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Mekonnen TH, Di Donato M, Collie A, Russell G. Time to Service and Its Relationship with Outcomes in Workers with Compensated Musculoskeletal Conditions: A Scoping Review. JOURNAL OF OCCUPATIONAL REHABILITATION 2024; 34:522-554. [PMID: 38214782 PMCID: PMC11364620 DOI: 10.1007/s10926-023-10160-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 01/13/2024]
Abstract
PURPOSE A comprehensive review of the literature on the time between the onset of symptoms and the first episode of care and its effects on important worker outcomes in compensated musculoskeletal conditions is currently lacking. This scoping review aimed to summarize the factors associated with time to service and describe outcomes in workers with workers' compensation accepted claims for musculoskeletal conditions. METHODS We used the JBI guidelines for scoping reviews and reported following the PRISMA-ScR protocol. We included peer-reviewed articles published in English that measured the timing of health service initiation. We conducted searches in six databases, including Medline (Ovid), Embase (Ovid), PsycINFO, Cinahl Plus (EBSCOhost), Scopus, and the Web of Science. Peer-reviewed articles published up to November 01, 2022 were included. The evidence was summarized using a narrative synthesis. RESULTS Out of the 3502 studies identified, 31 were included. Eight studies reported the factors associated with time to service. Male workers, availability of return to work programmes, physically demanding occupations, and greater injury severity were associated with a shorter time to service, whereas female workers, a high number of employees in the workplace, and having legal representation were associated with a longer time to service. The relationship between time service and worker outcomes was observed in 25 studies, with early access to physical therapy and biopsychosocial interventions indicating favourable outcomes. Conversely, early opioids, and MRI in the absence of severe underlying conditions were associated with a longer duration of disability, higher claim costs, and increased healthcare utilization. CONCLUSION Existing evidence suggests that the time to service for individuals with compensated musculoskeletal conditions was found to be associated with several characteristics. The relationship between time to service and worker outcomes was consistently indicated in the majority of the studies. This review highlights the need to consider patient-centred treatments and develop strategies to decrease early services with negative effects and increase access to early services with better outcomes.
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Affiliation(s)
- Tesfaye Hambisa Mekonnen
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, 3004, Australia.
| | - Michael Di Donato
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, 3004, Australia
| | - Alex Collie
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, 3004, Australia
| | - Grant Russell
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, 3004, Australia
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Sears JM, Wickizer TM, Franklin GM, Fulton-Kehoe D, Hannon PA, Harris JR, Graves JM, McGovern PM. Development and maturation of the occupational health services research field in the United States over the past 25 years: Challenges and opportunities for the future. Am J Ind Med 2023; 66:996-1008. [PMID: 37635638 DOI: 10.1002/ajim.23532] [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: 05/09/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 08/29/2023]
Abstract
Work is an important social determinant of health; unfortunately, work-related injuries remain prevalent, can have devastating impact on worker health, and can impose heavy economic burdens on workers and society. Occupational health services research (OHSR) underpins occupational health services policy and practice, focusing on health determinants, health services, healthcare delivery, and health systems affecting workers. The field of OHSR has undergone tremendous expansion in both definition and scope over the past 25 years. In this commentary, focusing on the US, we document the historical development and evolution of OHSR as a research field, describe current doctoral-level OHSR training, and discuss challenges and opportunities for the OHSR field. We also propose an updated definition for the OHSR field: Research and evaluation related to the determinants of worker health and well-being; to occupational injury and illness prevention and surveillance; to healthcare, health programs, and health policy affecting workers; and to the organization, access, quality, outcomes, and costs of occupational health services and related health systems. Researchers trained in OHSR are essential contributors to improvements in healthcare, health systems, and policy and programs to improve worker health and productivity, as well as equity and justice in job and employment conditions. We look forward to the continued growth of OHSR as a field and to the expansion of OHSR academic training opportunities.
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Affiliation(s)
- Jeanne M Sears
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington, USA
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA
- Harborview Injury Prevention and Research Center, Seattle, Washington, USA
- Institute for Work and Health, Toronto, Ontario, Canada
| | - Thomas M Wickizer
- Division of Health Services Management and Policy, The Ohio State University, Columbus, Ohio, USA
| | - Gary M Franklin
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington, USA
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA
- Department of Neurology, University of Washington, Seattle, Washington, USA
- Washington State Department of Labor and Industries, Tumwater, Washington, USA
| | - Deborah Fulton-Kehoe
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA
| | - Peggy A Hannon
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington, USA
- Health Promotion Research Center, University of Washington, Seattle, Washington, USA
| | - Jeffrey R Harris
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington, USA
- Health Promotion Research Center, University of Washington, Seattle, Washington, USA
| | - Janessa M Graves
- College of Nursing, Washington State University, Spokane, Washington, USA
| | - Patricia M McGovern
- Division of Environmental Health Sciences, University of Minnesota, Minneapolis, Minnesota, USA
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Martel Villagrán J, Martínez-Sánchez RT, Cebada-Chaparro E, Bueno Horcajadas AL, Pérez-Fernández E. Diagnostic accuracy of lumbar CT and MRI in the evaluation of chronic low back pain without red flag symptoms. RADIOLOGIA 2023; 65 Suppl 2:S59-S70. [PMID: 37858354 DOI: 10.1016/j.rxeng.2023.02.004] [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: 10/05/2022] [Accepted: 02/01/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Low back pain (LBP) is one of the most frequent reasons for medical consultation. Most of the patients will have nonspecific LBP, which usually are self-limited episodes. It is unclear which of the diagnostic imaging pathways is most effective and costeffective and how the imaging impacts on patient treatment. Imaging techniques are usually indicated if symptoms remain after 6 weeks. Magnetic resonance imaging (MRI) is the diagnostic imaging examination of choice in lumbar spine evaluation of low back pain; however, availability of MRI is limited. OBJECTIVES To evaluate the diagnostic accuracy of computed tomography (CT) with MRI (as standard of reference) in the evaluation of chronic low back pain (LBP) without red flags symptoms. To compare the results obtained by two radiologists with different grades of experience. MATERIALS AND METHODS Patients with chronic low back pain without red flags symptoms were retrospectively reviewed by two observers with different level of experience. Patients included had undergone a lumbar or abdominal CT and an MRI within a year. Once the radiological information was collected, it was then statistically reviewed. The aim of the statistical analysis is to identify the equivalence between both diagnostic techniques. To this end, sensitivity, specificity and validity index were calculated. In addition, intra and inter-observer reliability were measured by Cohen's kappa values and also using the McNemar test. RESULTS 340 lumbar levels were evaluated from 68 adult patients with chronic low back pain or sciatica. 