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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] [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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Altinger G, Sharma S, Maher CG, Cullen L, McCaffery K, Linder JA, Buchbinder R, Harris IA, Coiera E, Li Q, Howard K, Coggins A, Middleton PM, Gunja N, Ferguson I, Chan T, Tambree K, Varshney A, Traeger AC. Behavioural 'nudging' interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial. BMJ Open 2024; 14:e079870. [PMID: 38548366 PMCID: PMC10982715 DOI: 10.1136/bmjopen-2023-079870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 02/08/2024] [Indexed: 04/02/2024] Open
Abstract
INTRODUCTION Opioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and two in three will receive an opioid. NUDG-ED aims to determine the effectiveness of two different behavioural 'nudge' interventions on low-value care for ED patients with low back pain. METHODS AND ANALYSIS NUDG-ED is a 2×2 factorial, open-label, before-after, cluster randomised controlled trial. The trial includes 8 ED sites in Sydney, Australia. Participants will be ED clinicians who manage back pain, and patients who are 18 years or over presenting to ED with musculoskeletal back pain. EDs will be randomly assigned to receive (i) patient nudges, (ii) clinician nudges, (iii) both interventions or (iv) no nudge control. The primary outcome will be the proportion of encounters in ED for musculoskeletal back pain where a person received a non-indicated lumbar imaging test, an opioid at discharge or both. We will require 2416 encounters over a 9-month study period (3-month before period and 6-month after period) to detect an absolute difference of 10% in use of low-value care due to either nudge, with 80% power, alpha set at 0.05 and assuming an intra-class correlation coefficient of 0.10, and an intraperiod correlation of 0.09. Patient-reported outcome measures will be collected in a subsample of patients (n≥456) 1 week after their initial ED visit. To estimate effects, we will use a multilevel regression model, with a random effect for cluster and patient, a fixed effect indicating the group assignment of each cluster and a fixed effect of time. ETHICS AND DISSEMINATION This study has ethical approval from Southwestern Sydney Local Health District Human Research Ethics Committee (2023/ETH00472). We will disseminate the results of this trial via media, presenting at conferences and scientific publications. TRIAL REGISTRATION NUMBER ACTRN12623001000695.
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Affiliation(s)
- Gemma Altinger
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Sweekriti Sharma
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Woman's Hospital Health Service District, Herston, Queensland, Australia
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jeffrey A Linder
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ian A Harris
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute, Sydney, New South Wales, Australia
| | - Enrico Coiera
- Centre for Health Informatics, Macquarie University, Sydney, New South Wales, Australia
| | - Qiang Li
- George Institute for Global Health, Sydney, New South Wales, Australia
| | - Kirsten Howard
- Menzies Centre for Health Policy and Economics, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew Coggins
- Discipline of Emergency Medicine, The University of Sydney School of Medicine, Sydney, New South Wales, Australia
| | - Paul M Middleton
- South Western Emergency Research Institute, Ingham Institute for Applied Medical Research, Liverpool Hospital, Liverpool, New South Wales, Australia
- South West Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Naren Gunja
- Discipline of Emergency Medicine, The University of Sydney School of Medicine, Sydney, New South Wales, Australia
- Digital Health Solutions, Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Ian Ferguson
- South West Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Trevor Chan
- Emergency Care Institute, The Agency for Clinical Innovation, St Leonards Sydney, City of Willoughby, Australia
| | - Karen Tambree
- Consumer Advisor, The University of Sydney Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
| | - Ajay Varshney
- Consumer Advisor, The University of Sydney Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
| | - Adrian C Traeger
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
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Boaz A, Baeza J, Fraser A, Persson E. 'It depends': what 86 systematic reviews tell us about what strategies to use to support the use of research in clinical practice. Implement Sci 2024; 19:15. [PMID: 38374051 PMCID: PMC10875780 DOI: 10.1186/s13012-024-01337-z] [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: 11/01/2023] [Accepted: 01/05/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND The gap between research findings and clinical practice is well documented and a range of strategies have been developed to support the implementation of research into clinical practice. The objective of this study was to update and extend two previous reviews of systematic reviews of strategies designed to implement research evidence into clinical practice. METHODS We developed a comprehensive systematic literature search strategy based on the terms used in the previous reviews to identify studies that looked explicitly at interventions designed to turn research evidence into practice. The search was performed in June 2022 in four electronic databases: Medline, Embase, Cochrane and Epistemonikos. We searched from January 2010 up to June 2022 and applied no language restrictions. Two independent reviewers appraised the quality of included studies using a quality assessment checklist. To reduce the risk of bias, papers were excluded following discussion between all members of the team. Data were synthesised using descriptive and narrative techniques to identify themes and patterns linked to intervention strategies, targeted behaviours, study settings and study outcomes. RESULTS We identified 32 reviews conducted between 2010 and 2022. The reviews are mainly of multi-faceted interventions (n = 20) although there are reviews focusing on single strategies (ICT, educational, reminders, local opinion leaders, audit and feedback, social media and toolkits). The majority of reviews report strategies achieving small impacts (normally on processes of care). There is much less evidence that these strategies have shifted patient outcomes. Furthermore, a lot of nuance lies behind these headline findings, and this is increasingly commented upon in the reviews themselves. DISCUSSION Combined with the two previous reviews, 86 systematic reviews of strategies to increase the implementation of research into clinical practice have been identified. We need to shift the emphasis away from isolating individual and multi-faceted interventions to better understanding and building more situated, relational and organisational capability to support the use of research in clinical practice. This will involve drawing on a wider range of research perspectives (including social science) in primary studies and diversifying the types of synthesis undertaken to include approaches such as realist synthesis which facilitate exploration of the context in which strategies are employed.
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Affiliation(s)
- Annette Boaz
- Health and Social Care Workforce Research Unit, The Policy Institute, King's College London, Virginia Woolf Building, 22 Kingsway, London, WC2B 6LE, UK.
| | - Juan Baeza
- King's Business School, King's College London, 30 Aldwych, London, WC2B 4BG, UK
| | - Alec Fraser
- King's Business School, King's College London, 30 Aldwych, London, WC2B 4BG, UK
| | - Erik Persson
- Federal University of Santa Catarina (UFSC), Campus Universitário Reitor João Davi Ferreira Lima, Florianópolis, SC, 88.040-900, Brazil
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Tsega S, Krouss M, Alaiev D, Talledo J, Chandra K, Shin D, Garcia M, Zaurova M, Manchego PA, Cho HJ. Imaging Wisely Campaign: Initiative to Reduce Imaging for Low Back Pain Across a Large Safety Net System. J Am Coll Radiol 2024; 21:165-174. [PMID: 37517770 DOI: 10.1016/j.jacr.2023.07.012] [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: 04/24/2023] [Revised: 07/03/2023] [Accepted: 07/18/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES Low back pain is a common clinical presentation that often results in expensive and unnecessary imaging that may lead to undue patient harm, including unnecessary procedures. We present an initiative in a safety net system to reduce imaging for low back pain. METHODS This quality improvement study was conducted across 70 ambulatory clinics and 11 teaching hospitals. Three electronic health record changes, using the concept of a nudge, were introduced into orders for lumbar radiography (x-ray), lumbar CT, and lumbar MRI. The primary outcome was the number of orders per 1,000 patient-days or encounters for each imaging test in the inpatient, ambulatory, and emergency department (ED) settings. Variation across facilities was assessed, along with selected indications. RESULTS Across all clinical environments, there were statistically significant decreases in level differences pre- and postintervention for lumbar x-ray (-52.9% for inpatient encounters, P < .001; -23.7% for ambulatory encounters, P < .001; and -17.3% for ED only encounters, P < .01). There was no decrease in ordering of lumbar CTs in the inpatient and ambulatory settings, although 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. DISCUSSION Our intervention successfully decreased lumbar radiography across all clinical settings, with a reduction in lumbar CTs in the inpatient and ambulatory settings. There were no changes for lumbar MRI orders.
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Affiliation(s)
- Surafel Tsega
- Senior Director of Informatics, Office of Quality and Patient Safety, NYC Health + Hospitals, New York, New York.
| | - Mona Krouss
- Assistant Vice President of Quality and Patient Safety, Department of Medicine, NYC Health + Hospitals/Kings County, New York, New York; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Daniel Alaiev
- Office of Quality and Patient Safety, NYC Health + Hospitals, New York, New York
| | - Joseph Talledo
- Office of Quality and Patient Safety, NYC Health + Hospitals, New York, New York
| | - Komal Chandra
- Office of Quality and Patient Safety, NYC Health + Hospitals, New York, New York
| | - Dawi Shin
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Mariely Garcia
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Milana Zaurova
- Office of Quality and Patient Safety, NYC Health + Hospitals, New York, New York; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Peter Alarcon Manchego
- Office of Quality and Patient Safety, NYC Health + Hospitals, New York, New York; Department of Pediatrics, NYC Health + Hospitals/Kings County, New York, New York
| | - Hyung J Cho
- Vice President of Quality, Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts
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Metusela C, Mullan J, Kobel C, Rhee J, Batterham M, Barnett S, Bonney A. CHIME-GP trial of online education for prescribing, pathology and imaging ordering in general practice - how did it bring about behaviour change? BMC Health Serv Res 2023; 23:1346. [PMID: 38042789 PMCID: PMC10693689 DOI: 10.1186/s12913-023-10374-1] [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: 05/29/2023] [Accepted: 11/23/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND There is a need for scalable clinician education in rational medication prescribing and rational ordering of pathology and imaging to help improve patient safety and enable more efficient utilisation of healthcare resources. Our wider study evaluated the effectiveness of a multifaceted education intervention for general practitioners (GPs) in rational prescribing and ordering of pathology and imaging tests, in the context of Australia's online patient-controlled health record system, My Health Record (MHR), and found evidence for measurable behaviour change in pathology ordering among participants who completed the educational activities. This current study explored the mechanisms of behaviour change brought about by the intervention, with a view to informing the development of similar interventions in the future. METHODS This mixed methods investigation used self-reported questionnaires at baseline and post-education on MHR use and rational prescribing and test ordering. These were analysed using multi-level ordinal logistic regression models. Semi-structured interviews pre- and post-intervention were also conducted and were analysed thematically using the COM-B framework. RESULTS Of the 106 GPs recruited into the study, 60 completed baseline and 37 completed post-education questionnaires. Nineteen participants were interviewed at baseline and completion. Analysis of questionnaires demonstrated a significant increase in confidence using MHR and in self-reported frequency of MHR use, post-education compared with baseline. There were also similar improvements in confidence across the cohort pre-post education in deprescribing, frequency of review of pathology ordering regimens and evidence-based imaging. The qualitative findings showed an increase in GPs' perceived capability with, and the use of MHR, at post-education compared with baseline. Participants saw the education as an opportunity for learning, for reinforcing what they already knew, and for motivating change of behaviour in increasing their utilisation of MHR, and ordering fewer unnecessary tests and prescriptions. CONCLUSIONS Our education intervention appeared to provide its effects through providing opportunity, increasing capability and enhancing motivation to increase MHR knowledge and usage, as well as rational prescribing and test ordering behaviour. There were overlapping effects of skills acquisition and confidence across intervention arms, which may have contributed to wider changes in behaviour than the specific topic area addressed in the education. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ACTRN12620000010998) (09/01/2020).
