Are general practitioners referring patients with low back pain for CTs appropriately according to the guidelines: a retrospective review of 3609 medical records in Newfoundland using routinely collected data

Abstract

Background CT Imaging is often requested for patients with low back pain (LBP) by their general practitioners. It is currently unknown what reasons are common for these referrals and if CT images are ordered according to guidelines in one province in Canada, which has high rates of CT imaging. The objective of this study is to categorise lumbar spine CT referrals into serious spinal pathology, radicular syndrome, and non-specific LBP and evaluate the appropriateness of CT imaging referrals from general practitioners for patients with LBP. Methods A retrospective medical record review of electronic health records was performed in one health region in Newfoundland and Labrador, Canada. Inclusion criteria were lumbar spine CT referrals ordered by general practitioners for adults ≥18 years, and performed between January 1st-December 31st, 2016. Each CT referral was identified from linked databases (Meditech and PACS). To the study authors’ knowledge, guidelines regarding when to refer patients with low back pain for CT imaging had not been actively disseminated to general practitioners or implemented at clinics/hospitals during this time period. Data were manually extracted and categorised into three groups: red flag conditions (judged to be an appropriate referral), radicular syndrome (judged be unclear appropriateness), or nonspecific LBP (determined to be inappropriate). Results Three thousand six hundred nine lumbar spine CTs were included from 2016. The mean age of participants was 54.7 (SD 14 years), with females comprising 54.6% of referrals. 1.9% of lumbar CT referrals were missing/unclear, 6.5% of CTs were ordered on a red-flag suspicion, 75.6% for radicular syndromes, and 16.0% for non-specific LBP; only 6.5% of referrals were clearly appropriate. Key information including patient history and clinical exams performed at appointment were often missing from referrals. Conclusion This audit found high proportions of inappropriate or questionable referrals for lumbar spine CT and many were missing information needed to categorise. Further research to understand the drivers of inappropriate imaging and cost to the healthcare system would be beneficial.

Low back pain care pathways and costs: association with the type of initial contact health care provider. A retrospective cohort study

“…An evidence synthesis of studies published between 1995 and 2012 found for the treatment of acute/subacute LBP DCs had the highest percentage of concordance with CPGs (70.2%) followed by PTs (63.1%) and medical physicians (47.1%) [17]. Individual studies typically focused on a single type of health care provider (HCP) like; primary care physicians [18,19], chiropractors (DCs) [20], physical therapists (PTs) [21][22][23], or surgeons [24]). Real-world guideline concordance could not be assessed in cross-sectional surveys that used clinical vignettes [20][21][22][23].…”

“…Real-world guideline concordance could not be assessed in cross-sectional surveys that used clinical vignettes [20][21][22][23]. Retrospective cohort studies focused on specific services e.g., imaging utilization [18,19] or multiple service outcomes but were not subdivided by initial HCP type [24].…”

Imaging incidence and type in primary care patients with low back pain: a cross-sectional study on new referrals to an Australian specialist spinal surgical centre

“…To comprehensively define the cohort and their past medical histories would require interrogation of additional data sources; however, previous attempts at such an investigational approach have revealed vital data remains missing. 26 The size of the cohort selected for this preliminary study resulted in small subgroup sizes (post-hoc analysis suggests that increasing the sample size to 228 patients per subgroup would enable detection of statistically significant differences); however, the pilot study has revealed some useful data and trends in radiological investigations and practice in primary care. One unexpected finding was that 28 patients had undergone interventional spinal therapeutic procedures using image guidance.…”

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

“…In the province of NL, medical practitioners (e.g., general practitioners) and chiropractors are able to order x-rays and regularly manage patients with LBP [ 20 ]. Based on a medical record review from GPs in NL, only 6.5% of referrals for lumbar spine CT imaging were considered appropriate (i.e., concordant with guideline or best practice recommendations) [ 21 ]. Among chiropractors in NL, a survey on their knowledge of and adherence to radiographic guidelines found that about half of respondents were unaware of or did not know current guideline recommendations for LBP radiography, and one quarter of respondents indicated they did not use guidelines to inform their clinical decisions [ 22 ].…”