63.2% of them were women, with an average age of 60.3 years (SD 14.7). CT shows high values of sensitivity and specificity (>80%) in most of the items evaluated, but sensitivity was low for the evaluation of density of the disc (40%) and for the detection of disc herniation (55%). Moreover, agreement between MRI and CT in most of these items was substantial or almost perfect (Cohen's kappa-coefficient > 0'8), excluding Modic changes (kappa = 0.497), degenerative changes (kappa0.688), signal of the disc (kappa = 0.327) and disc herniation (kappa = 0.639). Finally, agreement between both observers is mostly high (kappa > 0.8). Foraminal stenosis, canal stenosis and the grade of the canal stenosis were overdiagnosed by the inexperienced observer in the evaluation of CT images. CONCLUSIONS AND SIGNIFICANCE CT is as sensitive as lumbar MRI in the evaluation of most of the items analysed, excluding Modic changes, degenerative changes, signal of the disc and disc herniation. In addition, these results are obtained regardless the experience of the radiologist. The rising use of diagnostic medical imaging and the improvement of image quality brings the opportunity of making a second look of abdominal CT in search of causes of LBP. Thereby, inappropriate medical imaging could be avoided (2). In addition, it would allow to reduce MRI waiting list and prioritize other patients with more severe pathology than LBP.
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Affiliation(s)
- J Martel Villagrán
- Radiología musculoesquelética, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | - E Cebada-Chaparro
- Radiología musculoesquelética, Hospital Universitario de Cáceres, Cáceres, Spain
| | - A L Bueno Horcajadas
- Radiología musculoesquelética, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - E Pérez-Fernández
- Metodología de la Investigación, Hospital Universitario Fundación Alcorcón, Madrid, Spain
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Martel Villagrán J, Martínez-Sánchez R, Cebada-Chaparro E, Bueno Horcajadas A, Pérez-Fernández E. Validez de la TC lumbar frente a la RM lumbar en el estudio de la lumbalgia y la lumbociatalgia crónica sin criterios de alarma. RADIOLOGIA 2023. [DOI: 10.1016/j.rx.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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Di Donato M, Sheehan LR, Gray S, Iles R, van Vreden C, Collie A. Development and initial application of a harmonised multi-jurisdiction work injury compensation database. Digit Health 2023; 9:20552076231176695. [PMID: 37312940 PMCID: PMC10259130 DOI: 10.1177/20552076231176695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 05/02/2023] [Indexed: 06/15/2023] Open
Abstract
Objectives Workers' compensation schemes provide funding for wage replacement and healthcare for injured and ill workers. In Australia, workers' compensation schemes operate independently in different jurisdictions, making comparisons of health service use challenging. We sought to develop and deploy a new database of health service and income support data, harmonising data from multiple Australian workers' compensation jurisdictions. Methods We worked with workers' compensation authorities from six Australian jurisdictions to combine claims, healthcare, medicines and wage replacement data for a sample of compensated workers with claims for musculoskeletal conditions. We designed a structured relational database and developed a bespoke health services coding scheme to harmonise data across jurisdictions. Results The Multi-Jurisdiction Workers' Compensation Database contains four data sets: claims, services, medicines and wage replacement. The claims data set contains 158,946 claims for low back pain (49.6%), limb fracture (23.8%) and non-specific limb conditions (26.7%). The services data set contains a total of 4.2 million cleaned and harmonised services including doctors (29.9%), physical therapists (56.3%), psychological therapists (2.8%), diagnostic procedures (5.5%) and examinations and assessments (5.6%). The medicines data set contains 524,380 medicine dispenses, with 208,504 (39.8%) dispenses for opioid analgesics. Conclusions The development of this database presents potential opportunities to gain a greater understanding of health service use in the Australian workers' compensation sector, to measure the impact of policy change on health services and to provide a method for further data harmonisation. Future efforts could seek to conduct linkage with other data sources.
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Affiliation(s)
- Michael Di Donato
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Luke R. Sheehan
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Shannon Gray
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ross Iles
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Caryn van Vreden
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alex Collie
- Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Di Donato M, Xia T, Iles R, Buchbinder R, Collie A. Patterns of opioid dispensing and associated wage replacement duration in workers with accepted claims for low back pain: a retrospective cohort study. Pain 2022; 163:e942-e952. [PMID: 34799531 DOI: 10.1097/j.pain.0000000000002539] [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: 10/30/2020] [Accepted: 11/08/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT This study aimed to identify patterns of opioid dispensing in Australian workers with low back pain (LBP) and determine the association of dispensing patterns with wage replacement duration. Australian workers' compensation claimants with LBP and at least 1 day of wage replacement were included. We used group-based trajectory modelling to identify opioid dispensing patterns over a two-and-a-half-year period from reported LBP onset and quantile regression to compare wage replacement duration between each dispensing pattern group. Opioids were dispensed to one-third of workers with LBP (N = 3205, 33.3%) at least once during their claim. Three dispensing patterns were identified. Most had a short-term low-volume opioid dispensing pattern (N = 2166, 67.6%), whereas 798 (24.9%) had a long-term moderate-volume pattern and 241 (7.5%) had a long-term high-volume pattern. Workers with dispensed opioids had significantly longer wage replacement duration than those without dispensed opioids (median [weeks]: 63.6 vs 7.1, respectively). In addition, moderate-volume and high-volume long-term dispensing groups had significantly longer wage replacement duration compared with the short-term dispensing group (median [weeks]: 126.9, 126.0, and 30.7, respectively). Without controlling for pain severity, these results offer limited evidence that opioids lead to longer wage replacement duration. Further research controlling for pain severity, psychosocial factors, and recovery expectations is required to confirm whether the relationship between opioid dispensing pattern and wage replacement duration is causal in nature.