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Affiliation(s)
- Christine Metusela
- Graduate School of Medicine, University of Wollongong, Wollongong, Australia.
| | - Judy Mullan
- Graduate School of Medicine, University of Wollongong, Wollongong, Australia
| | - Conrad Kobel
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Joel Rhee
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Marijka Batterham
- School of Mathematics and Applied Statistics, University of Wollongong, Wollongong, Australia
| | - Stephen Barnett
- Graduate School of Medicine, University of Wollongong, Wollongong, Australia
| | - Andrew Bonney
- Graduate School of Medicine, University of Wollongong, Wollongong, Australia
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Bonney A, Kobel C, Mullan J, Metusela C, Rhee JJ, Barnett S, Batterham M. Randomised trial of general practitioner online education for prescribing and test ordering. BMJ Open Qual 2023; 12:e002351. [PMID: 37857521 PMCID: PMC10603404 DOI: 10.1136/bmjoq-2023-002351] [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: 03/21/2023] [Accepted: 09/21/2023] [Indexed: 10/21/2023] Open
Abstract
INTRODUCTION Potentially inappropriate medicine prescriptions and low-value diagnostic testing pose risks to patient safety and increases in health system costs. The aim of the Clinical and Healthcare Improvement through My Health Record usage and Education in General Practice study was to evaluate a scalable online quality improvement intervention, integrating online education regarding a national shared electronic health record and rational prescribing, pathology and imaging ordering by Australian general practitioners (GPs). METHODS The study was a parallel three-arm randomised trial comprising a prescribing education arm, a pathology education arm and an imaging education arm. Currently practising GPs in Australia were eligible to participate and randomised on a 1:1:1 basis to the study arms after consenting. The response to the intervention in reducing potentially unnecessary medicine prescriptions and tests in each arm was assessed using the other two arms as controls. The primary outcome was the cost per 100 consultations of predefined medication prescriptions, pathology and radiology test ordering 6 months following the intervention, compared with 6 months prior. Outcomes were assessed on intention-to-treat and post hoc per-protocol bases using multilevel regression models, with the analysts blinded to allocation. RESULTS In total, 106 GPs were enrolled and randomised (prescribing n=35, pathology n=36, imaging n=35). Data were available for 97 GPs at the end of trial (prescribing n=33, pathology n=32, imaging n=32) with 44 fully completing the intervention. In intention-to-treat analysis, there were no significant differences in the rates of change in costs across the three arms. Per protocol, there was a statistically significant difference in the rate of change in pathology costs (p=0.03). In the pathology arm, the rate of increase in pathology costs was significantly lower by $A187 (95% CI -$A340, -$A33) than the prescribing arm, and non-significantly $A9 (95% CI -$A128, $A110) lower than the imaging arm. DISCUSSION This study provides some evidence for reductions in costs for low-value pathology test ordering in those that completed the relevant online education. The study experienced slow uptake and low completion of the education intervention during the COVID-19 pandemic. Changes were not significant for the primary endpoint, which included all participants. Improving completion rates and combining real-time feedback on prescribing or test ordering may increase the overall effectiveness of the intervention. Given the purely online delivery of the education, there is scope for upscaling the intervention, which may provide cost-effectiveness benefits. TRIAL REGISTRATION NUMBER ACTRN12620000010998.
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Affiliation(s)
- Andrew Bonney
- Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Conrad Kobel
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Judy Mullan
- Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Christine Metusela
- Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Joel J Rhee
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen Barnett
- Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Marijka Batterham
- School of Mathematics and Applied Statistics, University of Wollongong, Wollongong, New South Wales, Australia
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O'Leary H, Robinson K, Glynn L, Lenehan B, McCreesh K. "You're stuck in the middle here": a qualitative study of GPs' experiences of managing knee pain attributed to a degenerative meniscal tear. BMC PRIMARY CARE 2023; 24:127. [PMID: 37344762 DOI: 10.1186/s12875-023-02075-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 06/08/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Exercise is the recommended first-line therapy for a degenerative meniscal tear (DMT). Despite this, knee pain attributed to DMTs are a common presentation to specialist orthopaedic clinics. In the primary care setting, the general practitioner (GP) plays a central role in managing patients with knee pain, but to date their perspective has not been explored in relation to DMTs. This study explored GPs' experiences of managing people with knee pain attributed to a DMT. METHODS A qualitative research design was adopted and practices in the South and Mid-West of Ireland were contacted via recruitment emails circulated through professional and research networks. Interested GPs contacted the researchers via email, and purposive and snowball sampling was used for recruitment. Semi-structured interviews were conducted online or over the telephone. Interviews were digitally recorded and transcribed. Data was analysed using an inductive approach to thematic analysis. Ethical approval was granted by the Irish College of General Practitioners (ICGP_REC_21_0031). RESULTS Seventeen semi-structured one-on-one interviews were conducted. Three main themes were identified with related subthemes: (1) GPs' experiences of relational aspects of care, (2) GP beliefs about what constitutes best care for patients with a DMT, and (3) how GP practice is enacted within the current healthcare setting. GPs described the challenge of maintaining a strong clinical alliance, while managing perceived patient expectations of a 'quick fix' and advanced imaging. They reported slowing down clinical decisions and feeling 'stuck' with limited options when conservative treatment had failed. GPs believed that exercise should be the core treatment for DMTs and emphasised engaging patients in an active approach to recovery. Some GPs believed arthroscopy had a role in circumstances where patients didn't improve with physiotherapy. Limited access to public physiotherapy and orthopaedic services hampered GPs' management plans and negatively impacted patient outcomes. CONCLUSIONS GP beliefs around what constitutes best care for a DMT generally aligned with the evidence base. Nonetheless, there was sometimes tension between these beliefs and the patient's own treatment expectations. The ability to enact their beliefs was hampered by limited access to conservative management options, sometimes leading to early escalation of care.
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Affiliation(s)
- Helen O'Leary
- School of Allied Health and Health Research Institute, Faculty of Education and Health Science, University of Limerick, Limerick, Ireland.
| | - Katie Robinson
- School of Allied Health and Ageing Research Centre, Health Research Institute, Faculty of Education and Health Science, University of Limerick, Limerick, Ireland
| | - Liam Glynn
- Graduate Entry Medical School and Health Research Institute, University of Limerick, Limerick, Ireland
| | - Brian Lenehan
- Chief Clinical Director UL Hospitals Group and Consultant Orthopaedic Surgeon, Orthopaedics and Trauma Department, University Hospital Limerick, Limerick, Ireland
| | - Karen McCreesh
- School of Allied Health, and Ageing Research Centre, Health Research Institute, Faculty of Education and Health Science, University of Limerick, Limerick, Ireland
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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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10
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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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11
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Chawla JK, Sushil P, Kumar P. Translation and Validation of Low Back Pain Knowledge Questionnaire Among Hindi-Speaking Indian Women. J Pain Palliat Care Pharmacother 2023:1-10. [PMID: 36716286 DOI: 10.1080/15360288.2023.2169432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Low back pain (LBP) is a common problem encountered among women worldwide. This research aimed at the cross-cultural translation, adaptation, and equivalence assessment of the Low Back Pain Knowledge Questionnaire (LBPKQ) in the Hindi language. The LBPKQ, originally in English (E-LBPKQ) was translated and validated in the Hindi language (H-LBPKQ). The forward-backward procedure was adapted from the recommended guidelines for cross-cultural adaptation of measures. Psychometric properties of the H-LBPKQ were evaluated among 250 Hindi-speaking Indian women with LBP. Test-retest reliability was evaluated in the first 161 participants of the study sample. The overall LBPKQ scores obtained a mean of 3.1 ± 1.1. The internal consistency was excellent for both E-LBPKQ and H-LBPKQ, with Cronbach's alpha of 0.983 (95% confidence interval [CI], 0.980-0.986) and 0.975 (95% CI, 0.970-0.979), respectively. Construct validity was good, with Kaiser-Meyer-Olkin value of 0.892 for E-LBPKQ and 0.852 for H-LBPKQ. Bartlett's test of sphericity (P < .0001) was significant for E-LBPKQ and H-LBPKQ. Two factors were extracted through principal component analysis. The H-LBPKQ is valid and reliable to assess LBP knowledge among Hindi speaking population. Low LBPKQ scores indicate poor LBP knowledge; hence, LBP sensitization is needed among Indian women.
