USA: Study on Reducing Unnecessary Imaging for Low Back Pain

A recent study has revealed that in patients presenting with low back pain, a relatively simple electronic health record (EHR) intervention was shown to reduce the incidence of unnecessary X-rays by 53% among inpatients.

"Our intervention successfully reduced across all clinical settings, with a reduction in lumbar computed tomography (CTs) in the ambulatory and inpatient settings," Surafel Tsega, Office of Quality and Patient Safety, NYC Health + Hospitals, New York, NY, and colleagues wrote in their study published in the Journal of the American College of Radiology. No changes were observed for lumbar MRI (magnetic resonance imaging) orders.

Low back pain is a common presentation that often leads to expensive and unnecessary imaging resulting in undue patient harm, including radiation exposure, and potentially unnecessary surgical procedures with associated emotional distress and morbidity.

Tsega and the team present an initiative in a safety net system to reduce imaging for low back pain based on a quality improvement study conducted across quality improvement study and 70 ambulatory clinics.

Three EHR changes, utilizing the concept of a nudge, were introduced into orders for lumbar radiography (X-ray), lumbar MRI, and lumbar computed tomography.

The primary outcome of the study was determined as the number of orders per 1000 patient days or encounters for each imaging test in the ambulatory, inpatient, and ED (emergency department) settings. Variation across facilities was evaluated, along with selected indications.

Study Findings

• Across all clinical environments, there were statistically significant decreases in level differences pre- and post-intervention for lumbar X-rays (-52.9% for inpatient encounters; -23.7% for ambulatory encounters; and -17.3% for ED-only encounters).
• There was no decrease in ordering of lumbar CTs in the inpatient and ambulatory settings, though, there was an increase in lumbar CTs in ED-only encounters.
• There was no difference in lumbar MRI ordering.
• Variation was seen across all hospitals and clinics.

"We speculate that before our intervention, clinicians may have considered X-rays less harmful, low-cost, and easier to obtain compared to CTs or MRIs," the authors wrote. "This may have led to excessive use of X-rays as a first-line evaluation for back pain. This instance of supply sensitive overuse may have created greater opportunities in reducing potentially unnecessary imaging for X-rays versus CT or MRI."

According to the authors, the study will prompt the development of other interventions.

The authors concluded, "Future initiatives can expand on this model by offering a more robust analysis of the reduction in potentially unnecessary lumbar imaging."

Reference

Surafel Tsega et al. “Imaging Wisely Campaign: Initiative to Reduce Imaging for Low Back Pain Across a Large Safety Net System.” Journal of the American College of Radiology. July 27, 2023.