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Affiliation(s)
- Michael Di Donato
- Insurance Work and Health Group, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ting Xia
- Insurance Work and Health Group, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ross Iles
- Insurance Work and Health Group, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria, Australia
| | - Alex Collie
- Insurance Work and Health Group, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Di Donato M, Iles R, Buchbinder R, Xia T, Collie A. Prevalence, Predictors and Wage Replacement Duration Associated with Diagnostic Imaging in Australian Workers with Accepted Claims for Low Back Pain: A Retrospective Cohort Study. JOURNAL OF OCCUPATIONAL REHABILITATION 2022; 32:55-63. [PMID: 33913056 DOI: 10.1007/s10926-021-09981-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/16/2021] [Indexed: 06/12/2023]
Abstract
Objectives To determine in Australian workers with an accepted workers' compensation claim for low back pain (LBP) (1) the prevalence of diagnostic imaging of the spine and factors associated with its use, and (2) the association between spinal diagnostic imaging events and wage replacement duration. Methods Workers with accepted workers' compensation claims for LBP longer than 2 weeks were grouped by whether workers' compensation funded no, single, or multiple diagnostic spinal imaging in the 2 years since reported LBP onset. Ordinal logistic regression was used to define the demographic, occupational and social factors associated with each group. Time-to-event analysis was used to determine the association between spinal imaging and wage replacement duration. Results In the sample of 30,530 workers, 9267 (30.4%) received single spinal imaging and 6202 (20.3%) received multiple spinal imaging. Male workers and workers from the state of Victoria had significantly higher odds of multiple imaging. Socioeconomically advantaged workers and workers from remote Australia had significantly lower odds of multiple imaging. Magnetic Resonance Imaging was the most common imaging modality. Workers with single spinal imaging (median duration 17.0 weeks; HR 2.0, 95% CI 1.9, 2.1) and multiple spinal imaging (median duration 49.0 weeks; HR 4.0, 95% CI 3.9, 4.1) had significantly longer wage replacement duration than those with no imaging (median duration 6.1 weeks). Conclusions Over half of Australian workers with an accepted workers' compensation claim for LBP longer than 2 weeks received diagnostic spinal imaging. Receipt of diagnostic imaging, particularly multiple imaging, was associated with longer wage replacement duration.
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Affiliation(s)
- Michael Di Donato
- Insurance Work and Health Group, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
| | - Ross Iles
- Insurance Work and Health Group, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, 4 Drysdale St, Malvern, VIC, 3144, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 4 Drysdale St, Malvern, VIC, 3144, Australia
| | - Ting Xia
- Insurance Work and Health Group, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Alex Collie
- Insurance Work and Health Group, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
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Alhowimel AS, Alotaibi MA, Alamam DM, Alodaibi FA, Fritz JM. Attitudes and Beliefs of Primary Care Physicians Working in Saudi Arabia Regarding the Management of Low Back Pain: A Cross-Sectional Study. Int J Gen Med 2022; 14:10225-10233. [PMID: 35002292 PMCID: PMC8728917 DOI: 10.2147/ijgm.s343775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/10/2021] [Indexed: 12/29/2022] Open
Abstract
Introduction Healthcare professionals’ beliefs and attitudes towards low back pain management play a significant role during treatment. This is a crucial aspect of primary care physicians working as a first point of contact for people seeking healthcare for low back pain. Aim To identify the beliefs and behaviors of frontline healthcare professionals (primary care physicians) working in the Riyadh region with regard to low back pain management. Methods A cross-sectional design was implemented, in which the Pain Attitude and Beliefs Scale (PABS) questionnaire was used along with a low back pain clinical vignette with some questions. The PABS assesses healthcare provider orientations toward low back pain with two subscales: biomedical and behavioral. In total, 400 primary care physicians working in the Riyadh region of Saudi Arabia were invited to participate. Results The responding primary care physicians (n = 72, response rate = 18%) provided an average score on the behavioral subscale (mean = 31.5±7.1) that was lower than that on the biomedical subscale (36.5±7.8) of the PABS. The lower scores in the biomedical subscale are associated with the using of clinical guidelines for low back pain management (χ2 (1) = 4.7, p = 0.03). Moreover, providing guideline-based advices regarding activity and work was more likely to come from those scoring above the mean in the behavioral subscale. Conclusion The results of this study show that Saudi Arabian primary care physicians manage their patients within a biomedical framework; there is some compliance to the current low back pain clinical guidelines among these physicians, with under/post-graduate education being needed for these professionals to adopt a more biopsychosocial framework during low back pain management.