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12
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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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13
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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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14
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Korenstein D, Gillespie EF. Audit and Feedback-Optimizing a Strategy to Reduce Low-Value Care. JAMA 2022; 328:833-835. [PMID: 36066538 DOI: 10.1001/jama.2022.14173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Erin F Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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15
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Dunne CL, Elzinga JL, Vorobeichik A, Sudershan S, Keto-Lambert D, Lang E, Dowling S. A Systematic Review of Interventions to Reduce Computed Tomography Usage in the Emergency Department. Ann Emerg Med 2022; 80:548-560. [PMID: 35927114 DOI: 10.1016/j.annemergmed.2022.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/26/2022] [Accepted: 06/02/2022] [Indexed: 12/19/2022]
Abstract
STUDY OBJECTIVE Unnecessary computed tomography (CT) scans burden the health care system, leading to increased emergency department (ED) wait times and lengths of stay, costing almost a billion dollars annually. This study aimed to describe ED-based interventions that are most effective at reducing CT imaging while maintaining diagnostic accuracy and patient safety. METHODS Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and Google Scholar were searched until December 31, 2020. Randomized and nonrandomized studies that assessed the effect of an ED-based intervention on CT scan usage were included. Abstract screening, data extraction, and quality assessment were conducted in duplicate. The Grading of Recommendation Assessment, Development and Evaluation framework, with the Risk of Bias 2 and Risk of Bias in Nonrandomized Studies - of Interventions tools, was used to determine the certainty of evidence. Significant clinical and statistical heterogeneity precluded meta-analysis; hence, a narrative synthesis was conducted. RESULTS A total of 149 studies were included of 5,667 screened abstracts, with substantial interrater reliability among reviewers (Cohen's κ>0.60). The CT reduction strategies were categorized into 15 single and 11 multimodal interventions by consensus review. Interventions that consistently reduced CT usage included diagnostic pathways, alternative test availability, specialist involvement, and provider feedback. Family/patient education, clinical decision support tools, or passive guideline dissemination did not consistently reduce usage. Only 44% of studies reported unintended consequences of reduction strategies; however, these showed no increase in missed diagnoses or patient harm. The interventions that engaged multiple specialties during planning/implementation had a greater reduction effect than ED only. The certainty of evidence for the primary outcome was very low. CONCLUSION Multidisciplinary-led interventions that provided an alternative to CT imaging were the most effective at reducing usage and did so without compromising patient safety.
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Affiliation(s)
- Cody L Dunne
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Jason L Elzinga
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Allen Vorobeichik
- Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sanjana Sudershan
- Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Diana Keto-Lambert
- Alberta SPOR SUPPORT Unit, University of Calgary, Calgary, Alberta, Canada
| | - Eddy Lang
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shawn Dowling
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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16
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Oza SK, Joo P, Grochowalski JH, Rougas S, George P, Milan F. Novel use of an OSCE to assess medical students' responses to a request for a low value diagnostic imaging test: A mixed methods analysis. PATIENT EDUCATION AND COUNSELING 2022; 105:2264-2269. [PMID: 34716052 DOI: 10.1016/j.pec.2021.10.021] [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] [Received: 06/18/2021] [Revised: 10/08/2021] [Accepted: 10/20/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Evaluate medical students' communication skills with a standardized patient (SP) requesting a low value test and describe challenges students identify in addressing the request. METHODS In this mixed-methods study, third-year students from two medical schools obtained a history, performed a physical examination, and counseled an SP presenting with uncomplicated low back pain who requests an MRI which is not indicated. SP raters evaluated student communication skills using a 14-item checklist. Post-encounter, students reported whether they ordered an MRI and challenges faced. RESULTS Students who discussed practice guidelines and risks of unnecessary testing with the SP were less likely to order an MRI. Students cited several challenges in responding to the SP request including patient characteristics and circumstances, lack of knowledge about MRI indications and alternatives, and lack of communication skills to address the patient request. CONCLUSIONS Most students did not order an MRI for uncomplicated LBP, but only a small number of students educated the patient about the evidence to avoid unnecessary imaging or the harm of unnecessary testing. PRACTICE IMPLICATIONS Knowledge about unnecessary imaging in uncomplicated LBP may be insufficient to adhere to best practices and longitudinal training in challenging conversations is needed.
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Affiliation(s)
- Sandra K Oza
- Department of Medicine, Albert Einstein College of Medicine, Bronx, USA.
| | - Pablo Joo
- Department of Family Medicine, University of California Riverside School of Medicine, Riverside, USA
| | | | - Steven Rougas
- Department of Emergency Medicine, Office of Medical Education, Alpert Medical School of Brown University, Providence, USA
| | | | - Felise Milan
- Department of Medicine, Albert Einstein College of Medicine, Bronx, USA
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17
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van Dulmen SA, Tran NH, Wiersma T, Verkerk EW, Messaoudi JC, Burgers JS, Kool RB. Identifying and prioritizing do-not-do recommendations in Dutch primary care. BMC PRIMARY CARE 2022; 23:141. [PMID: 35658832 PMCID: PMC9164383 DOI: 10.1186/s12875-022-01713-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/18/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Low-value care provides minimal or no benefit for the patient, wastes resources, and can cause harm. Explicit do-not-do recommendations in clinical guidelines are a first step in reducing low-value care. The aim of this study was to identify and prioritize do-not-do recommendations in general practice guidelines with priority for implementation. METHODS We used a mixed method design in Dutch primary care. First, we identified do-not-do recommendations through a systematic assessment of 92 Dutch guidelines for general practitioners (GPs), resulting in 385 do-not-do recommendations. Second, we selected 146 recommendations addressing high prevalent conditions. Third, a random sample of 5000 Dutch GPs was invited for an online survey to prioritize recommendations based on the prevalence of the condition and low-value care practice, potential harm, and potential cost reduction on a scale from 1 to 5/6. Total scores could range from 4 to 22. Recommendations with a median score > 12 were included. In total, 440 GPs completed the survey. RESULTS The selection process led to 30 prioritised recommendations. These covered drug treatments (n = 12), diagnostics (n = 10), referral to other healthcare professions (n = 5), and non-drug treatment (n = 3). CONCLUSION Dutch clinical guidelines include many do-not-do recommendations that are perceived as highly relevant by the GPs. The list of 30 high-priority do-not-do recommendations can be used to raise awareness of low-value care among GPs. As the recommendations are supported with the latest evidence from international studies, primary healthcare professionals and policy makers worldwide can use the list for further validating the list in their local context and designing strategies to reduce low-value care.
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Affiliation(s)
- Simone A van Dulmen
- Radboud university medical center, Radboud Institute for Health Science, IQ healthcare, PO Box 9101 (160), 6500 HB, Nijmegen, the Netherlands.
| | - Ngoc Hue Tran
- Radboud university medical center, Radboud Institute for Health Science, IQ healthcare, PO Box 9101 (160), 6500 HB, Nijmegen, the Netherlands
| | - Tjerk Wiersma
- Dutch College of General Practitioners, Mercatorlaan 1200, 3528 BL, Utrecht, the Netherlands
| | - Eva W Verkerk
- Radboud university medical center, Radboud Institute for Health Science, IQ healthcare, PO Box 9101 (160), 6500 HB, Nijmegen, the Netherlands
| | - Jasmine Cl Messaoudi
- Radboud university medical center, Radboud Institute for Health Science, IQ healthcare, PO Box 9101 (160), 6500 HB, Nijmegen, the Netherlands
| | - Jako S Burgers
- Dutch College of General Practitioners, Mercatorlaan 1200, 3528 BL, Utrecht, the Netherlands
- Department Family Medicine, Care and Public Health Research Institute, Peter Debyeplein 1, 6229 HA, Maastricht, the Netherlands
| | - Rudolf B Kool
- Radboud university medical center, Radboud Institute for Health Science, IQ healthcare, PO Box 9101 (160), 6500 HB, Nijmegen, the Netherlands
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18
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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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20
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Witherow J, Jenkins H, Elliott J, Ip G, Maher C, Magnussen J, Hancock M. Characteristics and Effectiveness of Interventions That Target the Reporting, Communication, or Clinical Interpretation of Lumbar Imaging Findings: A Systematic Review. AJNR Am J Neuroradiol 2022; 43:493-500. [PMID: 35210277 PMCID: PMC8910802 DOI: 10.3174/ajnr.a7432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 12/23/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Patients and clinicians may misinterpret the clinical importance of imaging findings in patients with low back pain, leading to potential harm related to overdiagnosis. PURPOSE Our aims were to qualitatively summarize the characteristics of tested interventions that target the reporting, communication, or clinical interpretation of lumbar imaging findings and determine whether interventions are effective in improving low back pain-related health outcomes, health care use, or health care costs. DATA SOURCES PubMed, MEDLINE, CINAHL, EMBASE, PsycINFO, and the Cochrane Library were searched from inception to October 20, 2021. STUDY SELECTION The search retrieved 4394 articles, nine articles (seven studies) met the inclusion criteria to summarize intervention characteristics. Five of these studies had an adequate design for evaluating intervention effectiveness. DATA ANALYSES Intervention characteristics were summarized using the Template for Intervention Description and Replication checklist. Effectiveness data were extracted from short, intermediate, and long-term follow-up points. Studies were assessed for risk of bias, and Grading of Recommendations Assessment, Development and Evaluation methodology was used to determine the certainty of the evidence. DATA SYNTHESIS Four studies investigated the insertion of prevalence information into imaging reports. Single studies investigated withholding diagnostic information, education, and reassurance. Moderate-quality evidence (from 1 study) suggests that inserting prevalence information into imaging reports probably does not change the overall health care use in the long-term but may reduce opioid prescribing. LIMITATIONS The available evidence is limited, and a meta-analysis was not possible. CONCLUSIONS Further work is required to develop and test interventions that target the reporting, communication, and clinical interpretation of lumbar imaging findings that may reduce overdiagnosis and improve the management of low back pain.
