Imaging for Low Back Pain Unnecessary, but Hard to Avoid

Tara Haelle

October 17, 2016

Nearly all clinicians agree that imaging is unnecessary for patients with nonspecific low back pain, but that does not mean they find it easy to follow the recommendations against such imaging, suggests a study published online October 17 in JAMA Internal Medicine.

The Choosing Wisely campaign, which aims to reduce unnecessary procedures to improve patient care, includes seven recommendations against ordering imaging tests for patients with nonspecific lower back pain.

"[S]everal perceived barriers may prevent clinicians from following the recommendations in practice," write Erika D. Sears, MD, from the Veterans Affairs Center for Clinical Management Research in Ann Arbor, Michigan, and colleagues. "Clearly for these clinicians, knowing is not enough."

The researchers collected responses from 579 physicians, nurse practitioners, and physician assistants out of 1224 who were invited to take an online survey between October and December 2014. About a quarter of the respondents were nurse practitioners, 69.5% were physicians, and 6.6% were physician assistants.

In the survey, a hypothetical 45-year-old woman with nonspecific lower back pain and no red flag symptoms requested a computerized tomography (CT) or magnetic resonance imaging (MRI) scan. The respondents answered what they would do in this situation and what factors would influence their decision.

Only 3.3% of clinicians believed the hypothetical patient would benefit from imaging, and 77.1% expressed concern that ordering imaging could lead to additional unnecessary tests or procedures. Yet 57.8% of the clinicians worried that the patient would be upset if she did not undergo a CT or MRI, and 25.8% thought they would not have enough time during the visit to talk about risks and benefits of imaging with the patient.

Further, 75.7% of the respondents thought they would not be able to refer her to a specialist unless they did imaging first. Just more than a quarter (27.2%) of clinicians reported concern that not ordering imaging might leave them vulnerable to a malpractice claim.

Despite these barriers, the vast majority of the respondents, 94.2%, would not recommend an MRI or CT simply to satisfy the patient's request, and 89.4% felt they would have a "good strategy" for discussing with the patient why they would not order the imaging.

However, many clinicians said they would welcome additional support materials: 61.8% said a clinical decision support tool would be helpful in determining whether this patient would benefit from a CT or MRI, and 92.7% would welcome patient educational materials for discussing whether the patient should receive imaging or not. The survey respondents were split almost 50/50 on whether they thought most patients would prefer that the clinician decide whether to order imaging, but 62.9% expected most patients would have difficulty accepting the Choosing Wisely recommendation.

Overall, 14.8% of clinicians said it would be hard for them to follow the Choosing Wisely campaign recommendations, and this group was more likely to worry about liability. Those with less than 10 years since training were nearly twice as likely to be among this group compared with clinicians who had received their training 20 or more years prior.

"We will not be able to eliminate inappropriate imaging until the barriers such as those identified by the...respondents are addressed," Dr Sears and colleagues write.

"Reduction in low-value diagnostic testing for [low back pain] will require efficient patient education interventions to address patient demands within the limited time constraints of clinicians," the authors write. "Furthermore, greater attention to referral requirements is needed to assure that clinicians are able to follow evidence-based recommendations, while still being able to refer patients to specialty clinics."

The research was supported by multiple awards and fellowships from Veterans Affairs and the Veterans Health Administration. One coauthor reported consulting fees from the SeeChange Health and HealthMine. The other authors have disclosed no relevant financial relationships.

JAMA Internal Med. Published online October 17, 2016. Abstract

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