To Choose or Not To Choose: Evaluating the Effect of a Choosing Wisely Knowledge Translation Initiative for Imaging in Low Back Pain by Emergency Physicians

Abstract

Introduction: We aimed to quantify the baseline familiarity of emergency medicine (EM) physicians with the Choosing Wisely Canada (CWC)-EM recommendations. We then assessed whether a structured knowledge translation (KT) initiative affected awareness, knowledge, and practice patterns for imaging in low back pain. Methods: We completed a two-center, before and after practice evaluation study. Physicians working in two Canadian emergency departments (EDs) were asked to participate in a survey before a KT initiative, and were surveyed again at a six-month follow up period post-intervention. The primary outcome of physician practice was determined by analyzing the frequency of lumbar X-ray imaging for back pain. Results: A total of 37 physicians were asked to complete the pre- and post-intervention survey. Awareness of the CWC-EM recommendations increased following the intervention (63%; 95%CI: 43-79 at baseline vs. 86%; 66-96 post-intervention). Knowledge increased with 58% (39-76) of physicians responding correctly initially, and 86% (66-96) after the intervention. Despite increases in awareness and knowledge of the guidelines, the lumbar X-ray imaging rate increased from a baseline of 12% (9.9-14.5) to 16.2% (13.6-19.2; p = 0.023) following the intervention. Conclusion: We demonstrated some improvements in physician awareness and knowledge of the CWC-EM recommendations following our intervention. Despite these improvements, our KT intervention was associated with an increased frequency of imaging for low back pain, contrary to our expectations.

Interventions to reduce low-value imaging – a systematic review of interventions and outcomes

“…The most commonly targeted patient diagnosis was bronchiolitis [ 48 , 90 , 104 , 112 , 119 ], pulmonary embolism [ 49 , 58 , 60 , 82 , 100 , 102 , 121 , 122 , 125 ], and head injuries [ 67 , 70 , 77 , 79 , 87 , 94 , 101 , 123 , 126 , 127 ]. In studies targeting these complaints, a reduction in use of low-value imaging were reported in 78–80% of the studies, while imaging in lower back pain [ 38 , 45 , 51 , 53 , 54 , 65 , 68 , 71 , 75 , 89 , 115 , 118 ] were reduced in 58% of studies.…”

“…Among the 77 studies that reported improvements following the intervention [ 37 – 45 , 47 – 49 , 52 , 53 , 56 , 57 , 59 , 60 , 62 – 64 , 67 , 69 , 71 – 81 , 83 , 85 – 90 , 92 – 106 , 108 – 117 , 120 – 123 , 125 , 128 – 131 ], decreases in low-value imaging varied largely from < 1 to 62%. Of the remaining studies, three studies reported mixed results, where only some of the targeted low-value imaging examinations were reduced [ 46 , 54 , 68 ], and 16 studies showed a non-significant change or increase in the use of low-value imaging post-intervention [ 50 , 51 , 55 , 58 , 61 , 65 , 66 , 70 , 82 , 84 , 91 , 107 , 118 , 119 , 124 , 127 ].…”

“…Implementation of multi-component interventions (2 or more components in combination) reportedly reduced the use of low-value imaging among 94% of the included studies [ 40 – 44 , 47 , 48 , 51 , 53 , 56 , 59 , 63 , 72 , 78 , 79 , 81 , 83 , 86 , 87 , 94 , 101 , 104 , 105 , 111 , 115 , 116 , 118 , 120 , 122 , 123 , 126 , 128 ]. Multi-component interventions were found to be more effective when education was one of the components.…”

The influence of a MOBile-based video Instruction for Low back pain (MOBIL) on initial care decisions made by primary care providers: a randomized controlled trial

“…Perhaps more time to mentally process the information (instead of immediately before their consultation) would lead to greater advocacy for high-value care. While education has been targeted at clinicians with mixed results in the past [ 25 ], the clinicians in our trial were blinded to the treatment arm and entire educational component for the duration of the study. It is possible that some providers adapt to routines for managing specific conditions, where passive patient personalities are less likely to challenge any decisions made by clinicians.…”

“…In a study of 130 patients, 89% reported learning many of their misconceptions about back pain from previous health care providers, which provides some insight as to why these beliefs are so difficult to unravel [ 22 ]. Mass media campaigns that leverage psychosocial paradigms to improve the public’s health literacy related to misconceptions about the biomedical causes of back pain have been called for [ 23 ], but the magnitude of their effect is questionable leaving room for improvement [ 24 , 25 ]. Focusing on the individual patient at the point of care with a more engaging format, right when the problem is most pressing, could provide another influential opportunity for education.…”