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Affiliation(s)
- J.L. Witherow
- From the Faculty of Medicine, Health and Human Sciences (J.L.W., H.J.J., G.H.I., J.S.M., M.J.H), Macquarie University, Sydney, New South Wales, Australia
| | - H.J. Jenkins
- From the Faculty of Medicine, Health and Human Sciences (J.L.W., H.J.J., G.H.I., J.S.M., M.J.H), Macquarie University, Sydney, New South Wales, Australia
| | - J.M. Elliott
- Faculty of Medicine and Health (J.M.E.),The Kolling Institute of Medical Research (J.M.E.), Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - G.H. Ip
- From the Faculty of Medicine, Health and Human Sciences (J.L.W., H.J.J., G.H.I., J.S.M., M.J.H), Macquarie University, Sydney, New South Wales, Australia
| | - C.G. Maher
- Sydney School of Public Health (C.G.M.), Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia,Institute for Musculoskeletal Health (C.G.M.), Sydney, New South Wales, Australia
| | - J.S. Magnussen
- From the Faculty of Medicine, Health and Human Sciences (J.L.W., H.J.J., G.H.I., J.S.M., M.J.H), Macquarie University, Sydney, New South Wales, Australia
| | - M.J. Hancock
- From the Faculty of Medicine, Health and Human Sciences (J.L.W., H.J.J., G.H.I., J.S.M., M.J.H), Macquarie University, Sydney, New South Wales, Australia
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21
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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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22
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Blokzijl J, Lee H, Cullen L, Coggins A, Golding M, Gillett M, Middleton PM, Ferreira GE, Machado GC, Maher CG, Traeger AC. Diagnoses and trends in use of imaging for low back pain in four Australian emergency departments between 2012 and 2019. Emerg Med Australas 2022; 34:539-546. [DOI: 10.1111/1742-6723.13928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Johan Blokzijl
- Institute for Musculoskeletal Health Sydney Local Health District and The University of Sydney Sydney New South Wales Australia
- Physical Therapy Sciences, Program in Clinical Health Sciences, University Medical Center Utrecht Utrecht University Utrecht The Netherlands
| | - Hopin Lee
- Centre for Statistics in Medicine, Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences University of Oxford Oxford UK
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital The University of Queensland Brisbane Queensland Australia
| | - Andrew Coggins
- Emergency Department Westmead Hospital Sydney New South Wales Australia
| | - Michael Golding
- Emergency Department Prince of Wales Hospital Sydney New South Wales Australia
| | - Mark Gillett
- Emergency Department Royal North Shore Hospital Sydney New South Wales Australia
| | - Paul M Middleton
- Emergency Department Liverpool Hospital Sydney New South Wales Australia
- South Western Emergency Research Institute Liverpool Hospital Sydney New South Wales Australia
| | - Giovanni E Ferreira
- Institute for Musculoskeletal Health Sydney Local Health District and The University of Sydney Sydney New South Wales Australia
| | - Gustavo C Machado
- Institute for Musculoskeletal Health Sydney Local Health District and The University of Sydney Sydney New South Wales Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health Sydney Local Health District and The University of Sydney Sydney New South Wales Australia
| | - Adrian C Traeger
- Institute for Musculoskeletal Health Sydney Local Health District and The University of Sydney Sydney New South Wales Australia
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23
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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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [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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24
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Diniz LM, Oliveira CB, Machado GC, Maher CG, Verhagen AP, Fernandes DAM, Franco MR, Souza TR, Pinto RZ. Effectiveness of brief patient information materials for promoting correct beliefs about imaging and inevitable consequences of low back pain: A randomised controlled trial. Clin Rehabil 2021; 36:527-537. [PMID: 34931854 DOI: 10.1177/02692155211065974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate what format for providing patient information (i.e. written summary, infographic or video animation) is most effective for promoting correct beliefs about imaging and inevitable consequences of low back pain (LBP). DESIGN Randomised controlled trial. SETTING/PATIENTS One hundred and fifty-nine patients with non-specific LBP were recruited from outpatient physiotherapy clinics. INTERVENTION Participants were randomised to receive patient information in one of three formats: video animation, infographic or written summary. Patients were allowed to read or watch the materials for up to 20 min. MEASUREMENTS Outcome were assessed before and immediately after the intervention. The primary outcome was the Back Beliefs Questionnaire. The secondary outcome was beliefs about imaging for LBP assessed by two questions. RESULTS All 159 patients completed the study. Our findings revealed no difference between groups for the Back Beliefs Questionnaire. Correct beliefs about imaging were more likely with the infographic than the video animation (Question 1- Odds Ratio [OR] = 3.9, 95% confidence interval [CI]: 1.7, 8.7; Question 2- OR = 6.8, 95%CI: 2.7, 17.2) and more likely with the written summary than the video animation (Question 1- OR = 3.3, 95%CI: 1.5, 7.4; Question 2- OR = 3.7, 95%CI: 1.6, 8.5). No difference between infographic and written summary formats were reported for the questions assessing LBP imaging beliefs. CONCLUSION The three materials were equally effective in improving patient's general beliefs about LBP care. However, the traditional written summary or infographic formats were more effective than the video animation format for improving beliefs about imaging for LBP.
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Affiliation(s)
- Leandro M Diniz
- Department of Physical Therapy, 28114Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brasil
| | - Crystian B Oliveira
- Faculty of Medicine, 28108University of Western São Paulo (UNOESTE), Presidente Prudente, Sao Paulo, Brazil
| | - Gustavo C Machado
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Arianne P Verhagen
- Discipline of Physiotherapy, Graduate School of Health, 1994University of Technology Sydney, Sydney, Australia
| | - Daysiane A M Fernandes
- Department of Physical Therapy, 28114Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brasil
| | - Marcia R Franco
- Department of Physical Therapy, 218459Centro Universitário UNA, Belo Horizonte, Brasil
| | - Thales R Souza
- Department of Physical Therapy, 28114Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brasil
| | - Rafael Z Pinto
- Department of Physical Therapy, 28114Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brasil
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25
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Sharma S, Traeger AC, Tcharkhedian E, Middleton PM, Cullen L, Maher CG. Effect of a waiting room communication strategy on imaging rates and awareness of public health messages for low back pain. Int J Qual Health Care 2021; 33:6384520. [PMID: 34623440 DOI: 10.1093/intqhc/mzab129] [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: 05/17/2021] [Revised: 07/22/2021] [Accepted: 09/06/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Few studies have investigated the effects of waiting room communication strategies on health-care behavior. OBJECTIVE We aimed to determine the effect of a waiting room communication strategy, designed to raise awareness of potential harms of unnecessary imaging, on lumbar imaging rates in the emergency department (ED). METHODS We conducted a controlled experimental study with a replicated time series design. The design included a 6-week run-in time. Following this there were alternating 1-week intervention and control periods. The intervention group received a communication strategy describing the potential harms of unnecessary imaging for low back pain, shown on a 55" LCD screen positioned in the ED waiting room. The communication strategy was designed by a creative innovation agency and included five digital posters and a patient leaflet. The control group received standard messaging for the waiting room at the time, shown on the same 55" LCD screen, and access to the patient leaflet. The primary outcome was the number and proportion of people presenting to ED with low back pain who received at least one lumbar imaging test, measured using routinely collected ED data. Secondary patient-reported outcomes (patient satisfaction and awareness of campaign messages) were collected from a sample of people presenting for any condition who responded to a text-message-based survey. RESULTS For the imaging outcome, 337 people presenting to ED with low back pain were included over a 4-month period (intervention n = 99; control n = 238). All had available data on lumbar imaging. Use of lumbar imaging was 25% in those exposed to the communication strategy [95% confidence interval (CI) = 18% to 35%] compared with 29% in those exposed to the standard waiting room messaging [95% CI = 23% to 35%; odds ratio (OR) = 0.83, 95% CI = 0.49 to 1.41]. For the patient-reported outcomes, 349 patients presenting to ED for any condition responded to the survey (intervention n = 170; control n = 179; response rate = 33%). There was uncertain evidence that the intervention increased awareness of the communication strategy leaflet (OR = 2.00, 95% CI = 0.90 to 4.47). Other measures did not suggest between-group differences in patient satisfaction or awareness of the campaign messages. CONCLUSION A communication strategy displayed in the ED waiting room may slightly reduce the proportion of patients with low back pain who receive lumbar imaging, although there is uncertainty due to imprecision. The campaign did not appear to increase awareness of campaign messages or affect patient satisfaction in a sample of patients presenting to the ED for any reason. Larger studies should investigate whether simple, low-cost waiting room communication strategies can raise awareness of unnecessary healthcare and influence health-care quality. TRIAL REGISTRATION ACTRN12620000300976, 05/03/2020.
