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

Abstract

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...

Appropriateness of Referrals From Primary Care for Lumbar MRI

“…In cases like this, it was unclear what type or level of training had been performed or what period of time was involved (more or less than 6 weeks), which is essential information in the evaluation of appropriateness when using the ACR imaging guideline. If the criterion of duration was omitted, 38.3% (75.5 minus 37.2%) of the MRI referrals would have been inappropriate which is still higher but closer to the results reported in the previously mentioned literature [8,19]. It is possible that important clinical symptoms were absent due to oversight in the referrals or that information about non-surgical treatment or duration was not mentioned because of a lack of knowledge about imaging referral guidelines for LBP.…”

“…Many studies have investigated the appropriateness of lumbar MRI, and a variety of methods have been used [8, [15][16][17][18]. Some studies used imaging guidelines to clarify the appropriateness of MRI, and others used clinical symptoms and/or various standards of red ags [19,20]. The considerable variation in methods for classi cation of appropriateness of MRI makes it di cult to make comparisons between studies.…”

“…A scoping review from 2019 included 23 studies describing adult LBP imaging appropriateness in general practice [19]. A range of red ag features was utilised to determine imaging appropriateness.…”

“…Both the Australian systematic review from 2018 [8] and the scoping review from 2019 [19] conclude that many different methodologies are used to assess LBP imaging appropriateness.…”

Research designs and instruments to detect physiotherapy overuse of low-value care services in low back pain management: A scoping review protocol

“…Indirect measures contain quality indicator applications, survey studies of patients and healthcare providers or claims data analysis of regional differences in healthcare delivery [7]. However, research on medical overuse detection of low value care is still in its early stages: Authors of a critical review identi ed that most of overuse measures for LBP management aimed at imaging services [10] but even there, an international consent of de nitions and measures of imaging appropriateness in LBP is still not achieved [11]. Despite detections of inappropriate imaging services, a lacking availability of systematically collected administrative patient-level data still prohibits comprehensive overuse measures and fail to provide information about motives on individual low-value service provision [12].…”