Appropriateness of imaging decisions for low back pain presenting to the emergency department: a retrospective chart review study

Abstract

Background Imaging for low back pain is widely regarded as a target for efforts to reduce low value care. We aimed to estimate the prevalence of overuse and underuse of lumbar imaging in the Emergency Department. Methods Retrospective chart review study of five public hospital Emergency Departments 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 649 patients presented with a complaint of low back pain of which 158 (24.3%) were referred for imaging. 79 (12.2%) had a combination of features suggesting 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% to 11.2%) and 4.3% (28 of 649 cases, 95%CI 3.0% to 6.1%), respectively. 13 cases were classified as underuse because the patient was referred for an uninformative imaging modality (e.g. referred for radiography for suspected cauda equina syndrome). Conclusion In this study of emergency care there was evidence of 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.

Diagnoses and trends in use of imaging for low back pain in four Australian emergency departments between 2012 and 2019

“…It is unclear whether the proportion diagnosed with serious pathology without imaging suggests judicious use, inappropriate delays in imaging, or the fact that some patients had performed outside of ED, for example arranged by their GP, prior to presenting. Recent studies suggest that underuse of imaging happens in approximately 4.3% of encounters for LBP 22 . Further research that explores clinical features alongside use of imaging will help determine the extent of imaging underuse in those with specific spinal conditions.…”

“…Recent studies suggest that underuse of imaging happens in approximately 4.3% of encounters for LBP. 22 Further research that explores clinical features alongside use of imaging will help determine the extent of imaging underuse in those with specific spinal conditions. Similarly, we cannot say from these data whether those with NSLBP received 'unnecessary' imaging.…”

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

“…Clinician investigators who review the appropriateness of imaging will use a standardised survey in REDCap to extract data and score appropriateness. This process is informed by our previous work 35. We anticipate we will require 10–20 clinicians to assist with case note reviews.…”

“…We chose this composite outcome because it is a meaningful metric to ED clinicians. Clinician researchers will perform chart reviews every month for all participants who present with low back pain and receive imaging to understand and code if it was non-indicated imaging (ie, imaging provided in the absence of clinical features of serious pathology) using reliable methods we have published 35. Opioids provided or prescribed at discharge for patients diagnosed with ‘non-serious’ low back pain (ie, low back pain with non-specific cause or low back pain with neurological signs and symptoms—see online supplemental table 1) will be coded as low value.…”

Functional analysis of postural spinal and pelvic parameters using static and dynamic spinometry

“…However, surveys have shown that, despite medical guidelines, the diagnostic imaging of the lumbar spine remains subject to the personal preferences of the healthcare provider [ [ 11 ]]. Static X-rays are still commonly performed in emergency departments [ [ 12 ]].…”