Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis

Jenkins, Hazel; Downie, Aron; Maher, Christopher G.; Moloney, Niamh; Magnussen, John; Hancock, Mark J.

doi:10.1016/j.spinee.2018.05.004

Cited by 93 publications

(119 citation statements)

References 43 publications

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“…This scoping review built upon the work of a systematic review and meta-analysis by Jenkins et al that identified studies assessing appropriateness of imaging for LBP [7]. This review included studies identified by Jenkins et al published in the last 5 years (since 2014), plus studies from a repeat of the original search to identify subsequently published papers.…”

Section: Methodsmentioning

confidence: 99%

“…This review included studies identified by Jenkins et al published in the last 5 years (since 2014), plus studies from a repeat of the original search to identify subsequently published papers. MEDLINE, EMBASE, and CINAHL were searched from 1st of January 2018 to 20th of February 2019, using the same search terms as Jenkins et al [7]. Citation lists of included papers were also reviewed.…”

Section: Methodsmentioning

confidence: 99%

“…Multiple studies have investigated rates of inappropriate LBP imaging; estimates vary markedly ranging from 3.8 to 88.5% [7]. Appropriateness is often judged by red flags: clinical features thought to raise suspicion of serious pathology.…”

Section: Introductionmentioning

confidence: 99%

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Defining and measuring imaging appropriateness in low back pain studies: a scoping review

et al. 2020

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Purpose Patients with low back pain (LBP) rarely have serious underlying pathology but frequently undergo inappropriate imaging. A range of guidelines and red flag features are utilised to characterise appropriate imaging. This scoping review explores how LBP imaging appropriateness is determined and calculated in studies of primary care practice. Methods This scoping review builds upon a previous meta-analysis, incorporating articles identified that were published since 2014, with an updated search to capture articles published since the original search. Electronic databases were searched, and citation lists of included papers were reviewed. Inclusion criteria were studies assessing adult LBP imaging appropriateness in a primary care setting. Twenty-three eligible studies were identified. Results A range of red flag features were utilised to determine imaging appropriateness. Most studies considered appropriateness in a binary manner, by the presence of any red flag feature. Ten guidelines were referenced, with 7/23 (30%) included studies amending or not referencing any guideline. The method for calculating the proportion of inappropriate imaging varied. Ten per cent of the studies used the total number of patients presenting with LBP as the denominator, suggesting most studies overestimated the rate of inappropriate imaging, and did not capture where imaging is not performed for clinically suspicious LBP. Conclusion Greater clarity is needed on how we define and measure imaging appropriateness for LBP, which also accounts for the problem of failing to image when indicated. An internationally agreed methodology for imaging appropriateness studies would ultimately lead to an improvement in the care delivered to patients. Graphic abstractThese slides can be retrieved under Electronic Supplementary Material.Key points 1. Inappropriate imaging for low back pain (LBP) is common, and there are a range of guidelines available for determining imaging appropriateness.2. This study reviews the appropriateness criteria used in primary care studies, identifying broad variation in the criteria used.3. It identifies that many studies include red flags with poor predictive values for serious causes of LBP, and also highlights that studies using varying methods for calculating the proportion of inappropriate imaging.Yates M, Oliveira CB, Galloway JB, Maher CG (2019) Defining and measuring imaging appropriateness in low back pain studies: A scoping review. Eur Spine J; 0 5 10 15 20 Neurological impairment Urinary retenƟon or inconƟnence Fever Loss of anal sphincter tone/faecal inconƟnence Motor deficits Spinal malformaƟons Non mechanical pain Night pain Anaemia Sexual dysfuncƟon Response to NSAIDs Radiculopathy N Bar chart displaying relative frequencies of clinical features used as red flags for LBP imaging. Yates M, Oliveira CB, Galloway JB, Maher CG (2019) Defining and measuring imaging appropriateness in low back pain studies: A scoping review. Eur Spine J;Take Home Messages 1. There is much variation in red flags and method...

