What do we really know about the appropriateness of radiation emitting imaging for low back pain in primary and emergency care? A systematic review and meta-analysis of medical record reviews

Abstract

BackgroundSince 2000, guidelines have been consistent in recommending when diagnostic imaging for low back pain should be obtained to ensure patient safety and reduce unnecessary tests. This systematic review and meta-analysis was conducted to determine the pooled proportion of CT and x-ray imaging of the lumbar spine that were considered appropriate in primary and emergency care.MethodsPubmed, CINAHL, The Cochrane Database of Systematic Reviews and Embase were searched for synonyms of “low back pain”, “guidelines”, and “adherence” that were published after 2000. Titles, abstracts, and full texts were reviewed for inclusion with forward and backward tracking on included studies. Included studies had data extracted and synthesized. Risk of bias was performed on all studies, and GRADE was performed on included studies that provided data on CT and x-ray separately. A random effect, single proportion meta-analysis model was used.ResultsSix studies were included in the descriptive synthesis, and 5 studies included in the meta-analysis. Five of the 6 studies assessed appropriateness of x-rays; two of the six studies assessed appropriateness of CTs. The pooled estimate for appropriateness of x-rays was 43% (95% CI: 30%, 56%) and the pooled estimate for appropriateness of CTs was 54% (95% CI: 51%, 58%). Studies did not report adequate information to fulfill the RECORD checklist (reporting guidelines for research using observational data). Risk of bias was high in 4 studies, moderate in one, and low in one. GRADE for x-ray appropriateness was low-quality and for CT appropriateness was very-low-quality.ConclusionWhile this study determined a pooled proportion of appropriateness for both x-ray and CT imaging for low back pain, there is limited confidence in these numbers due to the downgrading of the evidence using GRADE. Further research on this topic is needed to inform our understanding of x-ray and CT appropriateness in order to improve healthcare systems and decrease patient harms.

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

“…We found a rate of appropriateness (6.5%) that is much lower than rates reported by the other two studies investigating this issue. It is also much lower than the pooled proportion in a recent systematic review and meta-analysis based on these two studies [13]. This is, perhaps, unsurprising given that these studies were conducted in different settings and used different definitions of appropriateness [9,23].…”

“…Given the small proportion of patients in which imaging will likely have a beneficial impact, this rate of 1 in 4 patients receiving an image seems rather high and poses the question regarding the appropriateness of the imaging referrals. Two reviews have investigated what is known about the appropriateness of imaging when comparing the referral reasons to the guidelines [12,13]. When looking at any imaging by any provider the first review found that 34.8% (95% CI: 27.1, 43.3) were considered inappropriate when compared to guidelines [12].…”

“…The second review focused on x-rays and CTs and found only 2 studies reported appropriateness of CTs in primary care settings. Among these studies the rate of appropriateness was 54% (95% CI: 51, 58%) [13]. In these two studies, the methodological quality was judged to be poor specifically regarding the lack of clarity regarding the definitions of the primary outcome of appropriateness [13].…”

“…Among these studies the rate of appropriateness was 54% (95% CI: 51, 58%) [13]. In these two studies, the methodological quality was judged to be poor specifically regarding the lack of clarity regarding the definitions of the primary outcome of appropriateness [13]. Other than these few studies, we know very little about the rates of appropriateness and we have virtually no information on the actual reasons for ordering those images that were deemed inappropriate, which is surprising given the safety risks to the patient and costs to the healthcare system [14].…”

Barriers to following imaging guidelines for the treatment and management of patients with low-back pain in primary care: a qualitative assessment guided by the Theoretical Domains Framework

“…Roughly 90% of LBP presentations in primary care are NSLBP [ 3 , 15 ] that should not be imaged as it isn’t useful and introduces potential harm to patients via unnecessary radiation exposure and inappropriate procedures due to incidental findings [ 12 ]. Nevertheless, up to half of all requests for lumbar spine imaging are estimated to be inappropriate [ 16 – 21 ]. As a result, one of Choosing Wisely Canada’s key de-implementation campaigns targeting healthcare providers focuses on reducing unnecessary lumbar spine imaging.…”