pain (LBP) are common. A new patient-education booklet was created to overcome identified barriers to the delivery of recommended care, including the use of inappropriate imaging. Our aim was to assess the effectiveness of this booklet as part of primary care for LBP patients in comparison to usual care. METHODS A cluster-randomized trial was performed. The intervention involved providing practitioners with the new patient-education booklet and a 30-min training session on its use. The booklet was provided during the clinical consult to all consenting LBP patients in the intervention group. Primary outcomes were the proportion of patients presenting with LBP who underwent imaging examinations during the first three months of follow-up and PROMIS PF-20 (Patient-Reported Outcomes Measurement Information System, 20-item physical functioning short form) change between baseline and three-month follow-up. Secondary outcomes, including sick leave and imaging examinations at 12 months, were investigated. Logistic regression using GEE-estimation was used for dichotomous outcomes, Poisson regression using GEE-estimation for count outcomes, and linear mixed models for continuous outcomes. RESULTS Using the patient education booklet appeared to substantially reduce the proportion of LBP patients who underwent an imaging examination at three months, but the result was not statistically significant (OR 0.57, 95% confidence interval (Cl) 0.27 to 1.22). At 12 months, the effect was slightly larger and statistically significant (OR 0.50, 95%Cl 0.30 to 0.83, p = 0.008). No difference was observed in the PROMIS PF-20 T-score change between baseline and 3 months or 12 months (p = 0.365 and p = 0.923, respectively). The number of sick leave days in the intervention group was less than that in the control group at 3 months (RR 0.47, 95%Cl 0.26 to 0.83, p = 0.010) and at 12 months (RR 0.36, 95%Cl 0.18 to 0.72, p = 0.004). CONCLUSIONS The booklet appeared to be effective in reducing the proportion of LBP patients who underwent imaging examinations over 12 months. The intervention had no discernible effect on the PROMIS PF20 T-score change. The number of sick leave days was substantially lower in the intervention group. TRIAL REGISTRATION ISRCTN, ISRCTN14389368 , Registered 4 April 2019-Retrospectively registered.
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Affiliation(s)
- Anna S Simula
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, P.O. Box 8000, 90014, Oulu, Finland. .,Department of General Medicine, the South Savo Social and Health Care Authority, Porrassalmenkatu 35-37, 50100, Mikkeli, Finland.
| | - Hazel J Jenkins
- Department of Health Professions, Faculty of Medicine, Health, and Human Sciences, Macquarie University, Balaclava Road, North Ryde, NSW, 2109, Australia.,Department of Chiropractic, Faculty of Medicine, Health, and Human Sciences, Macquarie University, Balaclava Road, North Ryde, NSW, 2109, Australia
| | - Mark J Hancock
- Department of Health Professions, Faculty of Medicine, Health, and Human Sciences, Macquarie University, Balaclava Road, North Ryde, NSW, 2109, Australia
| | - Antti Malmivaara
- Finnish Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland
| | - Neill Booth
- Faculty of Social Sciences (Health Sciences), Tampere University, Arvo Ylpön katu 34, 33014, Tampere, Finland
| | - Jaro Karppinen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, P.O. Box 8000, 90014, Oulu, Finland.,Finnish Institute of Occupational Health, Aapistie 1, 90220, Oulu, Finland.,Rehabilitation Services of South Karelia Social and Health Care District, Lappeenranta, Finland
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Impacts of a Re-designed Care Path for Back Pain Directing Patients to Physiotherapists: A Pre-Post Intervention Study. J Occup Environ Med 2021; 63:e276-e282. [PMID: 33605653 DOI: 10.1097/jom.0000000000002178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate impact of directing patients with back pain for first visit to a physiotherapist on sick leaves, healthcare utilization, and patient satisfaction. METHODS Pre-post intervention study of 70,138 patients treated in Poland for back pain: 27,034 before the care pathway redesign and 43,104 after. RESULTS After the redesign, all per-patient measures (mean ± SD) significantly decreased over the 12-month follow-up: sick leaves number from 0.32 ± 0.87 to 0.29 ± 0.86, sick leaves days from 2.78 ± 11.56 to 2.56 ± 11.25, doctors' visits from 2.02 ± 1.70 to 1.51 ± 1.63, diagnostic imaging services from 0.63 ± 0.79 to 0.43 ± 0.71 and rehabilitation services from 7.55 ± 14.90 to 4.70 ± 12.61.The Net Promoter Score was higher for physiotherapist (83), than for orthopedists (59), primary care (74), or neurologists (67). CONCLUSIONS Involving physiotherapists early in the back pain care may result in benefits for patients and healthcare organizations.