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Affiliation(s)
- Sweekriti Sharma
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, New South Wales 2050, Australia.,School of Public Health, The University of Sydney, New South Wales 2006, Australia
| | - Adrian C Traeger
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, New South Wales 2050, Australia.,School of Public Health, The University of Sydney, New South Wales 2006, Australia
| | - Elise Tcharkhedian
- Department of Physiotherapy, Liverpool Hospital, Sydney, NSW 2170, Australia
| | - Paul M Middleton
- South Western Emergency Research Institute, Liverpool Hospital, Liverpool, NSW 2170, Australia.,Discipline of Emergency Medicine, University of Sydney, Sydney, NSW 2006, Australia
| | - Louise Cullen
- Emergency and Trauma Center, Royal Brisbane and Women's Hospital, University of Queensland, Brisbane, QLD 4029, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, New South Wales 2050, Australia.,School of Public Health, The University of Sydney, New South Wales 2006, Australia
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26
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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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27
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Madani Larijani M, Azizian A, Carr T, Adams SJ, Groot G. Combined lumbar spine MRI and CT appropriateness checklist: a quality improvement project in Saskatchewan, Canada. Int J Qual Health Care 2021; 33:6347323. [PMID: 34374421 PMCID: PMC8398757 DOI: 10.1093/intqhc/mzab120] [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: 03/31/2021] [Revised: 07/05/2021] [Accepted: 08/09/2021] [Indexed: 11/25/2022] Open
Abstract
Background As rates of advanced imaging for lower back pain (LBP) continue to increase, there is a need to ensure the appropriateness of imaging. Objective The goal of this project was to reduce the number of inappropriate magnetic resonance imaging (MRI) and computed tomography (CT) requests for LBP patients and facilitate appropriate imaging by developing a combined imaging appropriateness checklist for lumbar spine MRI and CT. Methods In prior work, we developed and adopted individual evidence-based lumbar spine MRI and CT checklists into the radiology requisition process. In the current project, a combined checklist was developed and trialed in one of the former Saskatchewan health regions (Five Hills) beginning in May 2018. Using statistical process control, control charts compared the monthly number of imaging requests pre-checklist implementation and post-checklist implementation from May 2017 to February 2020. The monthly number of lumbar spine MRI and CT requisitions in the nearby former Saskatchewan Regina Qu’Appelle Health Region, in which the combined checklist was not trialed, was also plotted and compared as a balancing measure. Results In Five Hills, a shift (decrease) was observed in the monthly number of lumbar spine MRI requisitions 7 months following the implementation of the combined checklist. However, the monthly number of lumbar spine CT requisitions did not change significantly. In the Regina Qu’Appelle Health Region, there was a shift (increase) in the monthly number of lumbar spine MRI requisitions, while the monthly number of lumbar spine CT requests decreased after the implementation of the combined checklist. Conclusions The combined checklist with evidence-based indications for lumbar spine MRI and CT imaging in LBP patients appeared to reduce the complexity associated with two previous individual checklists and facilitate imaging appropriateness. Accountable benefits may include the reduction of radiation exposure as a result of unnecessary and repeated imaging and reduction in wait times for CT and/or MRI.
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Affiliation(s)
- Maryam Madani Larijani
- Community Health and Epidemiology, University of Saskatchewan, 107 Wiggins Road, Saskatoon, SK S7N 5E5, Canada
| | - Amir Azizian
- Saskatchewan Health Quality Council, Innovation Place, The Atrium, 111 Research Drive, Saskatoon, SK S7N 3R2, Canada
| | - Tracey Carr
- Community Health and Epidemiology, University of Saskatchewan, 107 Wiggins Road, Saskatoon, SK S7N 5E5, Canada
| | - Scott J Adams
- Department of Medical Imaging, University of Saskatchewan, 103 Hospital Drive, Saskatoon, SK S7N 0W8, Canada
| | - Gary Groot
- Community Health and Epidemiology, University of Saskatchewan, 107 Wiggins Road, Saskatoon, SK S7N 5E5, Canada
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28
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Bonney A, Metusela C, Mullan J, Barnett S, Rhee J, Kobel C, Batterham M. Clinical and healthcare improvement through My Health Record usage and education in general practice (CHIME-GP): a study protocol for a cluster-randomised controlled trial. Trials 2021; 22:569. [PMID: 34454563 PMCID: PMC8397855 DOI: 10.1186/s13063-021-05438-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 07/08/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND There is an international interest in whether improved primary care can lead to a more rational use of health resources. There is evidence that educational interventions can lead to improvements in the quality of rational prescribing and test ordering. A new national platform for shared medical records in Australia, My Health Record (MHR), poses new opportunities and challenges for system-wide implementation. This trial (CHIME-GP) will investigate whether components of a multifaceted education intervention in an Australian general practice setting on rational prescribing and investigation ordering leads to reductions in health-service utilisation and costs in the context of the use of a national digital health record system. METHODS The trial will be undertaken in Australian general practices. The aim of the research is to evaluate the effectiveness of components of a web-based educational intervention for general practitioners, regarding rational use of medicines, pathology and imaging in the context of the use of the MHR system. Our target is to recruit 120 general practitioners from urban and regional regions across Australia. We will use a mixed methods approach incorporating a three-arm pragmatic cluster randomised parallel trial and a prospective qualitative inquiry. The effect of each education component in each arm will be assessed, using the other two arms as controls. The evaluation will synthesise the results embedding qualitative pre/post interviews in the quantitative results to investigate implementation of the intervention, clinical behaviour change and mechanisms such as attitudes, that may influence change. The primary outcome will be an economic analysis of the cost per 100 consultations of selected prescriptions, pathology and radiology test ordering in the 6 months following the intervention compared with 6 months prior to the intervention. Secondary outcome measures include the rates per 100 consultations of selected prescriptions, pathology and radiology test ordering 6 months pre- and post-intervention, and comparison of knowledge assessment tests pre- and post-intervention. DISCUSSION The trial will produce robust health economic analyses on the evidence on educational intervention in reducing unnecessary prescribing, pathology and imaging ordering, in the context of MHR. In addition, the study will contribute to the evidence-base concerning the implementation of interventions to improve the quality of care in primary care practice. TRIAL REGISTRATION ClinicalTrials.gov ACTRN12620000010998 . Registered on 09 January 2020 with the Australian New Zealand Clinical Trials Registry.
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Affiliation(s)
- Andrew Bonney
- University of Wollongong, Northfields Avenue, Wollongong, NSW 2522 Australia
| | - Christine Metusela
- University of Wollongong, Northfields Avenue, Wollongong, NSW 2522 Australia
| | - Judy Mullan
- University of Wollongong, Northfields Avenue, Wollongong, NSW 2522 Australia
| | | | - Joel Rhee
- University of Wollongong, Northfields Avenue, Wollongong, NSW 2522 Australia
| | - Conrad Kobel
- University of Wollongong, Northfields Avenue, Wollongong, NSW 2522 Australia
| | - Marijka Batterham
- University of Wollongong, Northfields Avenue, Wollongong, NSW 2522 Australia
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29
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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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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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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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Alhowimel A, Alodaibi F, Alotaibi M, Alamam D, Alsobayel H, Fritz J. Development of a Logic Model for a Programme to Reduce the Magnetic Resonance Imaging Rate for Non-Specific Lower Back Pain in a Tertiary Care Centre. Healthcare (Basel) 2021; 9:healthcare9020238. [PMID: 33672242 PMCID: PMC7926309 DOI: 10.3390/healthcare9020238] [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: 01/29/2021] [Revised: 02/16/2021] [Accepted: 02/19/2021] [Indexed: 11/16/2022] Open
Abstract
Tertiary care centres continue to experience over-utilisation of diagnostic imaging services for lower back pain cases that may not be required. Moreover, these services may require additional time and consequently delay access to services that offer conservative management, i.e., physiotherapy, and hence, increase the direct and indirect costs with no added quality of care. A logic model was developed based on qualitative and quantitative studies that explains the plan and process evaluation strategies to reduce imaging for lower back pain in tertiary hospitals. Logic models are useful tools for defining programme components. The delivery of the components is ensured by well-defined process evaluations that identify any needed modifications. The proposed logic model provides a road map for spine clinics in tertiary care hospitals to decrease the number of patient referrals for magnetic resonance imaging and waiting times for consultations and services and promote early access to physiotherapy services.
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Affiliation(s)
- Ahmed Alhowimel
- Department of Health and Rehabilitation Science, Prince Sattam Bin Abdulaziz University, Al-Kharj 16278, Saudi Arabia;
- Correspondence:
| | - Faris Alodaibi
- College of Applied Medical Sciences, Health Rehabilitation Sciences, King Saud University, Riyadh 11451, Saudi Arabia; (F.A.); (D.A.); (H.A.)
| | - Mazyad Alotaibi
- Department of Health and Rehabilitation Science, Prince Sattam Bin Abdulaziz University, Al-Kharj 16278, Saudi Arabia;
| | - Dalyah Alamam
- College of Applied Medical Sciences, Health Rehabilitation Sciences, King Saud University, Riyadh 11451, Saudi Arabia; (F.A.); (D.A.); (H.A.)
| | - Hana Alsobayel
- College of Applied Medical Sciences, Health Rehabilitation Sciences, King Saud University, Riyadh 11451, Saudi Arabia; (F.A.); (D.A.); (H.A.)
| | - Julie Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT 84112, USA;
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Zomahoun HTV, Visca R, George N, Ahmed S. Effectiveness and harms of clinical decision support systems for referral within chronic pain practice: protocol for a systematic review and meta-analysis. Syst Rev 2021; 10:53. [PMID: 33563328 PMCID: PMC7874648 DOI: 10.1186/s13643-021-01596-7] [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] [Received: 08/05/2020] [Accepted: 01/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic pain is a common public health problem with negative consequences for individuals and societies. Fortunately, interdisciplinary chronic pain management has been shown to be effective for improving patients' outcomes and strongly recommended in clinical practice guidelines. Appropriate referral within the healthcare system based on individuals' needs and available services is essential to optimise health-related outcomes and maximise resources. Clinical decision support systems have been shown to be effective for supporting healthcare professionals in different practices. However, there is no knowledge synthesis on clinical decision support systems for referral within chronic pain practice. We aim to identify the clinical decision support systems for referral within chronic pain practices and assess their content, effectiveness, harms, and validation parameters. METHODS Using the methodology of Cochrane reviews, we will perform a systematic review and meta-analysis based on studies meeting the following criteria: Population, patients with chronic pain and/or healthcare professionals working in chronic pain; Intervention, clinical decision support systems for referral within chronic pain practice; Comparison, any other clinical tool, any usual care or practices; Outcomes, clinical outcomes of patients measuring how patients feel, function or survive including benefits, adverse effects, continuity of care, care appropriateness, care satisfaction, quality of life, healthcare professional performance, and cost outcomes; and Study design: randomized controlled trials, non-randomized controlled trials, before and after controlled studies and interrupted time series. We will search relevant literature with the support of an information specialist using Medline, Embase, PsycInfo, CINHAL, Web of Science and Cochrane Library from their inception onwards. Two reviewers will independently complete study selection, data extraction and risk of bias assessment. We will analyse data to perform both narrative syntheses and meta-analysis if appropriate. DISCUSSION Findings of this review will contribute to enhancing chronic pain care and research. Clinical decision support systems identified as effective in this review can be investigated for implementation in clinical practice and impact on improving patient, clinical and health system outcomes. Clinical decision support systems not yet ready for implementation that require further improvement will also be identified. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration: CRD42020158880 .