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Affiliation(s)
- Ahmed S Alhowimel
- Department of Health and Rehabilitation Sciences, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
| | - Mazyad A Alotaibi
- Department of Health and Rehabilitation Sciences, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
| | - Dalyah M Alamam
- Department of Rehabilitation Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Faris A Alodaibi
- Department of Rehabilitation Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Julie M Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT, USA
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Zare S, Mobarak Z, Meidani Z, Nabovati E, Nazemi Z. Effectiveness of Clinical Decision Support Systems on the Appropriate Use of Imaging for Central Nervous System Injuries: A Systematic Review. Appl Clin Inform 2022; 13:37-52. [PMID: 35021254 PMCID: PMC8754686 DOI: 10.1055/s-0041-1740921] [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] [Received: 07/26/2021] [Accepted: 11/08/2021] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND One of the best practices for timely and efficient diagnoses of central nervous system (CNS) trauma and complex diseases is imaging. However, rates of imaging for CNS are high and impose a lot of costs to health care facilities in addition to exposing patients with negative impact of ionizing radiation. OBJECTIVES This study aimed to systematically review the effects and features of clinical decision support systems (CDSSs) for the appropriate use of imaging for CNS injuries. METHOD We searched MEDLINE, SCOPUS, Web of Science, and Cochrane without time period restriction. We included experimental and quasiexperimental studies that assessed the effectiveness of CDSSs designed for the appropriate use of imaging for CNS injuries in any clinical setting, including primary, emergency, and specialist care. The outcomes were categorized based on imaging-related, physician-related, and patient-related groups. RESULT A total of 3,223 records were identified through the online literature search. Of the 55 potential papers for the full-text review, 11 eligible studies were included. Reduction of CNS imaging proportion varied from 2.6 to 40% among the included studies. Physician-related outcomes, including guideline adherence, diagnostic yield, and knowledge, were reported in five studies, and all demonstrated positive impact of CDSSs. Four studies had addressed patient-related outcomes, including missed or delayed diagnosis, as well as length of stay. These studies reported a very low rate of missed diagnosis due to the cancellation of computed tomography (CT) examine according to the CDSS recommendations. CONCLUSION This systematic review reports that CDSSs decrease the utilization of CNS CT scan, while increasing physicians' adherence to the rules. However, the possible harm of CDSSs to patients was not well addressed by the included studies and needs additional investigation. The actual effect of CDSSs on appropriate imaging would be realized when the saved cost of examinations is compared with the cost of missed diagnosis.
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Affiliation(s)
- Sahar Zare
- Health Information Management Research Center, Department of Health Information Management and Technology, Kashan University of Medical Sciences, Kashan, Iran
| | - Zohre Mobarak
- Health Information Management Research Center, Department of Health Information Management and Technology, Kashan University of Medical Sciences, Kashan, Iran
| | - Zahra Meidani
- Health Information Management Research Center, Department of Health Information Management and Technology, Kashan University of Medical Sciences, Kashan, Iran
| | - Ehsan Nabovati
- Health Information Management Research Center, Department of Health Information Management and Technology, Kashan University of Medical Sciences, Kashan, Iran
| | - Zahra Nazemi
- Health Information Management Research Center, Department of Health Information Management and Technology, Kashan University of Medical Sciences, Kashan, Iran
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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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Robinson NB, Gao M, Patel PA, Davidson KW, Peacock J, Herron CR, Baker AC, Hentel KA, Oh PS. Secondary review reduced inpatient MRI orders and avoidable hospital days. Clin Imaging 2021; 82:156-160. [PMID: 34844100 DOI: 10.1016/j.clinimag.2021.11.014] [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: 05/28/2021] [Revised: 10/21/2021] [Accepted: 11/09/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Medical centers have dramatically increased the use of magnetic resonance imaging (MRI). At 2 large academic tertiary care centers in New York City, nearly half of inpatient MRI orders took more than 12 h to complete, delaying patient discharge and increasing avoidable hospital days. We posited that transitioning inpatient MRIs to outpatient facilities, when safe and appropriate, could reduce inpatient MRI orders and avoidable hospital days. METHODS We manually reviewed 59 inpatient MRI orders delayed on the estimated date of discharge (EDD). These orders were often delayed due to no standard process to escalate orders for medical reasons or no system to coordinate outpatient orders. We developed a revised workflow involving an automation platform that flagged inpatient MRI orders requested within 24 h of the EDD and emailed the care team to request a second review of the order. The care team reconsidered whether the order was (1) required for discharge, (2) non-urgent and could be converted to an outpatient order, or (3) unnecessary and could be canceled. RESULTS Over 9 months, the automation platform flagged 618 inpatient MRI orders, of which 53.9% (333/618) were reviewed by the care team. Among the orders, 24.0% (80/333) of reviewed orders and 12.9% (80/618) of all orders were transitioned to either outpatient or canceled orders. These transitioned orders were associated with 267 fewer avoidable hospital days and a cost savings of $199,194. CONCLUSION A standardized process and second review of inpatient MRI orders on the EDD can reduce inappropriate orders and more effectively use inpatient imaging resources. PRECIS A standardized workflow and automation platform encouraged a second review of inpatient MRI orders to reduce inappropriate orders, avoidable hospital days, and hospital costs.
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Affiliation(s)
- N Bryce Robinson
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, 525 E 68th Street, New York, NY 10065, United States of America.
| | - Michael Gao
- Department of Medicine, New York-Presbyterian, Weill Cornell Medicine, 525 E 68th Street, New York, NY, United States of America.
| | - Parimal A Patel
- Department of Medicine, New York-Presbyterian, Weill Cornell Medicine, 525 E 68th Street, New York, NY, United States of America.
| | - Karina W Davidson
- Center for Personalized Health, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, United States of America.
| | - James Peacock
- Department of Medicine, White Plains Hospital, 41 East Post Road, White Plains, NY 10601, United States of America.
| | - Crystal R Herron
- Center for Personalized Health, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, United States of America.
| | - Alexandra C Baker
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, 525 E 68th Street, New York, NY 10065, United States of America
| | - Keith A Hentel
- Department of Radiology, New York-Presbyterian, Weill Cornell Medicine, 525 E 68th Street, New York, NY, United States of America.
| | - P Stephen Oh
- Department of Surgery, New York-Presbyterian, Weill Cornell Medicine, 525 E 68th Street, New York, NY 10065, United States of America.
