Reducing Low-Value Imaging for Low Back Pain: Systematic Review With Meta-analysis

Standardized Patient Communication and Low-Value Spinal Imaging: A Randomized Clinical Trial

Importance

Acute back pain is a common reason for primary care visits and often results in low-value spinal imaging.

Objective

To evaluate the effect of a standardized patient-delivered intervention on rates of low-value spinal imaging among primary care patients with acute low back pain.

Design, Setting, and Participants

In this randomized clinical trial, physicians or advanced practice clinicians were recruited from March 22 to August 5, 2021, from 10 adult primary care or urgent care clinics in Sacramento, California. The intervention period was from May 1, 2021, to March 30, 2022, with follow-up from October 28, 2021, to June 30, 2023. Analyses were performed from April 1 to June 25, 2024.

Intervention

Clinicians were randomized 1:1 to intervention or control. Intervention clinicians received 3 simulated office visits, each with a standardized patient instructor (SPI) portraying a patient with acute uncomplicated back pain. At each visit, SPIs provided clinician feedback guided by a 3-step model: (1) set the stage for deferred imaging by building trust, (2) convey empathy, and (3) communicate optimism while advocating watchful waiting without imaging. Control clinicians received no intervention.

Main Outcomes and Measures

The primary outcome was lumbar spinal imaging completion within 90 days of acute low back pain visits, with study clinicians assessed up to 18 months of follow-up. Secondary outcomes were cervical spine imaging completion after acute neck pain visits, any imaging completion after an adult visit, patient experience ratings of clinicians (scale range, 0-100), and use of targeted communication skills during an audio-recorded standardized patient evaluation visit at median follow-up of 16.8 months (range, 14.1-18.0 months).

Results

The analysis included 53 clinicians; mean (SD) age was 46.7 (1.0) years, and 35 (66.0%) reported female gender. A total of 25 were in the intervention group and 28 in the control group. After adjustment for prerandomization rates, patients with acute low back pain who saw intervention and control clinicians during follow-up had similar rates of lumbar imaging (194 of 1234 clinic visits [15.7%] vs 226 of 1306 clinic visits [17.3%]; adjusted ratio of postintervention vs preintervention odds ratios [AORR], 1.00; 95% CI, 0.72-1.40). Adjusted follow-up rates of imaging for acute neck pain (AORR, 1.16; 95% CI, 0.83-1.63) and overall imaging (AORR, 1.07; 95% CI, 0.97-1.19) were not significantly different among patients of intervention and control clinicians. Intervention and control clinicians had similar mean (SD) patient experience ratings during follow-up (88.6 [28.7] vs 88.8 [28.3]; adjusted mean difference-in-differences, -1.0; 95% CI, -3.0 to 0.9). During audio-recorded standardized patient visits, intervention clinicians had significantly better ratings than controls on eliciting the patient's perspective (adjusted standardized difference [ASD], 0.62; 95% CI, 0.05-1.19) and conveying empathy (ASD, 1.16; 95% CI, 0.55-1.77).

Conclusions and Relevance

In this randomized clinical trial of an educational intervention using simulated office visits to encourage a watchful waiting approach for acute low back pain, the intervention had no significant effect on low-value spinal imaging rates or patient experience ratings.

Trial Registration

ClinicalTrials.gov Identifier: NCT04255199.

Low-value interventions to deimplement: A secondary analysis of a systematic review of low back pain clinical practice guidelines

OBJECTIVE

To perform a secondary review of low back pain (LBP) clinical practice guidelines (CPG) identified in a recently conducted systematic review and to synthesize and summarize low-value recommendations as practices that may be candidates for deimplementation.

LITERATURE SURVEY

LBP (subacute or chronic) CPGs in English (symptom based, created by a governmental or professional society, published between January 1990 and May 2020) were previously identified using MEDLINE, EMBASE, CINAHL, Ortho Guidelines, CPG Infobase, Emergency Care Research Institute, Guidelines International Network, National Institute of Health and Care Excellence, and Scottish Intercollegiate Guideline Network.