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Defining and measuring imaging appropriateness in low back pain studies: a scoping review

et al. 2020

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“…Emery et al at Alberta University Hospital reported that only 44.3% of the lumbar MRI prescriptions were appropriate . The results from a systematic review mirrored the inappropriateness of 27.7% of lumbar MRI prescriptions …”

Section: Discussionmentioning

confidence: 99%

Analyzing inappropriate magnetic resonance imaging (MRI) prescriptions and resulting economic burden on patients suffering from back pain

Jahanmehr

Bigdeli

Salari

et al. 2019

Health Planning & Management

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Summary Introduction Back pain is a common global disorder and magnetic resonance imaging (MRI) is one method of assessing its cause. The lack of official and general clinical guidelines is the cause of inadequate supervision of lumbar MRI prescriptions. The goal of this research was to analyze inappropriate lumbar MRI prescriptions and the resulting economic burden on individuals. Method This is a descriptive‐analytical study carried out on a sample of 614 patients who visited four hospitals in Tehran. The appropriateness or inappropriateness of the MRI prescriptions was determined using clinical guidelines and a questionnaire based on previous studies. The economic burden created by inappropriate prescriptions for MRIs was determined after calculating the total direct and indirect costs. Findings The total MRI prescription cost paid by the study sample was $26 071, and the cost of inappropriate prescriptions was $10 310. The MRI prescription rate had a significant relationship with gender, age, education, employment, primary insurance type, and supplemental health insurance. Conclusion The research findings revealed relatively high rates of inappropriate MRI prescriptions in the private and public sectors. Hence, policymakers should design, create, and develop clinical guidelines and enforce the policies and rules to decrease inappropriate MRI prescriptions.

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“…USA PTs have demonstrated reliable behaviours, ordering imaging appropriately and consistent with evidence-based guidelines in 83-91% of cases (R. Boyles, 2013;Crowell et al, 2016;Deyle, 2011; A. P. Keil, Baranyi, Mehta, & Maurer, 2019;Learman, Ellis, Goode, Showalter, & Cook, 2014;Mabry, Ross, & Tall, 2010;Smith & Cleland, 2004). By comparison, primary care providers only order imaging consistent with evidence-based guidelines in 65-68% of cases (Jenkins et al, 2018). USA PTs have been shown to be significantly more accurate in ordering musculoskeletal imaging when compared with nonorthopaedic providers, more than doubling the rate of accuracy (Moore et al, 2005).…”

Section: Introductionmentioning

confidence: 99%

Physical therapy musculoskeletal imaging authority: A survey of the World Confederation for Physical Therapy Nations

Mabry

Boyles

Brismée

et al. 2019

Physiotherapy Res Intl

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Objectives Medical evidence largely supports PTs in expanded roles, however, healthcare policy within the United States (USA) typically restricts PTs from ordering musculoskeletal (MSK) imaging. It is unknown how MSK imaging policy in the USA compares to other World Confederation for Physical Therapy (WCPT) member nations. The primary objective of our study was to investigate the authority of PTs to order MSK imaging. A secondary objective was to identify factors associated with the authority for PTs to order MSK imaging. Methods 111 WCPT member nations were surveyed over a 2‐month period on the authority of PTs ordering MSK imaging within their nation. A secondary analysis utilizing a step‐wise binary regression compared member nation demographic statistics to MSK imaging authority. Results 81 member nations responded to the survey. 31 (38.3%) of member nations reported having some level of PT MSK imaging authority while 50 (61.7%) did not. Member nations with lower per capita healthcare costs were significantly more likely to allow PTs to order MSK imaging (p = 0.02). Those with direct access authority were 7.4 times more likely to authorize PTs to order MSK imaging (p < 0.01). Entry‐level clinical degree and years of entry‐level collegiate credit were not associated with imaging authority. Conclusion This is the first study to report MSK imaging policy within the WCPT member nations. While many nations within the WCPT allow PTs to order MSK imaging, the majority of nations still restrict PTs from such practice. Lower per capita healthcare costs and direct access authority were significant predictors of MSK imaging authority, however, causation cannot be established within the confines of this study. Future studies should consider issues such as restrictive policy origin (i.e. governmental vs. institutional), insurance reimbursement (i.e. private vs. public sector policy), and limitations on imaging modality

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Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis

Cited by 93 publications

References 43 publications

Defining and measuring imaging appropriateness in low back pain studies: a scoping review

Defining and measuring imaging appropriateness in low back pain studies: a scoping review

Analyzing inappropriate magnetic resonance imaging (MRI) prescriptions and resulting economic burden on patients suffering from back pain

Physical therapy musculoskeletal imaging authority: A survey of the World Confederation for Physical Therapy Nations

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