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Traeger AC, Machado GC, Bath S, Tran M, Roper L, Oliveira C, Peek A, Coombs D, Hall A, Tcharkhedian E, Maher CG. Appropriateness of imaging decisions for low back pain presenting to the emergency department: a retrospective chart review study. Int J Qual Health Care 2021; 33:6321318. [PMID: 34260690 DOI: 10.1093/intqhc/mzab103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/03/2021] [Accepted: 07/13/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Imaging for low back pain is widely regarded as a target for efforts to reduce low-value care. OBJECTIVE We aimed to estimate the prevalence of the overuse and underuse of lumbar imaging in patients presenting with low back pain to the emergency department (ED). METHODS This was a retrospective chart review study of five public hospital EDs in Sydney, Australia, in 2019-20. We reviewed the clinical charts of consecutive adult patients who presented with a complaint of low back pain and extracted clinical features relevant to a decision to request lumbar imaging. We estimated the proportion of encounters where a decision to request lumbar imaging was inappropriate (overuse) or where a clinician did not request an appropriate and informative lumbar imaging test when indicated (underuse). RESULTS Six hundred and forty-nine patients presented with a complaint of low back pain, of which 158 (24.3%) were referred for imaging. Seventy-nine (12.2%) had a combination of features suggesting that lumbar imaging was indicated according to clinical guidelines. The prevalence of overuse and underuse of lumbar imaging was 8.8% (57 of 649 cases, 95% CI 6.8-11.2%) and 4.3% (28 of 649 cases, 95% CI 3.0-6.1%), respectively. Thirteen cases were classified as underuse because the patients were referred for uninformative imaging modalities (e.g. referred for radiography for suspected cauda equina syndrome). CONCLUSION In this study of emergency care, there was evidence of not only overuse of lumbar imaging but also underuse through failure to request lumbar imaging when indicated or referral for an uninformative imaging modality. These three issues seem more important targets for quality improvement than solely focusing on overuse.
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Affiliation(s)
- Adrian C Traeger
- Faculty of Medicine and Health, Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), PO Box M179, Missenden Road, Sydney, NSW 2050, Australia
| | - Gustavo C Machado
- Faculty of Medicine and Health, Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), PO Box M179, Missenden Road, Sydney, NSW 2050, Australia
| | - Sally Bath
- Faculty of Medicine and Health, Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), PO Box M179, Missenden Road, Sydney, NSW 2050, Australia
| | - Martin Tran
- Faculty of Medicine and Health, Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), PO Box M179, Missenden Road, Sydney, NSW 2050, Australia
| | - Lucinda Roper
- Faculty of Medicine and Health, Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), PO Box M179, Missenden Road, Sydney, NSW 2050, Australia
| | - Crystian Oliveira
- Faculty of Medicine and Health, Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), PO Box M179, Missenden Road, Sydney, NSW 2050, Australia.,Physical Therapy Department, Faculty of Science and Technology, Sao Paulo State University, Presidente Prudente, R. Roberto Símonsen, 305 - Centro Educacional, Pres. Prudente - SP 19060-900, Brazil
| | - Aimie Peek
- Faculty of Medicine and Health, Sydney School of Health Sciences, The University of Sydney, Susan Wakil Building, Western Ave, Camperdown NSW 2050, Australia
| | - Danielle Coombs