METHODOLOGY

Twenty-one CPGs were reviewed from a systematic review (previously published). Full-text review of all 21 CPGs was conducted, and three recommendation categories indicative of low value (recommend strongly against, recommend weakly against, inconclusive/insufficient evidence) were identified using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) language and approach.

SYNTHESIS

One hundred thirty-five low-value recommendations were identified and classified under eight intervention categories: orthotics/support, traction, physical modalities, pharmacological interventions, injections, surgery, bed rest, and miscellaneous. Traction, transcutaneous electrical nerve stimulation (TENS), therapeutic ultrasound (TUS), and selective serotonin reuptake inhibitors (SSRI) had the most CPGs recommend strongly against their usage. Opioids were recommended strongly against by four CPGs. No significant difference (p > .05) was found between CPG quality and a specific deimplementation recommendation or between CPG quality and the number of strongly against, weakly against, and inconclusive/insufficient evidence recommendations.

CONCLUSIONS

Clinicians managing patients with chronic LBP should consider deimplementing these low-value interventions (traction, TENS, TUS, and SSRI).

Effectiveness of de-implementation of low-value healthcare practices: an overview of systematic reviews

BACKGROUND

Reducing low-value care (LVC) is crucial to improve the quality of patient care while increasing the efficient use of scarce healthcare resources. Recently, strategies to de-implement LVC have been mapped against the Expert Recommendation for Implementing Change (ERIC) compilation of strategies. However, such strategies' effectiveness across different healthcare practices has not been addressed. This overview of systematic reviews aimed to investigate the effectiveness of de-implementation initiatives and specific ERIC strategy clusters.

METHODS

We searched MEDLINE (Ovid), Epistemonikos.org and Scopus (Elsevier) from 1 January 2010 to 17 April 2023 and used additional search strategies to identify relevant systematic reviews (SRs). Two reviewers independently screened abstracts and full texts against a priori-defined criteria, assessed the SR quality and extracted pre-specified data. We created harvest plots to display the results.

RESULTS

Of 46 included SRs, 27 focused on drug treatments, such as antibiotics or opioids, twelve on laboratory tests or diagnostic imaging and seven on other healthcare practices. In categorising de-implementation strategies, SR authors applied different techniques: creating self-developed strategies (n = 12), focussing on specific de-implementation strategies (n = 14) and using published taxonomies (n = 12). Overall, 15 SRs provided evidence for the effectiveness of de-implementation interventions to reduce antibiotic and opioid utilisation. Reduced utilisation, albeit inconsistently significant, was documented in the use of antipsychotics and benzodiazepines, as well as in laboratory tests and diagnostic imaging. Strategies within the adapt and tailor to context, develop stakeholder interrelationships, and change infrastructure and workflow ERIC clusters led to a consistent reduction in LVC practices.

CONCLUSION

De-implementation initiatives were effective in reducing medication usage, and inconsistent significant reductions were observed for LVC laboratory tests and imaging. Notably, de-implementation clusters such as change infrastructure and workflow and develop stakeholder interrelationships emerged as the most encouraging avenues. Additionally, we provided suggestions to enhance SR quality, emphasising adherence to guidelines for synthesising complex interventions, prioritising appropriateness of care outcomes, documenting the development process of de-implementation initiatives and ensuring consistent reporting of applied de-implementation strategies.

REGISTRATION

OSF Open Science Framework 5ruzw.

Factors influencing imaging clinical decision-making in low back pain management. A scoping review

BACKGROUND

The use of diagnostic imaging in low back pain (LBP) management is often inappropriate, despite recommendations from clinical practice guidelines. There is a limited understanding of factors that influence the imaging clinical decision-making (CDM) process.

AIM

Explore the literature on factors influencing imaging CDM for people with LBP and consider how these findings could be used to reduce inappropriate use of imaging in LBP management.

DESIGN

Scoping review.

METHOD

This review followed the Preferred Reporting Items for Systematic Review extension for scoping reviews. A digital search was conducted in Medline, the Cumulative Index of Nursing and Allied Health Literature, Scopus, and the Cochrane Central Register of Controlled Trials for eligible studies published between January 2010-2023. Data reporting influences on imaging CDM were extracted. Data were then analysed through an inductive process to group the influencing factors into categories.

