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Impact of IT-enabled Intervention on MRI Use for Back Pain

  • Ivan K. Ip
    Correspondence
    Requests for reprints should be addressed to Ivan K. Ip, MD, MPH, Center for Evidence-Based Imaging, Department of Radiology and Medicine, Brigham and Women's Hospital, 20 Kent Street, 2nd floor, Boston, MA 02120.
    Affiliations
    Center for Evidence-Based Imaging, Harvard Medical School, Boston, Mass

    Department of Radiology, Harvard Medical School, Boston, Mass

    Department of Medicine, Harvard Medical School, Boston, Mass

    Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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  • Esteban F. Gershanik
    Affiliations
    Center for Evidence-Based Imaging, Harvard Medical School, Boston, Mass

    Department of Radiology, Harvard Medical School, Boston, Mass

    Department of Medicine, Harvard Medical School, Boston, Mass

    Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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  • Louise I. Schneider
    Affiliations
    Center for Evidence-Based Imaging, Harvard Medical School, Boston, Mass

    Department of Radiology, Harvard Medical School, Boston, Mass

    Department of Medicine, Harvard Medical School, Boston, Mass

    Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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  • Ali S. Raja
    Affiliations
    Center for Evidence-Based Imaging, Harvard Medical School, Boston, Mass

    Department of Radiology, Harvard Medical School, Boston, Mass

    Brigham and Women's Hospital, Harvard Medical School, Boston, Mass

    Department of Emergency Medicine, Harvard Medical School, Boston, Mass
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  • Wenhong Mar
    Affiliations
    Center for Evidence-Based Imaging, Harvard Medical School, Boston, Mass

    Department of Radiology, Harvard Medical School, Boston, Mass
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  • Steven Seltzer
    Affiliations
    Department of Radiology, Harvard Medical School, Boston, Mass

    Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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  • Michael J. Healey
    Affiliations
    Department of Medicine, Harvard Medical School, Boston, Mass

    Brigham and Women's Hospital, Harvard Medical School, Boston, Mass

    Brigham and Women's Physician Organization, Harvard Medical School, Boston, Mass
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  • Ramin Khorasani
    Affiliations
    Center for Evidence-Based Imaging, Harvard Medical School, Boston, Mass

    Department of Radiology, Harvard Medical School, Boston, Mass

    Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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Published:February 10, 2014DOI:https://doi.org/10.1016/j.amjmed.2014.01.024

      Abstract

      Background

      The purpose of this study was to examine the impact of a multifaceted, clinical decision support (CDS)-enabled intervention on magnetic resonance imaging (MRI) use in adult primary care patients with low back pain.

      Methods

      After a baseline observation period, we implemented a CDS targeting lumbar-spine MRI use in primary care patients with low back pain through our computerized physician order entry, as well as 2 accountability tools: mandatory peer-to-peer consultation when test utility was uncertain and quarterly practice pattern variation reports to providers. Our primary outcome measure was rate of lumbar-spine MRI use. Secondary measures included utilization of MRI of any body part, comparing it with that of a concurrent national comparison, as well as proportion of lumbar-spine MRI performed in the study cohort that was adherent to evidence-based guideline. Chi-squared, t-tests, and logistic regression were used to assess pre- and postintervention differences.

      Results

      In the study cohort preintervention, 5.3% of low back pain-related primary care visits resulted in lumbar-spine MRI, compared with 3.7% of visits postintervention (P <.0001, adjusted odds ratio 0.68). There was a 30.8% relative decrease (6.5% vs 4.5%, P <.0001, adjusted odds ratio 0.67) in the use of MRI of any body part by the primary care providers in the study cohort. This difference was not detected in the control cohort (5.6% vs 5.3%, P = .712). In the study cohort, adherence to evidence-based guideline in the use of lumbar-spine MRI increased from 78% to 96% (P = .0002).

      Conclusions

      CDS and associated accountability tools may reduce potentially inappropriate imaging in patients with low back pain.