- Faculty of Medicine and Health, Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), PO Box M179, Missenden Road, Sydney, NSW 2050, Australia
| | - Amanda Hall
- Faculty of Medicine, Memorial University, 300 Prince Philip Dr, St. John's, NL A1B 3V6, Canada
| | - Elise Tcharkhedian
- Physiotherapy Department, Liverpool Hospital, Southwest Sydney Local Health District, Liverpool, 75 Elizabeth St, Liverpool NSW 2170, Australia
| | - Chris G Maher
- Faculty of Medicine and Health, Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), PO Box M179, Missenden Road, Sydney, NSW 2050, Australia
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Sajid IM, Parkunan A, Frost K. Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care. BMJ Open Qual 2021; 10:e001287. [PMID: 34215659 PMCID: PMC8256731 DOI: 10.1136/bmjoq-2020-001287] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 06/07/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES The largest proportion of general practitioner (GP) magnetic resonance imaging (MRI) is musculoskeletal (MSK), with consistent annual growth. With limited supporting evidence and potential harms from early imaging overuse, we evaluated practice to improve pathways and patient safety. METHODS Cohort evaluation of routinely collected diagnostic and general practice data across a UK metropolitan primary care population. We reviewed patient characteristics, results and healthcare utilisation. RESULTS Of 306 MSK-MRIs requested by 107 clinicians across 29 practices, only 4.9% (95% CI ±2.4%) appeared clearly indicated and only 16.0% (95% CI ±4.1%) received appropriate prior therapy. 37.0% (95% CI ±5.5%) documented patient imaging request. Most had chronic symptoms and half had psychosocial flags. Mental health was addressed in only 11.8% (95% CI ±6.3%) of chronic sufferers with psychiatric illness, suggesting a solely pathoanatomical approach to MSK care. Only 7.8% (95% CI ±3.0%) of all patients were appropriately managed without additional referral. 1.3% (95% CI ±1.3%) of scans revealed diagnoses leading to change in treatment (therapeutic yield). Most imaged patients received pathoanatomical explanations to their symptoms, often based on expected age or activity-related changes. Only 16.7% (95% CI ±4.2%) of results appeared correctly interpreted by GPs, with spurious overperception of surgical targets in 65.4% (95% CI ±5.3%) who suffered 'low-value' (ineffective, harmful or wasteful) post-MRI referral cascades due to misdiagnosis and overdiagnosis. Typically, 20%-30% of GP specialist referrals convert to a procedure, whereas MRI-triggered referrals showed near-zero conversion rate. Imaged patients experienced considerable delay to appropriate care. Cascade costs exceeded direct-MRI costs and GP-MSK-MRI potentially more than doubles expenditure compared with physiotherapist-led assessment services, for little-to-no added therapeutic yield, unjustifiable by cost-consequence or cost-utility analysis. CONCLUSION Unfettered GP-MSK-MRI use has reached unaccceptable indication creep and disutility. Considerable avoidable harm occurs through ubiquitous misinterpretation and salient low-value referral cascades for two-thirds of imaged patients, for almost no change in treatment. Any marginally earlier procedural intervention for a tiny fraction of patients is eclipsed by negative consequences for the vast majority. Only 1-2 patients need to be scanned for one to suffer mismanagement. Direct-access imaging is neither clinically, nor cost-effective and deimplementation could be considered in this setting. GP-MSK-MRI fuels unnecessary healthcare utilisation, generating nocebic patient beliefs and expectations, whilst appropriate care is delayed and a high burden of psychosocial barriers to recovery appear neglected.