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Affiliation(s)
- Hervé Tchala Vignon Zomahoun
- Faculty of Medicine, School of Physical and Occupational Therapy, Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec Canada
- McGill University Health Centre, Montreal, Quebec Canada
- Department of Social and Preventive Medicine, Université Laval, Quebec, Quebec Canada
- VITAM Research Centre of Health Sustainability, Quebec, Quebec Canada
| | - Regina Visca
- Faculty of Medicine, School of Physical and Occupational Therapy, Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec Canada
- McGill University Health Centre, Montreal, Quebec Canada
- McGill RUIS Centre of Expertise in Chronic Pain, Montreal, Quebec Canada
- Department of Family Medicine, McGill University, Montreal, Quebec Canada
| | - Nicole George
- Faculty of Medicine, School of Physical and Occupational Therapy, Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec Canada
- McGill University Health Centre, Montreal, Quebec Canada
| | - Sara Ahmed
- Faculty of Medicine, School of Physical and Occupational Therapy, Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec Canada
- McGill University Health Centre, Montreal, Quebec Canada
- McGill RUIS Centre of Expertise in Chronic Pain, Montreal, Quebec Canada
- Centre de recherche interdisciplinaire en réadaptation (CRIR), Constance Lethbridge Rehabilitation Center du CIUSSS du Centre-Ouest-de-l’Île-de-Montréal, Montreal, Canada
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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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Shashar S, Ellen M, Codish S, Davidson E, Novack V. Medical Practice Variation Among Primary Care Physicians: 1 Decade, 14 Health Services, and 3,238,498 Patient-Years. Ann Fam Med 2021; 19:30-37. [PMID: 33431388 PMCID: PMC7800753 DOI: 10.1370/afm.2627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/14/2020] [Accepted: 07/24/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Variation in medical practice is associated with poorer health outcomes, increased costs, disparities in care, and increased burden on the public health system. In the present study, we sought to describe and assess inter- and intra-primary care physician variation, adjusted for patient and clinic characteristics, over a decade of practice and across a broad range of health services. METHODS We assessed practice patterns of 251 primary care physicians in southern Israel. For each of 14 health services (imaging tests, cardiac tests, laboratory tests, and specialist visits) we described interphysician and intraphysician variation, adjusted for patient case mix and clinic characteristics, using the coefficient of variation. The adjusted rates were assessed by generalized linear negative-binomial mixed models. RESULTS The variation between physicians was on average 3-fold greater than the variation of individual physician practice over the years. Services with low utilization were associated with greater inter- and intraphysician variation: rs = (-0.58), P = .03 and rs = (-0.39), P = .17, respectively. In addition, physician utilization ranks averaged over all health services were consistent across the 14 health services (intraclass correlation coefficient, 0.94; 95% CI, 0.93-0.95). CONCLUSIONS Our results show greater variation in practice patterns between physicians than for individual physicians over the years. It appears that the variation remains high even after adjustment for patient and clinic characteristics and that the individual physician utilization patterns are stable across health services. We propose that personal behavioral characteristics of medical practitioners might explain this variation.
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Affiliation(s)
- Sagi Shashar
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
| | - Moriah Ellen
- Department of Health Services Management, Guilford Glazer Faculty of Business and Management, Ben Gurion University of the Negev, Be'er-Sheva, Israel.,Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,McMaster Health Forum, McMaster University, Hamilton, Ontario, Canada
| | - Shlomi Codish
- Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
| | - Ehud Davidson
- General Management, Clalit Health Services, Tel-Aviv, Israel
| | - Victor Novack
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
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Kiel S, Raus C, Sierocinski E, Knauthe P, Chenot JF. Concordance of patient beliefs and expectations regarding the management of low back pain with guideline recommendations - a cross-sectional study in Germany. BMC FAMILY PRACTICE 2020; 21:275. [PMID: 33342429 PMCID: PMC7751122 DOI: 10.1186/s12875-020-01352-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 12/10/2020] [Indexed: 12/19/2022]
Abstract
Background Low back pain is a common reason for patients to seek medical care. Physician non-adherence to clinical guidelines has been observed. We investigated the extent to which patient expectations correspond to recommendations of the German national guideline for management of low back pain (G-LBP) and whether patient characteristics, history of LBP and previous treatment experience are associated with expectations. Methods A cross-sectional study including patients from 13 general practices was conducted. Data were collected using a questionnaire. Inverse probability weights were used to address non-response bias. Descriptive analysis and multivariate logistic regression models were performed. Results A total of 977 patients were included in analyses (median age 57 years, 39% male). 75% of patients reported experiencing LBP currently or within the last year. More than 65% indicated they would agree to forgo further examinations if their LBP was judged by their physician to be of no serious concern. This was associated with the highest level of education and no prior imaging, and negatively associated with good-to-poor health status and moderate-to-severe pain intensity. 40% of participants expected imaging. The highest educational level, female gender and no prior imaging were associated with a decreased expectation of imaging. 70% expected prescriptions for massages. Females, participants with good-to-poor health status, current LBP or LBP in the last 12 months had an increased expectation for massages. Expectations for injection therapy (45%) were mainly associated with previous injections. Expectations for physiotherapy (64%) were associated with female gender, lower educational level, good-to-poor health status, current LBP or in the last 12 months. The perspective that daily activities should be continued (66%) was associated with female gender and higher educational level. Participants who agreed to the statement ‘There is no effective treatment for LBP’ (11%) had a poor health status, current LBP and a severe pain intensity. Conclusion Patient views regarding LBP management are partially concordant with guideline recommendations and are strongly influenced by previous treatment experiences and education level. Exploration of patient expectations and experiences in LBP treatment may help minimize dissatisfaction of patients expecting treatments not endorsed by guidelines and simultaneously increase physician guideline adherence.
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Affiliation(s)
- Simone Kiel
- Department of General Practice, Institute of Community Medicine, University Medicine Greifswald, Fleischmannstraße 6, 17475, Greifswald, Germany.
| | - Christina Raus
- Department of General Practice, Institute of Community Medicine, University Medicine Greifswald, Fleischmannstraße 6, 17475, Greifswald, Germany
| | - Elizabeth Sierocinski
- Department of General Practice, Institute of Community Medicine, University Medicine Greifswald, Fleischmannstraße 6, 17475, Greifswald, Germany
| | | | - Jean-François Chenot
- Department of General Practice, Institute of Community Medicine, University Medicine Greifswald, Fleischmannstraße 6, 17475, Greifswald, Germany
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Hudson D, Knapp K, Benwell M. An evaluation of MRI lumbar spine scans within a community-based diagnostic setting. Musculoskeletal Care 2020; 19:384-395. [PMID: 33278329 DOI: 10.1002/msc.1529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 11/16/2020] [Accepted: 11/20/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND With an ongoing move towards more management of patients within the community setting, demand for magnetic resonance imaging (MRI) is increasing and commonly used in lower back conditions. There is well recorded overuse of MRI in this scenario which goes against evidence-based practice and adds to rising healthcare costs. METHODS The study was a retrospective review of lumbar spine MRI scans performed within a community-based setting over an 18-month period. The review took a randomised purposive sample of patients (n = 450); looking at adherence to, and relevance of, guidelines in managing lower back conditions. Data extracted provided information on demographics and prevalence of clinical presentation and report observations. RESULTS There is variation in practice and utlisation of MRI with this patient group which warrants further exploration. Results support inappropriate use, lacking adherence to guidelines and pathways, leading to unnecessary imaging. 46% of referrals were considered clinically justified with 38% of report findings considered abnormal and of clinical relevance. Chi-square and binomial logistic regression were used to assess the significance and relationship of any factors on referral justification and report outcome. No difference was found between type of referrer, with patient age and leg symptoms being significant factors. CONCLUSION The study highlights the opportunity to integrate better referral criteria to improve referral quality, its suitability and the relevance of final reports. In the current climate this would help manage appropriate use of imaging resources during the post COVID-19 pandemic recovery phase, as well as support recommendations regarding diagnostic reform and a move towards more community-based diagnostics.