      Keywords

      • Evidence-based clinical decision support (CDS), with embedded consequences for ignoring evidence, was associated with a statistically significant decrease in lumbar-spine magnetic resonance imaging (MRI) use in patients with low back pain.
      • A targeted CDS-enabled intervention was associated with an absolute increase in guideline adherence rate in the use of MRI.
      • Health information technology tools can help improve quality and reduce waste by promoting evidence-based practice for diagnostic imaging.
      SEE RELATED EDITORIAL p. 463
      With the substantial financial investment associated with the Health Information Technology for Economic and Clinical Health provisions of the American Recovery and Reinvestment Act of 2009 comes great expectations that health information technology (HIT) will not only enhance patient safety and improve quality of care but also reduce waste such as unnecessary high-cost medical imaging. Yet, the impact of HIT on health care delivery remains largely unclear. Kellermann and Jones
      • Kellermann A.L.
      • Jones S.S.
      What it will take to achieve the as-yet-unfulfilled promises of health information technology.
      noted that we have yet to fully capitalize on the $81 billion in annual cost savings that was originally projected. In fact, McCormick et al
      • McCormick D.
      • Bor D.H.
      • Woolhandler S.
      • Himmelstein D.U.
      Giving office-based physicians electronic access to patients' prior imaging and lab results did not deter ordering of tests.
      reported that HIT may even be associated with an unintended consequence of increasing cost.
      Low back pain (LBP) is very common,
      • Freburger J.K.
      • Holmes G.M.
      • Agans R.P.
      • et al.
      The rising prevalence of chronic low back pain.
      affecting approximately 70%-85% of Americans over their lifetimes,
      • Andersson G.B.
      Epidemiological features of chronic low-back pain.
      and one quarter of US adults report LBP within the previous 3 months.
      • Deyo R.A.
      • Mirza S.K.
      • Martin B.I.
      Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002.
      The estimated direct health care costs associated with spine problems exceeded $85 billion, representing 9% of national health expenditures.
      • Martin B.I.
      • Deyo R.A.
      • Mirza S.K.
      • et al.
      Expenditures and health status among adults with back and neck problems.
      While lumbar spine magnetic resonance imaging (LS-MRI) is the preferred diagnostic examination for most spinal diseases (eg, cauda equina syndrome, infection, or neoplasm), its value in the investigation of simple back pain may be limited,
      • Chou R.
      • Fu R.
      • Carrino J.A.
      • Deyo R.A.
      Imaging strategies for low-back pain: systematic review and meta-analysis.
      as imaging abnormalities and clinical symptoms are poorly correlated
      • Van Tulder M.W.
      • Assendelft W.J.
      • Koes B.W.
      • Bouter L.M.
      Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies.
      and routine imaging is not associated with better pain relief, higher functioning, or improved quality of life.
      • Modic M.T.
      • Obuchowski N.A.
      • Ross J.S.
      • et al.
      Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome.
      • Gilbert F.J.
      • Grant A.M.
      • Gillan M.G.C.
      • et al.
      Low back pain: influence of early MR imaging or CT on treatment and outcome—multicenter randomized trial.
      • Kendrick D.
      • Fielding K.
      • Bentley E.
      • Kerslake R.
      • Miller P.
      • Pringle M.
      Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial.
      • Kerry S.
      • Hilton S.
      • Dundas D.
      • Rink E.
      • Oakeshott P.
      Radiography for low back pain: a randomised controlled trial and observational study in primary care.
      Based on an extensive systematic review, the joint guidelines of the American College of Physicians and the American Pain Society (ACP/APS) recommend against routine imaging in patients with nonspecific LBP (ie, no severe or progressive neurologic deficits or evidence of serious underlying conditions).
      • Chou R.
      • Qaseem A.
      • Snow V.
      • et al.
      Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society.
      Qaseem et al
      • Qaseem A.
      • Alguire P.
      • Dallas P.
      • et al.
      Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care.
      identified imaging in patients with nonspecific LBP to be one clinical situation that does not reflect high-value care.
      Despite evidence that routine imaging does not improve patient outcomes, clinical practice is often inconsistent with the ACP/APS guidelines. The use of LS-MRI has continued to increase, and there is evidence of wide practice variation.
      • Srinivas S.V.
      • Deyo R.A.
      • Berger Z.D.
      Application of “less is more” to low back pain.
      • Lurie J.D.
      • Birkmeyer N.J.
      • Weinstein J.N.
      Rates of advanced spinal imaging and spine surgery.
      Mafi et al
      • Mafi J.N.
      • McCarthy E.P.
      • Davis R.B.
      • Landon B.E.
      Worsening trends in the management and treatment of back pain.
      recently found that the management of back pain has relied increasingly on guideline-discordant care, with more frequent use of narcotics and high-cost imaging since 1999. The purpose of this study was to examine the impact of a multifaceted, clinical decision support (CDS)-enabled intervention based on the published ACP/APS guidelines,