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12
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Kjelle E, Andersen ER, Soril LJJ, van Bodegom-Vos L, Hofmann BM. Interventions to reduce low-value imaging - a systematic review of interventions and outcomes. BMC Health Serv Res 2021; 21:983. [PMID: 34537051 PMCID: PMC8449221 DOI: 10.1186/s12913-021-07004-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/02/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND It is estimated that 20-50% of all radiological examinations are of low value. Many attempts have been made to reduce the use of low-value imaging. However, the comparative effectiveness of interventions to reduce low-value imaging is unclear. Thus, the objective of this systematic review was to provide an overview and evaluate the outcomes of interventions aimed at reducing low-value imaging. METHODS An electronic database search was completed in Medline - Ovid, Embase-Ovid, Scopus, and Cochrane Library for citations between 2010 and 2020. The search was built from medical subject headings for Diagnostic imaging/Radiology, Health service misuse or medical overuse, and Health planning. Keywords were used for the concept of reduction and avoidance. Reference lists of included articles were also hand-searched for relevant citations. Only articles written in English, German, Danish, Norwegian, Dutch, and Swedish were included. The Mixed Methods Appraisal Tool was used to appraise the quality of the included articles. A narrative synthesis of the final included articles was completed. RESULTS The search identified 15,659 records. After abstract and full-text screening, 95 studies of varying quality were included in the final analysis, containing 45 studies found through hand-searching techniques. Both controlled and uncontrolled before-and-after studies, time series, chart reviews, and cohort studies were included. Most interventions were aimed at referring physicians. Clinical practice guidelines (n = 28) and education (n = 28) were most commonly evaluated interventions, either alone or in combination with other components. Multi-component interventions were often more effective than single-component interventions showing a reduction in the use of low-value imaging in 94 and 74% of the studies, respectively. The most addressed types of imaging were musculoskeletal (n = 26), neurological (n = 23) and vascular (n = 16) imaging. Seventy-seven studies reported reduced low-value imaging, while 3 studies reported an increase. CONCLUSIONS Multi-component interventions that include education were often more effective than single-component interventions. The contextual and cultural factors in the health care systems seem to be vital for successful reduction of low-value imaging. Further research should focus on assessing the impact of the context in interventions reducing low-value imaging and how interventions can be adapted to different contexts.
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Affiliation(s)
- Elin Kjelle
- Institute for the Health Sciences at 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 at 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, Alberta 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
| | - Bjørn Morten Hofmann
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
- Centre of Medical Ethics, University of Oslo, Postbox 1130, Blindern, 0318 Oslo, Norway
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13
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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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14
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Hall A, Richmond H, Pike A, Lawrence R, Etchegary H, Swab M, Thompson JY, Albury C, Hayden J, Patey AM, Matthews J. What behaviour change techniques have been used to improve adherence to evidence-based low back pain imaging? Implement Sci 2021; 16:68. [PMID: 34215284 PMCID: PMC8254222 DOI: 10.1186/s13012-021-01136-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 06/09/2021] [Indexed: 11/20/2022] Open
Abstract
Background Despite international guideline recommendations, low back pain (LBP) imaging rates have been increasing over the last 20 years. Previous systematic reviews report limited effectiveness of implementation interventions aimed at reducing unnecessary LBP imaging. No previous reviews have analysed these implementation interventions to ascertain what behaviour change techniques (BCTs) have been used in this field. Understanding what techniques have been implemented in this field is an essential first step before exploring intervention effectiveness. Methods We searched EMBASE, Ovid (Medline), CINAHL and Cochrane CENTRAL from inception to February 1, 2021, as well as and hand-searched 6 relevant systematic reviews and conducted citation tracking of included studies. Two authors independently screened titles, abstracts, and full texts for eligibility and extracted data on study and intervention characteristics. Study interventions were qualitatively analysed by three coders to identify BCTs, which were mapped to mechanisms of action from the theoretical domains framework (TDF) using the Theory and Techniques Tool. Results We identified 36 eligible studies from 1984 citations in our electronic search and a further 2 studies from hand-searching resulting in 38 studies that targeted physician behaviour to reduce unnecessary LBP imaging. The studies were conducted in 6 countries in primary (n = 31) or emergency care (n = 7) settings. Thirty-four studies were included in our BCT synthesis which found the most frequently used BCTs were ‘4.1 instruction on how to perform the behaviour’ (e.g. Active/passive guideline dissemination and/or educational seminars/workshops), followed by ‘9.1 credible source’, ‘2.2 feedback on behaviour’ (e.g. electronic feedback reports on physicians’ image ordering) and 7.1 prompts and cues (electronic decision support or hard-copy posters/booklets for the office). This review highlighted that the majority of studies used education and/or feedback on behaviour to target the domains of knowledge and in some cases also skills and beliefs about capabilities to bring about a change in LBP imaging behaviour. Additionally, we found there to be a growing use of electronic or hard copy reminders to target the domains of memory and environmental context and resources. Conclusions This is the first study to identify what BCTs have been used to target a reduction in physician image ordering behaviour. The majority of included studies lacked the use of theory to inform their intervention design and failed to target known physician-reported barriers to following LBP imaging guidelines. Protocol Registation PROSPERO CRD42017072518 Supplementary Information The online version contains supplementary material available at 10.1186/s13012-021-01136-w.