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Affiliation(s)
| | - Karen Knapp
- Medical Imaging, College of Medicine and Health, Exeter University, Exeter, UK
| | - Martin Benwell
- Medical Imaging, College of Medicine and Health, Exeter University, Exeter, UK
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38
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Wang Y, Hussain SM, Wluka AE, Lim YZ, Urquhart DM, Mishra GD, Teede H, Doust J, Brown WJ, Cicuttini FM. Rates, costs and determinants of lumbar spine imaging in population-based women born in 1973-1978: Data from the Australian Longitudinal Study on Women's Health. PLoS One 2020; 15:e0243282. [PMID: 33270739 PMCID: PMC7714143 DOI: 10.1371/journal.pone.0243282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 11/18/2020] [Indexed: 12/01/2022] Open
Abstract
Objective There are concerns that lumbar spine imaging represents low value care. Our aim was to examine the use of lumbar spine imaging [radiography, computed tomography (CT), magnetic resonance imaging (MRI)] over 20 years, and costs and person-level characteristics of imaging in a large cohort of Australian women. Methods The Australian Longitudinal Study on Women’s Health (ALSWH) is a longitudinal population-based survey of women randomly selected from national health insurance scheme (Medicare) database. This study examined 13458 women born in 1973–1978 who consented to link their ALSWH and Medical Benefits Scheme records. Self-reported data on demographics, body mass index, depression, physical and mental health, and back pain were collected in each survey performed in 1996, 2000, 2003, 2006, 2009, 2012, and 2015. Data on lumbar spine imaging from 1996 to 2015 were obtained from the Medical Benefits Scheme database. Results 38.9% of women underwent some form of lumbar spine imaging over 20 years. While radiography increased from 1996 to 2011 and decreased thereafter, CT and MRI continued to increase from 1996 to 2015. In women with self-reported back pain, depression and poorer physical health were associated with imaging, with no significant differences in types of imaging. Based on imaging rates in ALSWH, the estimated costs for Australian women aged 30–39 years were AU$51,735,649 over 2011–2015. Conclusions Lumbar spine imaging was common in population-based Australian women, with rates increasing over 20 years. Depression and poor physical health were associated with lumbar spine imaging. Raising awareness of this in clinicians is likely to result in significant cost savings if clinical guidelines are followed, with the potential of freeing resources for high value care and health outcomes.
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Affiliation(s)
- Yuanyuan Wang
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Sultana Monira Hussain
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Anita E. Wluka
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Yuan Z. Lim
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Donna M. Urquhart
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Gita D. Mishra
- School of Public Health, University of Queensland, Brisbane, Queensland, Australia
| | - Helena Teede
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Victoria, Australia
| | - Jenny Doust
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Wendy J. Brown
- School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Flavia M. Cicuttini
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- * E-mail:
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Alhowimel A, Alotiabi M, Coulson N, Radford K. Feasibility study and process evaluation of MRI plus physiotherapy vs. physiotherapy alone in non-specific chronic low back pain among patients in Saudi Arabia. Pilot Feasibility Stud 2020; 6:188. [PMID: 33292710 PMCID: PMC7702682 DOI: 10.1186/s40814-020-00731-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/18/2020] [Indexed: 11/12/2022] Open
Abstract
Aim To determine the feasibility of conducting a definitive randomised control trial (RCT) to answer the following questions: (1) Is early physiotherapy treatment acceptable and feasible for patients and direct healthcare providers? and (2) Is early physiotherapy intervention associated with better disability and psychosocial outcomes compared with the practice of routine MRIs? Methods In a feasibility RCT in Riyadh City from 01 March 2018 until 29 July 2018, chronic low back pain (CLBP) patients presenting to spine clinics were randomised to receive an MRI (intervention) plus physiotherapy rehabilitation or physiotherapy alone (control group). The acceptability of randomisation to the control group (non-MRI) was tested during the recruitment by qualitatively interviewing study participants and referring physicians. Moreover, interviews with study participants explored the broader social, political, economic, and environmental (context) aspects that may influence trial delivery and intervention implementation. Results The recruitment target was not met: 16/24 (66%) participants were recruited in 4 months (12.4% of those screened); 33% declined. The process evaluation identified numerous factors that may affect the success of a definitive RCT in Saudi Arabia. These were research resources, the lack of research infrastructure to support recruitment to trials, limited research capacity in terms of knowledge and skills of the healthcare team, and limited funding. Conclusion A definitive RCT to test the influence of MRI diagnosis on the psychosocial and disability outcomes in people with CLBP treated with physiotherapy in Saudi Arabia is feasible. However, the lack of research infrastructure, research capacity, the impact of MRI on patient outcomes, and a lack of clinical equipoise in the treatment and management of CLBP in Saudi Arabia pose major barriers to clinical trials.
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Affiliation(s)
- Ahmed Alhowimel
- Physical Therapy and Rehabilitation Science Department, Prince Sattam Bin AbdulAziz University, Alkarj, Saudi Arabia.
| | - Mazyad Alotiabi
- Physical Therapy and Rehabilitation Science Department, Prince Sattam Bin AbdulAziz University, Alkarj, Saudi Arabia
| | - Neil Coulson
- Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Kathryn Radford
- Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
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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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Sharma S, Traeger AC, Reed B, Hamilton M, O'Connor DA, Hoffmann TC, Bonner C, Buchbinder R, Maher CG. Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis. BMJ Open 2020; 10:e037820. [PMID: 32830105 PMCID: PMC7451538 DOI: 10.1136/bmjopen-2020-037820] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Overuse of diagnostic imaging for patients with low back pain remains common. The underlying beliefs about diagnostic imaging that could drive overuse remain unclear. We synthesised qualitative research that has explored clinician, patient or general public beliefs about diagnostic imaging for low back pain. DESIGN A qualitative evidence synthesis using a thematic analysis. METHODS We searched MEDLINE, EMBASE, CINAHL, AMED and PsycINFO from inception to 17 June 2019. Qualitative studies that interviewed clinicians, patients and/or general public exploring beliefs about diagnostic imaging for low back pain were included. Four review authors independently extracted data and organised these according to themes and subthemes. We used the Critical Appraisal Skills Programme tool to critically appraise included studies. To assess confidence in review findings, we used the GRADE-Confidence in the Evidence from Reviews of Qualitative Research method. RESULTS We included 69 qualitative studies with 1747 participants. Key findings included: Patients and clinicians believe diagnostic imaging is an important test to locate the source of low back pain (33 studies, high confidence); patients with chronic low back pain believe pathological findings on diagnostic imaging provide evidence that pain is real (12 studies, moderate confidence); and clinicians ordered diagnostic imaging to reduce the risk of a missed diagnosis that could lead to litigation, and to manage patients' expectations (12 studies, moderate confidence). CONCLUSION Clinicians and patients can believe that diagnostic imaging is an important tool for locating the source of non-specific low back pain. Patients may underestimate the harms of unnecessary imaging tests. These beliefs could be important targets for intervention. PROSPERO REGISTRATION NUMBER CRD42017076047.
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Affiliation(s)
- Sweekriti Sharma
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Adrian C Traeger
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Ben Reed
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Melanie Hamilton
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Denise A O'Connor
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Tammy C Hoffmann
- Faculty of Health Sciences and Medicine, Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Carissa Bonner
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Elzinga JL, Dunne CL, Vorobeichik A, Keto-Lambert D, Grigat D, Lang E, Dowling S. A Systematic Review Protocol to Determine the Most Effective Strategies to Reduce Computed Tomography Usage in the Emergency Department. Cureus 2020; 12:e9509. [PMID: 32884867 PMCID: PMC7461135 DOI: 10.7759/cureus.9509] [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: 07/10/2020] [Accepted: 08/01/2020] [Indexed: 12/28/2022] Open
Abstract
This study describes the protocol for a systematic review and meta-analysis. The primary objective of the review is to identify experimental studies assessing the effectiveness of interventions that aim to reduce the proportion of computed tomography (CT) in emergency departments (EDs). Data permitting, our secondary objectives will be to assess the impact of reduction in CT utilization on the length of stay, admission to hospital, and uptake/satisfaction with the intervention. When available, balancing measures such as readmission to hospital or ED revisit rates will be included. Pre-defined subgroup analyses include patient populations (adult or pediatric), type of ED, and the nature of the intervention. Through this review, the research team aims to inform knowledge translation initiatives aimed at lowering CT usage in the ED by identifying the most effective interventions to safely improve CT resource stewardship.
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Affiliation(s)
| | - Cody L Dunne
- Emergency Medicine, University of Calgary, Calgary, CAN
| | | | - Diana Keto-Lambert
- Pediatrics, University of Alberta Evidence-Based Practice Center, Edmonton, CAN
| | - Daniel Grigat
- Emergency Medicine, Strategic Clinical Network, Alberta Health Services, Calgary, CAN
| | - Eddy Lang
- Emergency Medicine, University of Calgary, Calgary, CAN
| | - Shawn Dowling
- Emergency Medicine, Alberta Health Services, Calgary, CAN
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Gransjøen AM, Wiig S, Lysdahl KB, Hofmann BM. Health care personnel's perception of guideline implementation for musculoskeletal imaging: a process evaluation. BMC Health Serv Res 2020; 20:397. [PMID: 32393317 PMCID: PMC7212587 DOI: 10.1186/s12913-020-05272-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 04/29/2020] [Indexed: 01/29/2023] Open
Abstract
Background The increasing complexity and variability in radiology have significantly fueled the need for guidelines. There are many methods for disseminating and implementing guidelines however; and obtaining lasting changes has been difficult. Implementation outcome is usually measured in a decrease in unwarranted examinations, and qualitative data are rarely used. This study’s aim was to evaluate a guideline implementation process and identify factors influencing implementation outcome using qualitative data. Methods Seven general practitioners and five radiological personnel from a Norwegian county participated in four focus group interviews in 2019. The data were analyzed using qualitative content analysis, where some categories were predetermined, while most were drawn from the data. Results Four main categories were developed from the data material. 1) Successful/unsuccessful parts of the implementation, 2) perceived changes/lack of changes after the implementation, 3) environment-related factors that affected guideline use, and 4) User related factors that affect guideline use. Conclusions Our findings show that clinical guideline implementation is difficult, despite the implementation strategy being tailored to the target groups. Several environment- and user-related factors contributed to the lack of changes experienced in practice for both general practitioners and radiological personnel.