      American College of Emergency Physicians. ACEP Policy Statement on Health Information Technology. Available at: http://www.acep.org/Content.aspx?id=29534. Accessed October 24, 2012.

      on the use of MRI in adult primary care patients with low back pain.

      Materials and Methods

      Study Setting and Cohort

      Our study site consists of an integrated health system centered around an urban academic quaternary care hospital, with an outpatient network that spans 183 practices and 1200 physicians. The requirement to obtain informed consent was waived by the system's Institutional Review Board for this Health Insurance Portability and Accountability Act-compliant study. The study cohort included all adult patients who presented with LBP to a primary care physician (PCP) affiliated with our institution between 2007 and 2010. To identify primary care visits for LBP-related conditions, we queried our institutional billing database to identify all primary care encounters of patients aged 18 years or older with an associated primary or top 2 secondary diagnosis of LBP using International Classification of Diseases, 9th Revision (ICD-9) codes (Appendix Table).
      • Mafi J.N.
      • McCarthy E.P.
      • Davis R.B.
      • Landon B.E.
      Worsening trends in the management and treatment of back pain.
      • Jarvik J.G.
      • Comstock B.A.
      • Bresnahan B.W.
      • et al.
      Study protocol: the Back Pain Outcomes using Longitudinal Data (BOLD) registry.

      Control Cohort

      To account for secular differences in MRI utilization, we selected a control cohort consisting of primary care visits of patients with LBP captured from the publicly available National Ambulatory Medical Care Survey (NAMCS) during the same time period. The NAMCS survey was designed to be representative of outpatient care in the US, with data collected using a standardized form completed during each patient visit. NAMCS included data on patient's demographics, medications listed, laboratory and imaging studies ordered during the visit, as well as up to 3 diagnoses derived from ICD-9 codes. NAMCS does not provide details of the specific body part imaged with MRI, hence the need to compare MRI of any body part utilization. Using surveys conducted between 2007 and 2010, we included only primary care visits in adult patients aged 18 years or older. We used ICD-9 diagnosis (primary or secondary) to identify back pain-related visits based on the same codes as for the study cohort.

      Intervention

      After a baseline data-gathering observational period of 7 quarters, we implemented a multifaceted intervention to promote guideline adherence in the use of LS-MRI in patients with LBP-related primary care visits in the study cohort. Our institution's computerized physician order entry (CPOE) system for imaging (Percipio, Medicalis Corp, San Francisco, Calif) is integrated into our health information technology infrastructure.
      • Ip I.K.
      • Schneider L.I.
      • Hanson R.
      • et al.
      Adoption and meaningful use of computerized physician order entry with an integrated clinical decision support system for radiology: ten-year analysis in an urban teaching hospital.
      Based on the clinical history input via the CPOE system, real-time CDS launches, advising the orderer about the best diagnostic strategy if evidence is available. The CDS content for LS-MRI is derived from the ACP/APS guidelines,
      • Chou R.
      • Qaseem A.
      • Snow V.
      • et al.
      Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society.
      which are based on systematic review and supported by moderate quality evidence. In the absence of any clinical “red flags” (for which LS-MRI would be considered appropriate), CDS suggests that the LS-MRI is not indicated (Figure 1). The clinician may cancel the request, or ignore the CDS and proceed with the order. Preintervention, LS-MRI orders were placed via the CPOE system but did not trigger CDS. Only PCPs received the intervention, triggered based on their primary practice affiliation; medical and surgical subspecialists and emergency physicians placed orders for LS-MRI without receiving CDS.
      Figure thumbnail gr1
      Figure 1Screenshot of decision support for lumbar-spine MRI in patients with low back pain.
      In addition to CDS, our intervention included 2 components we termed “accountability tools.” The first was a mandatory near-real-time peer-to-peer telephonic consultation with a radiologist or internist familiar with the evidence before order completion when the orderer ignored a “not indicated” CDS alert. Alternatively, the orderer could avoid the peer-to-peer consultation workflow by cancelling the order. As a second accountability tool, quarterly practice pattern variation reports were sent to individual PCPs, depicting their LS-MRI utilization (number of LS-MRIs ordered per number of LBP-related visits) in comparison to peers.