RESULTS

After screening, 35 studies (5 qualitative and 30 quantitative) were included in the review, which reported factors influencing imaging CDM. Three categories were developed: clinical features (such as red flags, pain, and neurological deficit), non-modifiable factors (such as age, sex, and ethnicity) and modifiable factors (such as beliefs about consequences and clinical practice). Most studies reported non-modifiable factors.

CONCLUSIONS

The results of this scoping review challenge the perception that imaging CDM is purely based on clinical history and objective findings. There is a complex interplay between clinical features, patient and clinician characteristics, beliefs, and environment. These findings should be considered when designing strategies to address inappropriate imaging behaviour.

Global prevalence of hospital admissions for low back pain: a systematic review with meta-analysis

OBJECTIVES

To determine the proportion of low back pain presentations that are admitted to hospital from the emergency department (ED), the proportion of hospital admissions due to a primary diagnosis of low back pain and the mean hospital length of stay (LOS), globally.

METHODS

We searched MEDLINE, CINAHL, EMBASE, Web of Science, PsycINFO and LILACS from inception to July 2022. Secondary data were retrieved from publicly available government agency publications and international databases. Studies investigating admitted patients aged >18 years with a primary diagnosis of musculoskeletal low back pain and/or lumbosacral radicular pain were included.

RESULTS

There was high heterogeneity in admission rates for low back pain from the ED, with a median of 9.6% (IQR 3.3-25.2; 9 countries). The median percentage of all hospital admissions that were due to low back pain was 0.9% (IQR 0.6-1.5; 30 countries). The median hospital LOS across 39 countries was 6.2 days for 'dorsalgia' (IQR 4.4-8.6) and 5.4 days for 'intervertebral disc disorders' (IQR 4.1-8.4). Low back pain admissions per 100 000 population had a median of 159.1 (IQR 82.6-313.8). The overall quality of the evidence was moderate.

CONCLUSION

This is the first systematic review with meta-analysis summarising the global prevalence of hospital admissions and hospital LOS for low back pain. There was relatively sparse data from rural and regional regions and low-income countries, as well as high heterogeneity in the results.

Adherence to spinal imaging guidelines and utilization of lumbar spine diagnostic imaging for low back pain at a Canadian Chiropractic College: a historical clinical cohort study

Background

Diagnostic imaging is useful for assessing low back pain (LBP) when a clinician suspects a specific underlying pathology. Evidence-based imaging guidelines assist clinicians in appropriately determining the need for imaging when assessing LBP. A previous study reported high adherence to three clinical guidelines, with utilization rate of 12.3% in imaging of LBP patients attending a chiropractic teaching clinic. A new imaging guideline for spinal disorders has been published and used in teaching. Thus, the aims of our study were to assess the adherence to the new guideline and X-ray utilization in new episodes of LBP.

Methods

We conducted a historical clinical cohort study using patient electronic health record audits at seven teaching clinics over a period of 20 months. Records of patients who were at least 18 years of age, presented with a new onset of LBP, and consented to data collection were included. Abstracted data included patient demographics, the number and type of red flags, and the decision to image. Rate of guideline adherence (proportion of those not recommended for imaging, given no red flags) and rate of image utilization were descriptively analyzed.

Results

We included 498 patients in this study. At least 81% of included patients had one or more red flags reported. The most commonly reported individual red flag was age ≥ 50 (43.8%) followed by pain at rest (15.7%). In those referred for imaging, age ≥ 50 (93.3%) was the most frequently reported red flag. No red flag(s) were identified in 93 patient records, and none were referred for imaging of their LBP, yielding an adherence rate of 100% (95% CI 96, 100%). A total of 17 of 498 patients were recommended for imaging for their low back pain, resulting in an imaging utilization rate of 3.4% (95% CI 1.8, 5.0%).

Conclusion

The imaging utilization rate was 3.4%, lower than 12.3% previously reported at a chiropractic teaching clinic. None without red flags were referred for imaging, yielding a 100%, adherence rate to current LBP imaging guidelines. Future research should consider currency of guideline, accuracy of red flags and factors influencing clinicians’ decision, when assessing imaging adherence rates.