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Affiliation(s)
- Ann Mari Gransjøen
- Department of Health sciences in Gjøvik, Norwegian University of Science and Technology in Gjøvik (NTNU), Teknologiveien 22, 2815, Gjøvik, Norway.
| | - Siri Wiig
- SHARE-Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Kjell Arholmsgate 41, 4036, Stavanger, Norway
| | - Kristin Bakke Lysdahl
- Department of Optometry, Radiography and Lighting Design, Faculty of Health Sciences, University of South-Eastern Norway, Box 235, 3603, Kongsberg, PO, Norway
| | - Bjørn Morten Hofmann
- Department of Health sciences in Gjøvik, Norwegian University of Science and Technology in Gjøvik (NTNU), Teknologiveien 22, 2815, Gjøvik, Norway.,Center for medical ethics, University of Oslo, PO Box 1130, Blindern, 0318, Oslo, Norway
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Chen D, Bhambhvani HP, Hom J, Mahoney M, Wintermark M, Sharp C, Ratliff J, Chen YR. Effect of Electronic Clinical Decision Support on Imaging for the Evaluation of Acute Low Back Pain in the Ambulatory Care Setting. World Neurosurg 2020; 134:e874-e877. [DOI: 10.1016/j.wneu.2019.11.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 11/04/2019] [Accepted: 11/05/2019] [Indexed: 10/25/2022]
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Babaa A, Al-Hihi M, Abujudeh HH. An Overview of Strategies Targeting Inappropriate Advanced Diagnostic Imaging in the Setting of Acute Uncomplicated Low Back Pain. CURRENT RADIOLOGY REPORTS 2020. [DOI: 10.1007/s40134-020-0345-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Lim YZ, Chou L, Au RT, Seneviwickrama KMD, Cicuttini FM, Briggs AM, Sullivan K, Urquhart DM, Wluka AE. Correspondence: Reply to Hopayian. J Physiother 2020; 66:65. [PMID: 31859148 DOI: 10.1016/j.jphys.2019.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 11/25/2019] [Indexed: 10/25/2022] Open
Affiliation(s)
- Yuan Z Lim
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne
| | - Louisa Chou
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne
| | - Rebecca Tm Au
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne
| | - Kl Maheeka D Seneviwickrama
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne
| | - Flavia M Cicuttini
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne
| | - Andrew M Briggs
- School of Physiotherapy and Exercise Science, Curtin University, Perth
| | - Kaye Sullivan
- Monash University Library, Monash University, Melbourne, Australia
| | - Donna M Urquhart
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne
| | - Anita E Wluka
- Department of Epidemiology and Preventative Medicine, School of Public Health and Preventative Medicine, Monash University, Melbourne
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Simula AS, Jenkins HJ, Holopainen R, Oura P, Korniloff K, Häkkinen A, Takala EP, Hancock MJ, Karppinen J. Transcultural adaption and preliminary evaluation of "understanding low back pain" patient education booklet. BMC Health Serv Res 2019; 19:1010. [PMID: 31888605 PMCID: PMC6936060 DOI: 10.1186/s12913-019-4854-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 12/20/2019] [Indexed: 12/21/2022] Open
Abstract
Background Low back pain (LBP) is the number one cause of disability globally. LBP is a symptom associated with biological, psychological and social factors, and serious causes for pain are very rare. Unhelpful beliefs about LBP and inappropriate imaging are common. Practitioners report pressure from patients to provide inappropriate imaging. A recently developed patient education and management booklet, ‘Understanding low back pain’, was designed to target previously identified barriers for reducing inappropriate imaging. The booklet includes evidence-based information on LBP and supports communication between patients and practitioners. Our aim was to 1) describe the translation process into Finnish and 2) study patients’ and practitioners’ attitudes to the booklet and to evaluate if it improved patients’ understanding of LBP and practitioners’ ability to follow imaging guidelines. Methods We translated the booklet from English to Finnish. Preliminary evaluation of the booklet was obtained from LBP patients (n = 136) and practitioners (n = 32) using web-based questionnaires. Open-ended questions were analysed using thematic analysis. Results Approximately half of the patients reported that reading the booklet helped them to understand LBP, while a third thought it encouraged them to perform physical activity and decreased LBP-related fear. Eighty percent of practitioners reported that the booklet helped them to follow imaging guidelines. In addition, practitioners reported that they found the booklet helpful and that it decreased the need for imaging. Conclusions The booklet seemed to be helpful in LBP management and in decreasing the need for LBP imaging according to patients and practitioners. Further research on the clinical effectiveness of the booklet in controlled study settings is needed. Trial registration ISRCTN, ISRCTN14389368, Registered 4 April 2019 - Retrospectively registered; ISRCTN11875357, Registered 22 April 2019 - Retrospectively registered.
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Affiliation(s)
- Anna Sofia Simula
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland. .,Faculty of Medicine, Center for Life Course Health Research, Faculty of Medicine, University of Oulu, P.O. Box 5000, 90014, Oulu, Finland. .,Department of General Medicine Mikkeli Central Hospital (Essote), Mikkeli, Finland.
| | - Hazel J Jenkins
- Department of Health Professions, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Balaclava Road, North Ryde, NSW, 2109, Australia.,Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, Australia
| | - Riikka Holopainen
- Faculty of Sport and Health Sciences, University of Jyväskylä, PO Box 35, FI-40014, Jyväskylä, Finland
| | - Petteri Oura
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.,Faculty of Medicine, Center for Life Course Health Research, Faculty of Medicine, University of Oulu, P.O. Box 5000, 90014, Oulu, Finland
| | - Katariina Korniloff
- School of Health and Social Studies, JAMK University of Applied Sciences, PO BOX 207, FI-40101, Jyväskylä, Finland
| | - Arja Häkkinen
- Faculty of Sport and Health Sciences, University of Jyväskylä, PO Box 35, FI-40014, Jyväskylä, Finland.,Department of Physical Medicine and Rehabilitation, Jyväskylä Central Hospital, Keskussairaalantie 19, 40620, Jyväskylä, Finland
| | - Esa-Pekka Takala
- Finnish Institute of Occupational Health, P.O. Box 40, FI-00032, Helsinki and Oulu, Työterveyslaitos, Finland
| | - Mark J Hancock
- Department of Health Professions, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Balaclava Road, North Ryde, NSW, 2109, Australia
| | - Jaro Karppinen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.,Faculty of Medicine, Center for Life Course Health Research, Faculty of Medicine, University of Oulu, P.O. Box 5000, 90014, Oulu, Finland.,Finnish Institute of Occupational Health, P.O. Box 40, FI-00032, Helsinki and Oulu, Työterveyslaitos, Finland
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Morgan T, Wu J, Ovchinikova L, Lindner R, Blogg S, Moorin R. A national intervention to reduce imaging for low back pain by general practitioners: a retrospective economic program evaluation using Medicare Benefits Schedule data. BMC Health Serv Res 2019; 19:983. [PMID: 31864352 PMCID: PMC6925437 DOI: 10.1186/s12913-019-4773-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 11/22/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The overuse of diagnostic imaging for low back pain (LBP) in Australia results in unnecessary cost to the health system and, for patients, avoidable exposure to radiation. The 2013 NPS MedicineWise LBP program aimed to reduce unnecessary diagnostic imaging for non-specific acute LBP in the Australian primary care setting. The LBP program delivered referral pattern feedback, a decision support tool and patient information to 19,997 (60%) of registered Australian general practitioners (GPs). This study describes the findings from evaluation of the effectiveness of the 2013 LBP program at reducing X-ray and computed tomography (CT) scans of the lower back, and the financial costs and benefits of the program to the government funder. METHODS The effectiveness of the 2013 LBP program was evaluated using population-based time-series analysis of administrative claims data of Medicare Benefits Schedule (MBS) funded X-ray and CT scan services of the lower back. The CT scan referral trend of non-GP health professionals was used as an observational control group in a Bayesian structural time-series model. A retrospective cost-benefit analysis and cost-effectiveness analysis was conducted using program costs from organisational records and reimbursement data from the MBS. RESULTS The 2013 NPS MedicineWise LBP program was associated with a statistically significant 10.85% relative reduction in the volume of CT scans of the lumbosacral region, equating to a cost reduction to the MBS of AUD$11,600,898. The best available estimate of program costs was AUD$141,154. Every dollar of funding spent on the 2013 LBP program saved AUD$82 of funding to the MBS for CT scan reimbursements. Therefore, from the perspective of the Australian Government Department of Health, the 2013 LBP program was cost saving. The program cost AUD$2.82 per CT scan averted in comparison to the scenario of no program. No association between the 2013 NPS MedicineWise LBP program and the volume of X-ray items on the MBS was observed. CONCLUSIONS The 2013 NPS MedicineWise LBP program reduced CT scan referral by GPs, in line with the program's messages and clinical guidelines. Reducing this low-value care produced savings to the health system that exceeded the costs of program implementation.
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Affiliation(s)
- Tessa Morgan
- NPS MedicineWise, Sydney, New South Wales Australia
| | - Jianyun Wu
- NPS MedicineWise, Sydney, New South Wales Australia
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Investigating the appropriateness of physician-ordered diagnostic computed tomography for patient management in a rural hospital in New South Wales, Australia. Clin Radiol 2019; 74:977.e17-977.e23. [DOI: 10.1016/j.crad.2019.08.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 08/14/2019] [Indexed: 11/18/2022]
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50
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What is usual care for low back pain? A systematic review of health care provided to patients with low back pain in family practice and emergency departments. Pain 2019; 161:694-702. [DOI: 10.1097/j.pain.0000000000001751] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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