Do not routinely offer imaging for uncomplicated low back pain

Hall, Amanda; Aubrey‐Bassler, Kris; Thorne, Bradley; Maher, Chris G

doi:10.1136/bmj.n291

Cited by 47 publications

(32 citation statements)

References 23 publications

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“…Lower disease prevalence in primary care results in lower yields from diagnostic strategies and guidelines have increasingly called for more selective imaging. 30 31 Additionally, investment in readily accessible and evidenced community MSK 'interface' triage services, [32][33][34][35] recommended in national MSK transformation strategy, 36 calls into question the need for continued GP-MSK-MRI access.…”

Section: Open Accessmentioning

confidence: 99%

Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care

2021

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ObjectivesThe largest proportion of general practitioner (GP) magnetic resonance imaging (MRI is musculoskeletal (MSK), with consistent annual growth. With limited supporting evidence and potential harms from early imaging overuse, we evaluated practice to improve pathways and patient safety.MethodsCohort evaluation of routinely collected diagnostic and general practice data across a UK metropolitan primary care population. We reviewed patient characteristics, results and healthcare utilisation.ResultsOf 306 MSK-MRIs requested by 107 clinicians across 29 practices, only 4.9% (95% CI ±2.4%) appeared clearly indicated and only 16.0% (95% CI ±4.1%) received appropriate prior therapy. 37.0% (95% CI ±5.5%) documented patient imaging request. Most had chronic symptoms and half had psychosocial flags. Mental health was addressed in only 11.8% (95% CI ±6.3%) of chronic sufferers with psychiatric illness, suggesting a solely pathoanatomical approach to MSK care. Only 7.8% (95% CI ±3.0%) of all patients were appropriately managed without additional referral. 1.3% (95% CI ±1.3%) of scans revealed diagnoses leading to change in treatment (therapeutic yield). Most imaged patients received pathoanatomical explanations to their symptoms, often based on expected age or activity-related changes. Only 16.7% (95% CI ±4.2%) of results appeared correctly interpreted by GPs, with spurious overperception of surgical targets in 65.4% (95% CI ±5.3%) who suffered ‘low-value’ (ineffective, harmful or wasteful) post-MRI referral cascades due to misdiagnosis and overdiagnosis. Typically, 20%–30% of GP specialist referrals convert to a procedure, whereas MRI-triggered referrals showed near-zero conversion rate. Imaged patients experienced considerable delay to appropriate care. Cascade costs exceeded direct-MRI costs and GP-MSK-MRI potentially more than doubles expenditure compared with physiotherapist-led assessment services, for little-to-no added therapeutic yield, unjustifiable by cost–consequence or cost–utility analysis.ConclusionUnfettered GP-MSK-MRI use has reached unaccceptable indication creep and disutility. Considerable avoidable harm occurs through ubiquitous misinterpretation and salient low-value referral cascades for two-thirds of imaged patients, for almost no change in treatment. Any marginally earlier procedural intervention for a tiny fraction of patients is eclipsed by negative consequences for the vast majority. Only 1–2 patients need to be scanned for one to suffer mismanagement. Direct-access imaging is neither clinically, nor cost-effective and deimplementation could be considered in this setting. GP-MSK-MRI fuels unnecessary healthcare utilisation, generating nocebic patient beliefs and expectations, whilst appropriate care is delayed and a high burden of psychosocial barriers to recovery appear neglected.

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Section: Open Accessmentioning

confidence: 99%

Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care

2021

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“…For example, if a patient scores high on ‘the attitude towards not needing to know the cause of back pain to manage it effectively, the clinician could devote more time during the consultation towards other aspects of first-line care such as promoting physical activity. Whereas if a patient has a negative attitude towards this factor, the clinician could prioritise time and resources to discuss how imaging may do more harm than good when serious conditions are not suspected and is likely to prolong recovery [ 47 ]. Future research would be needed to evaluate the effectiveness of using the AxEL-Q in this way.…”

Section: Discussionmentioning

confidence: 99%

Development and measurement properties of the AxEL (attitude toward education and advice for low-back-pain) questionnaire