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Affiliation(s)
- Imran Mohammed Sajid
- NHS West London Clinical Commissioning Group, London, UK
- University of Global Health Equity, Kigali, Rwanda
| | - Anand Parkunan
- Healthshare Community NHS Musculoskeletal Services, London, UK
| | - Kathleen Frost
- NHS Central London Clinical Commissioning Group, London, UK
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To D, De Carvalho D, Pike A, Etchegary H, Patey A, Toomey E, Hall A. Exploring perceived barriers and enablers to fidelity of training and delivery of an intervention to reduce imaging for low back pain: a qualitative interview study protocol. HRB Open Res 2021. [DOI: 10.12688/hrbopenres.13292.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background: Diagnostic imaging has limited utility in the assessment and management of non-specific low back pain (LBP), but remains commonly used in clinical practice. Interventions have been designed to reduce non-indicated imaging for LBP; however, evidence of effectiveness has been variable. It is unclear whether intervention fidelity was adequately assessed in these interventions, which may have an impact on the interpretation of trial results. Within implementation research, intervention fidelity refers to the degree to which an intervention was delivered as intended and to the strategies used to monitor and enhance this process. Intervention fidelity covers five domains: design, training, delivery, receipt, and enactment. Objectives: The objectives of this study are to explore perceived barriers and enablers to fidelity of training and delivery of a proposed theory-informed intervention aimed at reducing non-indicated imaging for LBP by general practitioners (GPs) and chiropractors in Newfoundland and Labrador (NL), Canada. Methods: Semi-structured interviews will be conducted with GPs and chiropractors in NL to explore their views on barriers and enablers towards enhancing and/or assessing fidelity of training and delivery. Interviews will be audio-recorded, transcribed verbatim, and analysed with the Theoretical Domains Framework. Relevant domains related to perceived barriers and enablers will be identified by: the frequency of beliefs; the presence of conflicting beliefs; and the perceived strength of the impact a belief may have on the target behaviours. Discussion: Results of this study will aid in the development of a fidelity protocol for an upcoming cluster randomised controlled trial of a theory-informed intervention aimed at reducing non-indicated imaging for LBP. Our results may help to ensure that the proposed intervention will be delivered with good fidelity and that fidelity can be appropriately assessed.
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48
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Krogh SB, Jensen TS, Rolving N, Laursen M, Thomsen JNL, Hansen CB, Werenberg CH, Rasmussen E, Carlson R, Jensen RK. Categorisation of lumbar spine MRI referrals in Denmark as compliant or non-compliant to international imaging guidelines: an inter-rater reliability study. Chiropr Man Therap 2021; 29:12. [PMID: 33761956 PMCID: PMC7988995 DOI: 10.1186/s12998-021-00370-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Managing low back pain (LBP) often involves MRI despite the fact that international guidelines do not recommend routine imaging. To allow us to explore the topic and use this knowledge in further research, a reliable method to review the MRI referrals is needed. Consequently, this study aimed to assess the inter-rater reliability of a method evaluating lumbar spine MRI referrals' appropriateness. METHODS Four inexperienced students (chiropractic master's students) and a senior clinician (chiropractor) were included as independent raters in this inter-rater reliability study. Lumbar spine MRI referrals from primary care on patients (> 18 years) with LBP with or without leg pain were included. The referrals were classified using a modified version of the American College of Radiology (ACR) imaging appropriateness criteria for LBP. Categories of appropriate referrals included; fractures, cancer, previous surgery, candidate for surgery or suspicion of cauda equina. Inappropriate referrals included lacking information on previous non-surgical treatment, no word on non-surgical treatment duration, or "other reasons" for inappropriate referrals. After two rounds of training and consensus sessions, 50 lumbar spine MRI referrals were reviewed independently by the five raters. Inter-rater reliability was quantified using unweighted Kappa statistics, and the observed agreement was calculated with both a pairwise comparison and an overall five-rater comparison. RESULTS Inter-rater reliability was substantial, with a Kappa value for appropriate vs. inappropriate referrals of 0.76 (95% CI: 0.55-0.89). When six and eight subcategories were evaluated, the Kappa values were 0.77 (95% CI: 0.58-0.91) and 0.82 (95% CI: 0.72-0.92), respectively. The overall percentage of agreement for appropriate and inappropriate referrals was 92% and ranged from 88 to 98% for the pairwise comparisons of the five raters' results. For the six and eight subcategories, the overall agreement was 92 and 88%, respectively, ranging from 88 to 98% and 84-92%, respectively, for the pairwise comparisons. CONCLUSION The inter-rater reliability of the evaluation of the appropriateness of lumbar spine MRI referrals, according to the modified ACR-appropriateness criteria, was found to range from substantial to almost perfect and can be used for research and quality assurance purposes.