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Affiliation(s)
- Amanda Hall
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University, 300 Prince Phillip Drive, St. John's, Newfoundland, A1B 3V6, Canada.
| | - Helen Richmond
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University, 300 Prince Phillip Drive, St. John's, Newfoundland, A1B 3V6, Canada
| | - Andrea Pike
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University, 300 Prince Phillip Drive, St. John's, Newfoundland, A1B 3V6, Canada
| | - Rebecca Lawrence
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University, 300 Prince Phillip Drive, St. John's, Newfoundland, A1B 3V6, Canada
| | - Holly Etchegary
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University, 300 Prince Phillip Drive, St. John's, Newfoundland, A1B 3V6, Canada
| | - Michelle Swab
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University, 300 Prince Phillip Drive, St. John's, Newfoundland, A1B 3V6, Canada
| | - Jacqueline Y Thompson
- Public Health, Institute of Applied Health Research, College of Medicine and Dentistry, University of Birmingham, Birmingham, B15 2TT, UK
| | - Charlotte Albury
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England
| | - Jill Hayden
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Andrea M Patey
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - James Matthews
- School of Public Health, Physiotherapy & Sports Science, University College Dublin, Belfield, Dublin 4, Ireland
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15
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Wang KY, Chong I, Consul N, Lincoln CM. To Sustain or not to Sustain: Varying Educational Sessions on Advanced Imaging of Low Back Pain and R-SCAN. Curr Probl Diagn Radiol 2020; 50:774-778. [PMID: 33250294 DOI: 10.1067/j.cpradiol.2020.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/29/2020] [Accepted: 10/16/2020] [Indexed: 01/24/2023]
Abstract
PURPOSE The aim is to present our long-term institutional experience on the use of the American College of Radiology's (ACR's) Radiology Support, Communication, and Alignment Network (R-SCAN) via educational presentations and guideline dissemination in sustaining lumbar spine magnetic resonance imaging (MRI) appropriateness for low back pain. METHODS Initial educational presentations on appropriate use criteria for lumbar spine MRI were given to referring providers at three county clinics in April and May of 2016. A second educational refresher was given to the same 3 clinics in November 2017: Clinic A received guideline dissemination, Clinic B served as a control group, and Clinic C received a refresher presentation. Wilcoxon rank-sum test was used to compare the monthly MRI referral rate and ACR Appropriateness Criteria rating. RESULTS There was no significant difference in monthly referral rates and ACR Appropriateness Criteria after the second education. Monthly referral rates were significantly lower than the baseline rates before the first education for Clinic A (P <0.001), C (P = 0.004), and the combined total (P = 0.002). ACR Appropriateness Criteria ratings were significantly higher than the baseline ratings before the first education for Clinic C (P = 0.002) and the combined total (P = 0.024). DISCUSSION After the second education, inappropriateness, and referral rates remained significantly lower when compared to rates before but not after the first education. Radiology Support, Communication, and Alignment Network is an invaluable online tool for both radiology practices and referring clinicians to become familiar in preparing to comply with the Protecting Access to Medicare Act and satisfying the Improvement Activities category of the Merit Based Incentive Payment Systems.
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Affiliation(s)
- Kevin Yuqi Wang
- Department of Radiology, Stanford University School of Medicine, Stanford, CA.
| | - Insun Chong
- Department of Radiology, Baylor College of Medicine, Houston, TX
| | - Nikita Consul
- Department of Radiology, Baylor College of Medicine, Houston, TX
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16
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The impact of income support systems on healthcare quality and functional capacity in workers with low back pain: a realist review. Pain 2020; 161:2690-2709. [PMID: 32618874 DOI: 10.1097/j.pain.0000000000001978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Low back pain (LBP) is a leading cause of work disability. While absent from work, workers with LBP may receive income support from a system such as workers' compensation or social security. This study examines how and in what contexts income support systems impact the healthcare quality for people with work disability and LBP and their functional capacity. We performed a realist review. Five initial theories about the relationship between income support systems and outcomes were developed, tested, and refined by acquiring and synthesising academic literature from purposive and iterative electronic database searching. This process was supplemented with gray literature searches for policy documents and semistructured interviews with experts in income support, health care, and LBP. Income support systems influence healthcare quality through funding restrictions, healthcare provider administrative burden, and allowing employers to select providers. They also influence worker functional capacity through the level of participation and financial incentives for employers, measures to prove the validity of the worker's LBP, and certain administrative procedures. These mechanisms are often exclusively context-dependent, and generate differing and unintended outcomes depending on features of the healthcare and income support system, as well as other contextual factors such as socioeconomic status and labour force composition. Research and policy design should consider how income support systems may indirectly influence workers with LBP through the workplace.
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17
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Utilization Review in Workers' Compensation: Review of Current Status and Recommendations for Future Improvement. J Occup Environ Med 2020; 62:e273-e286. [PMID: 32502086 DOI: 10.1097/jom.0000000000001893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
: Utilization review (UR) is a process that assesses aspects of a treating provider's care plans and then provides recommendations to payors/insurance carriers, third party administrators, etc, concerning the appropriateness of the proposed care. UR has become an integral part of medical practice and has influenced medical care within the workers' compensation (WC) system and is mandated in several states and jurisdictions. This guidance statement from the American College of Occupational and Environmental Medicine (ACOEM) reviews structural elements of UR programs and proposes a possible template for operational standards. UR has a unique role in protecting patients and educating providers on evidence-based guidelines, new research, and best practices.