O’Hagan

Skinner

Jones

et al. 2022

Health Qual Life Outcomes

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Introduction Clinician time and resources may be underutilised if the treatment they offer does not match patient expectations and attitudes. We developed a questionnaire (AxEL-Q) to guide clinicians toward elements of first-line care that are pertinent to their patients with low back pain. Methods We used guidance from the COSMIN consortium to develop the questionnaire and evaluated it in a sample of people with low back pain of any duration. Participants were recruited from the community, were over 18 years and fluent in English. Statements that represented first-line care were identified. Semantic scales were used to measure attitude towards these statements. These items were combined to develop the questionnaire draft. Construct validity was evaluated with exploratory factor analysis and hypotheses testing, comparing to the Back Beliefs Questionnaire and modified Pain Self-Efficacy Questionnaire. Reliability was evaluated and floor and ceiling effects calculated. Results We recruited 345 participants, and had complete data for analysis for 313 participants. The questionnaire draft was reduced to a 3-Factor questionnaire through exploratory factor analysis. Factor 1 comprised 9 items and evaluated Attitude toward staying active, Factor 2 comprised 4 items and evaluated Attitude toward low back pain being rarely caused by a serious health problem, Factor 3 comprised 4 items and evaluated Attitude toward not needing to know the cause of back pain to manage it effectively. There was a strong inverse association between each factor and the Back Beliefs Questionnaire and a moderate positive association with the modified Pain Self-Efficacy Questionnaire. Each independent factor demonstrated acceptable internal consistency; Cronbach α Factor 1 = 0.92, Factor 2 = 0.91, Factor 3 = 0.90 and adequate interclass correlation coefficients; Factor 1 = 0.71, Factor 2 = 0.73, Factor 3 = 0.79. Conclusion This study demonstrates acceptable construct validity and reliability of the AxEL-Q, providing clinicians with an insight into the likelihood of patients following first-line care at the outset.

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“…Non-indicated imaging for LBP is a form of low-value care and the routine use of imaging is not recommended in clinical practice 24 . Interventions that are aimed at targeting this behaviour are needed to improve patient outcomes and reduce overutilisation of healthcare resources.…”

Section: Discussionmentioning

confidence: 99%

Exploring perceived barriers and enablers to fidelity of training and delivery of an intervention to reduce imaging for low back pain: a qualitative interview study protocol

Carvalho

Pike

et al. 2021

HRB Open Res

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Background: Diagnostic imaging has limited utility in the assessment and management of non-specific low back pain (LBP), but remains commonly used in clinical practice. Interventions have been designed to reduce non-indicated imaging for LBP; however, evidence of effectiveness has been variable. It is unclear whether intervention fidelity was adequately assessed in these interventions, which may have an impact on the interpretation of trial results. Within implementation research, intervention fidelity refers to the degree to which an intervention was delivered as intended and to the strategies used to monitor and enhance this process. Intervention fidelity covers five domains: design, training, delivery, receipt, and enactment. Objectives: The objectives of this study are to explore perceived barriers and enablers to fidelity of training and delivery of a proposed theory-informed intervention aimed at reducing non-indicated imaging for LBP by general practitioners (GPs) and chiropractors in Newfoundland and Labrador (NL), Canada. Methods: Semi-structured interviews will be conducted with GPs and chiropractors in NL to explore their views on barriers and enablers towards enhancing and/or assessing fidelity of training and delivery. Interviews will be audio-recorded, transcribed verbatim, and analysed with the Theoretical Domains Framework. Relevant domains related to perceived barriers and enablers will be identified by: the frequency of beliefs; the presence of conflicting beliefs; and the perceived strength of the impact a belief may have on the target behaviours. Discussion: Results of this study will aid in the development of a fidelity protocol for an upcoming cluster randomised controlled trial of a theory-informed intervention aimed at reducing non-indicated imaging for LBP. Our results may help to ensure that the proposed intervention will be delivered with good fidelity and that fidelity can be appropriately assessed.

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Do not routinely offer imaging for uncomplicated low back pain

Cited by 47 publications

References 23 publications

Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care

Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care

Development and measurement properties of the AxEL (attitude toward education and advice for low-back-pain) questionnaire

Exploring perceived barriers and enablers to fidelity of training and delivery of an intervention to reduce imaging for low back pain: a qualitative interview study protocol

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