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Affiliation(s)
| | - Tue Secher Jensen
- Department of Diagnostic Imaging, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Chiropractic Knowledge Hub, Odense, Denmark
| | | | - Malene Laursen
- Research Unit, Centre of Elective Surgery, Regional Hospital of Silkeborg, Silkeborg, Denmark
| | | | - Casper Brink Hansen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Christoffer Høj Werenberg
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Erik Rasmussen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Rune Carlson
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Rikke Krüger Jensen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.,Chiropractic Knowledge Hub, Odense, Denmark
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Affiliation(s)
- Amanda M Hall
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St John's, Newfoundland A1B 3V6, Canada
| | - Kris Aubrey-Bassler
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St John's, Newfoundland A1B 3V6, Canada
| | - Bradley Thorne
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St John's, Newfoundland A1B 3V6, Canada
| | - Chris G Maher
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Sydney, Australia
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De Carvalho D, Bussières A, French SD, Wade D, Brake-Patten D, O'Keefe L, Elliott B, Budgell K, O'Reilly S, To D, Hall A. Knowledge of and adherence to radiographic guidelines for low back pain: a survey of chiropractors in Newfoundland and Labrador, Canada. Chiropr Man Therap 2021; 29:4. [PMID: 33461555 PMCID: PMC7812732 DOI: 10.1186/s12998-020-00361-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/20/2020] [Indexed: 12/19/2022] Open
Abstract
Background Low back pain (LBP) rarely requires routine imaging of the lumbar spine in the primary care setting, as serious spinal pathology is rare. Despite evidence-based clinical practice guidelines recommending delaying imaging in the absence of red flags, chiropractors commonly order imaging outside of these guidelines. The purpose of this study was to survey chiropractors to determine the level of knowledge, adherence to, and beliefs about, clinical practice guidelines related to the use of lumbar radiography for LBP in Newfoundland and Labrador (NL), Canada. Methods A cross-sectional survey of chiropractors in NL (n = 69) was conducted between May and June 2018, including questions on demographics, awareness of radiographic guidelines, and beliefs about radiographs for LBP. We assessed behavioural simulation using clinical vignettes to determine levels of adherence to LBP guideline recommendations. Results The response rate was 77% (n = 53). Half of the participants stated they were aware of current radiographic guideline recommendations, and one quarter of participants indicated they did not use guidelines to inform clinical decisions. The majority of participants agreed that x-rays of the lumbar spine are useful for patients with suspected pathology, are indicated when a patient is non-responsive to 4 weeks of conservative treatment for LBP, and when there are neurological signs associated with LBP. However, a small proportion indicated that there is a role for full spine x-rays (~ 21%), x-rays to evaluate patients with acute LBP (~ 13%), and that patient expectations play a role in decision making (4%). Adherence rate to radiographic guidelines measured using clinical vignettes was 75%. Conclusions While many chiropractors in this sample reported being unsure of specific radiographic guidelines, the majority of respondents adhered to guideline recommendations measured using clinical vignettes. Nonetheless, a small proportion still hold beliefs about radiographs for LBP that are discordant with current radiographic guidelines. Future research should aim to determine barriers to guideline uptake in this population in order to design and evaluate tailored knowledge translation strategies to reduce unnecessary LBP imaging. Supplementary Information The online version contains supplementary material available at 10.1186/s12998-020-00361-2.
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Affiliation(s)
- Diana De Carvalho
- Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, A1B 3V6, Canada.
| | - André Bussières
- School of Physical and Occupational Therapy, McGill University, Montréal, QC, Canada.,Département chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Simon D French
- Department of Chiropractic, Macquarie University, Sydney, New South Wales, Australia
| | | | | | | | - Barbara Elliott
- Patient Engagement Partner, North Bay, ON, Canada.,Faculty of Education and Professional Studies - School of Nursing, Nipissing University, North Bay, ON, Canada
| | | | - Sara O'Reilly
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Daphne To
- Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, A1B 3V6, Canada
| | - Amanda Hall
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
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