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18
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Nevedal AL, Lewis ET, Wu J, Jacobs J, Jarvik JG, Chou R, Barnett PG. Factors Influencing Primary Care Providers' Unneeded Lumbar Spine MRI Orders for Acute, Uncomplicated Low-Back Pain: a Qualitative Study. J Gen Intern Med 2020; 35:1044-1051. [PMID: 31832927 PMCID: PMC7174262 DOI: 10.1007/s11606-019-05410-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 09/20/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Clinical practice guidelines suggest that magnetic resonance imaging of the lumbar spine (LS-MRI) is unneeded during the first 6 weeks of acute, uncomplicated low-back pain. Unneeded LS-MRIs do not improve patient outcomes, lead to unnecessary surgeries and procedures, and cost the US healthcare system about $300 million dollars per year. However, why primary care providers (PCPs) order unneeded LS-MRI for acute, uncomplicated low-back pain is poorly understood. OBJECTIVE To characterize and explain the factors contributing to PCPs ordering unneeded LS-MRI for acute, uncomplicated low-back pain. DESIGN Qualitative study using semi-structured interviews. PARTICIPANTS Veterans Affairs PCPs identified from administrative data as having high or low rates of guideline-concordant LS-MRI ordering in 2016. APPROACH Providers were interviewed about their use of LS-MRI for acute, uncomplicated low-back pain and factors contributing to their decision-making. Directed content analysis of transcripts was conducted to identify and compare environmental-, patient-, and provider-level factors contributing to unneeded LS-MRI. KEY RESULTS Fifty-five PCPs participated (8.6% response rate). Both low (n = 33) and high (n = 22) guideline-concordant providers reported that LS-MRIs were required for specialty care referrals, but they differed in how other environmental factors (stringency of radiology utilization review, management of patient travel burden, and time constraints) contributed to LS-MRI ordering patterns. Low- and high-guideline-concordant providers reported similar patient factors (beliefs in value of imaging and pressure on providers). However, provider groups differed in how provider-level factors (guideline familiarity and agreement, the extent to which they acquiesced to patients, and belief in the value of LS-MRI) contributed to LS-MRI ordering patterns. CONCLUSIONS Results describe how diverse environmental, patient, and provider factors contribute to unneeded LS-MRI for acute, uncomplicated low-back pain. Prior research using a single intervention to reduce unneeded LS-MRI has been ineffective. Results suggest that multifaceted de-implementation strategies may be required to reduce unneeded LS-MRI.
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Affiliation(s)
- Andrea L Nevedal
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, 795 Willow Road, Menlo Park, CA, 94025, USA.
| | - Eleanor T Lewis
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, 795 Willow Road, Menlo Park, CA, 94025, USA.,Program Evaluation and Resource Center, VA Office of Mental Health and Suicide Prevention, Menlo Park, CA, USA
| | - Justina Wu
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, 795 Willow Road, Menlo Park, CA, 94025, USA
| | - Josephine Jacobs
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, 795 Willow Road, Menlo Park, CA, 94025, USA.,Health Economics Resource Center, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Jeffrey G Jarvik
- Departments of Radiology, Neurological Surgery, and Health Services, University of Washington, Seattle, WA, USA
| | - Roger Chou
- Department of Clinical Epidemiology and Medical Informatics and Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Paul G Barnett
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, 795 Willow Road, Menlo Park, CA, 94025, USA.,Health Economics Resource Center, VA Palo Alto Healthcare System, Menlo Park, CA, USA
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19
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Akuthota V, Meron AJ, Singh JR, Boimbo S, Laker SR, Brakke Holman R, Sridhar BV, Friedrich J, Sullivan WJ. The utility of magnetic resonance imaging results in physician decision-making before initial lumbar spinal injection. Spine J 2019; 19:1455-1462. [PMID: 31009770 DOI: 10.1016/j.spinee.2019.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 04/15/2019] [Accepted: 04/17/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The need for advanced imaging before spinal intervention is an area of ongoing debate. Many studies have demonstrated the accuracy of magnetic resonance imaging (MRI) results in evaluating structural pathology in the lumbar spine, but few have addressed how frequently MRI findings change clinical management. A randomized controlled trial showed that viewing MRI results did not impact outcomes in patients with radiculopathy undergoing epidural steroid injection (ESI). The results suggested ESIs that correlated with both imaging and clinical findings experienced slightly more benefit than the blinded cohort, although statistically insignificantly. PURPOSE Three related studies were conducted to (1) increase understanding of the opinions of interventional spine physicians regarding the utility of viewing imaging before injection and (2) evaluate the impact of viewing MRI results on injection planning (retrospective and prospective analyses). STUDY DESIGN Survey, prospective, and retrospective analysis. PATIENT SAMPLE Patients presenting to a university-based spine center for initial evaluation of back or leg pain who were candidates for spinal intervention. OUTCOME MEASURES Self-reported measures from a clinical practice questionnaire distributed to interventional spine physicians to determine rates and rationale for utilization of MRI before spine injection, physiologic measures including MRI results, functional measures including physician decision-making regarding type and location of injection performed. METHODS This study was funded by the University of Colorado Health and Welfare Trust. A survey was sent to interventional spine physicians to assess their utilization of MRI results before spine procedures. A retrospective analysis of patients who were candidates for ESI was conducted to evaluate how initial injection plan compared with the postviewing of MRI results on injection performed. In a prospective analysis, injection plans pre- and post-MRI were compared among patients presenting for initial evaluation of low back or leg pain. RESULTS Survey responses showed that specialists order MRI studies to correlate with physical exam (91%) and to detect the presence of synovial cysts (68%), whereas tumor/infection (93%) was most likely to cause a change in their approach. In the retrospective review, the physician's planned approach before viewing the MRI was concordant with the actual procedure 49% of the time. A different type of procedure was performed in 15% of planned injections. In such cases, the initial treatment plan was altered (ie, same procedure at a different or additional level or side) in 35% of planned injections. In the prospective data collection, 43% of injections were different from the initial physician decision. The most common reasons for altering the injection was different level affected (36%), facet pathology (22%), and different nerve root affected (16%). CONCLUSIONS In clinical practice, MRI before injection frequently changes management decisions in the planning and delivery of lumbar spine injections.
