Understanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study

Abstract

BackgroundOveruse of lumbar imaging in the Emergency Department is a well-recognised healthcare challenge. Studies to date have not provided robust evidence that available interventions can reduce overuse. For an intervention aimed at reducing imaging to be effective, insight into how both patients and clinicians view lumbar imaging tests is essential.AimTo explore factors that might influence overuse of lumbar imaging in the Emergency Department.MethodsParticipants were recruited from three hospitals in Sydney, Australia between April and August 2019. We conducted focus groups and/or interviews with 14 patients and 12 clinicians. Sessions were audio-recorded and transcribed verbatim. Data were analysed using framework analysis by a team of four researchers with diverse backgrounds.ResultsPatients described feeling that the decision about lumbar imaging was made by their Emergency Department clinician and reported little involvement in the decision-making process. Other potential drivers of lumbar imaging overuse from the patients’ perspective were strong expectations for lumbar imaging, a reluctance to delay receiving a diagnosis, and requirements from third parties (eg, insurance companies) to have imaging. Emergency Department clinicians suggested that the absence of an ongoing therapeutic relationship, and the inability to manage perceived patient pressure could drive overuse of lumbar imaging. Suggested protective factors included: involving patients in the decision, ensuring clinicians have the ability to explain the reasons to avoid imaging and collaborative approaches to care both within the Emergency Department and with primary care.Conclusion and key findingsWe found several factors that could contribute to overuse of lumbar imaging in the Emergency Department. Solutions to overuse of lumbar imaging in the Emergency Department could include: (1) strategies to involve patients in decisions about imaging; (2) training and support to provide thorough and well explained clinical assessment for low back pain; and (3) systems that support collaborative approaches to care.

What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review

“…Barriers and enablers were the focus of 12 qualitative,48–59 8 quantitative60–67 and 4 mixed-methods studies 68–71. Studies of barriers and enablers explored testing/treatment in infant bronchiolitis,54 55 68 antibiotic stewardship,53 56 57 62 70 cranial CT scans in minor head injury,49 52 guideline implementation in chest pain51 and syncope,69 urinalysis,56 67 urinary catheter insertion,50 lumbar radiographs in back pain,48 respiratory viral testing,54 potentially inappropriate medications in older patients58 and perspectives about low-value care 59 60 64–66 71…”

“…Barriers and enablers were reported at the level of emergency providers, patients or systems. Limited provider abilities,48 53 55 patient expectations,66 diagnostic uncertainty,53 55 69 insufficient provider insight,72 habit,57 conflict between guidelines and clinical judgement,52 68 69 time constraints,48 53 55 68 70 perceived benefits of defensive practice59 and fear of litigation60 emerged as key barriers.…”

Diagnoses and trends in use of imaging for low back pain in four Australian emergency departments between 2012 and 2019

“…Our study provides estimates for the probability of underlying pathology when patients present to the ED with back pain. Large multi‐site studies could help explain higher rates of imaging at some sites and the importance of factors such as culture within the ED, differences of case mix and/or age, uptake of new model of care, differences in patient requests, and patient flow, in determining lumbar imaging use in ED 25 …”

The diagnostic yield of head and neck imaging in symptomatic patients with a normal clinical examination

“…This is a campaign ran by the American Board of Internal Medicine which discusses avoiding unnecessary tests, treatments, and procedures. [11][12][13] It is important to avoid unnecessary testing to reduce patient anxiety and save resources. 14,15 Although the utility of imaging patients with unilateral otalgia in the absence of clinical findings has previously been studied, this has not been broadened to include patients with all symptoms of HNC.…”

“…The overuse of diagnostic imaging is a developing area of research, which has led to the development of the “Choosing Wisely Initiative.” This is a campaign ran by the American Board of Internal Medicine which discusses avoiding unnecessary tests, treatments, and procedures 11–13 . It is important to avoid unnecessary testing to reduce patient anxiety and save resources 14,15 .…”