A national intervention to reduce imaging for low back pain by general practitioners: a retrospective economic program evaluation using Medicare Benefits Schedule data

Abstract

BackgroundThe 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.MethodsThe 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.ResultsThe 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.ConclusionsThe 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.

The Lancet Series call to action to reduce low value care for low back pain: an update

“… 48 A 2019 times-series analysis of a national strategy designed to reduce general practitioner requests for X-rays and computed tomography (CT) scans that was implemented by the Australian National Prescribing Service in 2013 reported a 11% relative reduction in lumbar spine CT scans over that year, equating to a cost reduction to the government of AUD$11,600,898. 66 Based upon an estimated cost of the program which was delivered to almost 20,000 general practitioners (60% of all registered general practitioners in Australia), the program cost $AUD2.82 per CT scan averted. No effects on X-ray requests were observed, and it is not known whether or not there was any substitution of CT scans by medical specialist referral for magnetic resonance imaging.…”

What behaviour change techniques have been used to improve adherence to evidence-based low back pain imaging?

“…Nineteen (50%) of the studies were conducted in the last 5 years (between 2015-present) in both primary care (82%) [ 30 – 38 , 40 – 42 , 44 – 48 , 50 , 52 – 60 , 62 – 64 ] and emergency settings (18%) [ 28 , 29 , 39 , 43 , 49 , 51 , 61 , 65 ] in the US ( n = 17) [ 28 , 30 , 33 , 35 , 38 , 39 , 41 – 43 , 46 , 47 , 54 , 56 , 59 , 62 , 64 ], the UK ( n = 8) [ 31 , 32 , 40 , 45 , 50 , 53 , 55 , 61 ], Australia ( n = 6) [ 7 , 44 , 48 , 49 , 52 , 58 ], Canada ( n = 3) [ 29 , 34 , 51 ], the Netherlands ( n = 2) [ 60 , 63 ], Finland ( n = 1) [ 57 ] and Germany ( n = 1) [ 65 ]. Study designs included RCTs/Cluster RCTs ( n = 12) [ 31 – 33 , 36 , 45 , 48 , 53 , 55 , 56 , …”

“…Specific prompts at the time of consultation are powerful strategy and have been shown to alter GPs’ behaviour. Painter : No theory Kerry 2000 [ 45 ] UK x-ray Cluster RCT No intervention Components: Educational materials (guidelines) (provided twice) + audit and feedback (provided once) Provider: a) Study team b) Study team Rationale : No Painter : No theory Oakeshott 1994 [ 53 ] UK x-ray Cluster RCT No intervention Components: Educational materials (posted guidelines) Provider: Study team Dose: Provided once Rationale : No Painter : No theory Morgan 2019 [ 52 ] Australia X-ray, CT ITS No intervention Components: Audit and feedback (given once) + ongoing access to a prescription pad and online decision support tool Provider: a) Study team b) NPS MedicineWise c) Study team and the George Institute Rationale : Yes, previous evidence and literature Painter : No theory Zafar 2019 [ 64 ] US MRI Cluster RCT Historic control Components: a) Audit and feedback (provided every 4-6 months) or b) Real-time decision support (provided for every lumbar MRI) or c) Both a and b Provider: a) Unclear b) Computerised physician order entry system c) As above Rationale : Yes, previous evidence and literature Painter : No theory Jenkins 2018 [ 44 ] Australia None Development of intervention, not looking at imaging outcomes Components: a) Educational workshop (provided once) b) Educational materials provided once) c) Decision support (provided for every LBP patient) d) Patient education materials (provided for every LBP patient without indication for imaging) Provider: a) Study team b) Study team c) Study team (used by GP) d) Study team (given to patients by GP) Rationale : Yes, previous evidence and literature Painter : Yes, informed by theory Wang 2020 [ 62 ] USA ...…”

“…The remaining 34 studies either i) solely targeted a reduction in imaging, ii) used the same intervention strategy for all of its target behaviours or iii) specified which BCTs targeted LBP imaging behaviour. We identified 18 BCTs across the 34 studies (see Table 3 ); the most common techniques were ‘4.1 instruction on how to perform the behaviour’ ( n = 31 interventions; 26 studies) [ 29 , 32 , 33 , 35 , 36 , 40 – 42 , 44 – 48 , 50 , 52 , 53 , 55 , 57 – 65 ], defined as ‘advise or agree on how to perform the behaviour’, and ‘9.1 credible source’ ( n = 21 interventions; 18 studies) [ 29 , 30 , 32 , 35 , 36 , 40 – 42 , 45 , 46 , 48 , 50 , 53 , 55 , 58 , 59 , 62 , 63 ], defined as ‘present verbal or visual communication from a credible source in favour of or against the behaviour’, ‘7.1 prompts/cues’ ( n = 14 interventions; 14 studies) [ 29 , 30 , 32 , 35 , 41 , 42 , 44 , 46 , 53 , 54 , 57 , 59 , 61 , 64 ] defined as ‘introduce or define environmental or social stimulus with the purpose of prompting or cuing the behaviour’, and ‘2.2 feedback on behaviour’ ( n = 13 interventions; 12 studies) [ 30 , 32 , 33 , 35 , 41 , 45 , 48 , 52 , …”

Patient Provider Continuity and Prostate Specific Antigen Testing: Impact of Continuity on Receipt of a Non-recommended Test

“…A variety of strategies have been used to try and minimize low value care. The case of imaging for low back pain provides some lessons ( 10 , 20 ). For example, a best practice advisory or electronic medical record (EMR) alert is presented when a physician or other health care provider is attempting to order the test in question ( 21 ).…”