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Affiliation(s)
- Venu Akuthota
- University of Colorado, Department of Physical Medicine and Rehabilitation, 12631 E. 17th Ave, Mail Stop F493, Academic Office 1 (AO1), Room 2510, Aurora, Colorado 80045, USA.
| | - Adele J Meron
- University of Colorado, Department of Physical Medicine and Rehabilitation, 12631 E. 17th Ave, Mail Stop F493, Academic Office 1 (AO1), Room 2510, Aurora, Colorado 80045, USA
| | - Jaspal Ricky Singh
- University of Colorado, Department of Physical Medicine and Rehabilitation, 12631 E. 17th Ave, Mail Stop F493, Academic Office 1 (AO1), Room 2510, Aurora, Colorado 80045, USA
| | - Sandra Boimbo
- University of Colorado, Department of Physical Medicine and Rehabilitation, 12631 E. 17th Ave, Mail Stop F493, Academic Office 1 (AO1), Room 2510, Aurora, Colorado 80045, USA
| | - Scott R Laker
- University of Colorado, Department of Physical Medicine and Rehabilitation, 12631 E. 17th Ave, Mail Stop F493, Academic Office 1 (AO1), Room 2510, Aurora, Colorado 80045, USA
| | - Rachel Brakke Holman
- University of Colorado, Department of Physical Medicine and Rehabilitation, 12631 E. 17th Ave, Mail Stop F493, Academic Office 1 (AO1), Room 2510, Aurora, Colorado 80045, USA
| | - Balaji V Sridhar
- University of Colorado, Department of Physical Medicine and Rehabilitation, 12631 E. 17th Ave, Mail Stop F493, Academic Office 1 (AO1), Room 2510, Aurora, Colorado 80045, USA
| | - Jason Friedrich
- University of Colorado, Department of Physical Medicine and Rehabilitation, 12631 E. 17th Ave, Mail Stop F493, Academic Office 1 (AO1), Room 2510, Aurora, Colorado 80045, USA
| | - William J Sullivan
- University of Colorado, Department of Physical Medicine and Rehabilitation, 12631 E. 17th Ave, Mail Stop F493, Academic Office 1 (AO1), Room 2510, Aurora, Colorado 80045, USA
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20
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Hall AM, Scurrey SR, Pike AE, Albury C, Richmond HL, Matthews J, Toomey E, Hayden JA, Etchegary H. Physician-reported barriers to using evidence-based recommendations for low back pain in clinical practice: a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework. Implement Sci 2019; 14:49. [PMID: 31064375 PMCID: PMC6505266 DOI: 10.1186/s13012-019-0884-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 03/27/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Adoption of low back pain guidelines is a well-documented problem. Information to guide the development of behaviour change interventions is needed. The review is the first to synthesise the evidence regarding physicians' barriers to providing evidence-based care for LBP using the Theoretical Domains Framework (TDF). Using the TDF allowed us to map specific physician-reported barriers to individual guideline recommendations. Therefore, the results can provide direction to future interventions to increase physician compliance with evidence-based care for LBP. METHODS We searched the literature for qualitative studies from inception to July 2018. Two authors independently screened titles, abstracts, and full texts for eligibility and extracted data on study characteristics, reporting quality, and methodological rigour. Guided by a TDF coding manual, two reviewers independently coded the individual study themes using NVivo. After coding, we assessed confidence in the findings using the GRADE-CERQual approach. RESULTS Fourteen studies (n = 318 physicians) from 9 countries reported barriers to adopting one of the 5 guideline-recommended behaviours regarding in-clinic diagnostic assessments (9 studies, n = 198), advice on activity (7 studies, n = 194), medication prescription (2 studies, n = 39), imaging referrals (11 studies, n = 270), and treatment/specialist referrals (8 studies, n = 193). Imaging behaviour is influenced by (1) social influence-from patients requesting an image or wanting a diagnosis (n = 252, 9 studies), (2) beliefs about consequence-physicians believe that providing a scan will reassure patients (n = 175, 6 studies), and (3) environmental context and resources-physicians report a lack of time to have a conversation with patients about diagnosis and why a scan is not needed (n = 179, 6 studies). Referrals to conservative care is influenced by environmental context and resources-long wait-times or a complete lack of access to adjunct services prevented physicians from referring to these services (n = 82, 5 studies). CONCLUSIONS Physicians face numerous barriers to providing evidence-based LBP care which we have mapped onto 7 TDF domains. Two to five TDF domains are involved in determining physician behaviour, confirming the complexity of this problem. This is important as interventions often target a single domain where multiple domains are involved. Interventions designed to address all the domains involved while considering context-specific factors may prove most successful in increasing guideline adoption. REGISTRATION PROSPERO 2017, CRD42017070703.
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Affiliation(s)
- Amanda M Hall
- Primary Healthcare Research Unit (PHRU), Faculty of Medicine, Memorial University, Room 417
- Janeway Hostel, Health Sciences Centre, 300 Prince Philip Parkway, St. John's, NL, A1B 3V6, Canada.
| | - Samantha R Scurrey
- Primary Healthcare Research Unit (PHRU), Faculty of Medicine, Memorial University, Room 417
- Janeway Hostel, Health Sciences Centre, 300 Prince Philip Parkway, St. John's, NL, A1B 3V6, Canada
| | - Andrea E Pike
- Primary Healthcare Research Unit (PHRU), Faculty of Medicine, Memorial University, Room 417
- Janeway Hostel, Health Sciences Centre, 300 Prince Philip Parkway, St. John's, NL, A1B 3V6, Canada
| | - Charlotte Albury
- Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Helen L Richmond
- Centre for Rehabilitation Research in Oxford, University of Oxford, Oxford, UK
| | - James Matthews
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Elaine Toomey
- School of Psychology, National University of Ireland Galway, Galway, Ireland
| | - Jill A Hayden
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Holly Etchegary
- Clinical Epidemiology, Faculty of Medicine, Memorial University, St. John's, Newfoundland and Labrador, Canada
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Blackmore CC. The Relationship Between Medicare Outpatient Efficiency Measure OP8 and Lumbar MRI Utilization. J Am Coll Radiol 2019; 16:276-281. [DOI: 10.1016/j.jacr.2018.10.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/18/2018] [Accepted: 10/30/2018] [Indexed: 10/27/2022]
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Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work. 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 2019; 28:937-950. [DOI: 10.1007/s00586-019-05918-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 01/18/2019] [Accepted: 02/10/2019] [Indexed: 12/21/2022]
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