      Data Collection and Sources

      Patient demographics and imaging use in the study cohort were collected from electronic medical records. Any MRI ordered on the day of primary care visit from a primary care site, or an LS-MRI order from a specialist or PCP within 30 days after the date of primary care visit, was attributed to the visit. Similar data of patient demographics and MRI of any body part ordering patterns in the control cohort was collected directly from the NAMCS database. Due to the design of the NAMCS survey, the specific body part of MRI and subsequent imaging orders from specialists were not available.
      To evaluate whether LS-MRI orders were guideline-adherent in the study cohort, 2 board-certified attending physicians reviewed the medical records. Based on power calculation with alpha of 0.05, power of 0.8, and confidence interval of 15%, charts of 200 randomly selected patients with visits in the pre- and postintervention periods (100 in each group) were reviewed to determine whether each study ordered was in adherence with the ACP/APS guidelines. Records also were reviewed to verify concordance between physician note documentation and CPOE system input. For example, a case would be considered not concordant if review of the physician note showed that an order was guideline-adherent while the LS-MRI order requisition (entered into the CPOE system) illustrated otherwise.

      Statistical Analyses

      The primary outcome measure in our study cohort was the intensity of LS-MRI use, defined as the number of completed LS-MRI examinations that were ordered by PCP per LBP-related visit. As a secondary measure, we also examined the intensity of MRI of any body part use, an element that is captured by the NAMCS survey, thus allowing us to compare utilization in the study cohort to that of a concurrent control. MRI use intensity in the preintervention period was compared with that postintervention. For MRI of any body part, the change in MRI use intensity between the pre- and postintervention periods was compared with the control cohort to account for secular confounders. We also examined in the study cohort the rates of utilization of LS-MRI by both primary care and specialists, adherence rate to ACP/APS guideline for LS-MRI use, as well as the rate of follow-up LBP-related primary care visits within 30 days of the index visit. The 30-day follow-up timeframe was based on the ACP guideline recommendation of follow-up within 4 weeks.
      • Chou R.
      • Qaseem A.
      • Snow V.
      • et al.
      Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society.
      Analyses were performed using JMP 10 (SAS Institute, Cary, NC). Chi-squared and t-tests were used to assess pre- and postintervention differences. To adjust for demographic differences between the study and control cohorts, a logistic regression was performed. A 2-tailed P-value of <.05 was defined as statistically significant.

      Results

      Between 2007 and 2010, there were 21,445 LBP-related primary care visits (8437 preintervention and 13,008 postintervention) by patients aged 18 years or older in the study cohort. There were 2240 (945 preintervention and 1295 postintervention) LBP-related primary care visits in the control cohort. Overall, 3.7% of primary care encounters in the pooled study and control cohorts were LBP-related (3.6% in the study cohort; 6.5% in the control). In the study cohort, the mean patient age was 53.0 years, and 69.7% of patients were female. This represented a slightly older and more female-concentrated cohort than the control (50.5 years mean age, 57.3% female). Details of the patient demographic characteristics of the study and control cohorts are shown in Table 1.
      Table 1Patient Characteristics of Study and Control Cohorts
      CharacteristicStudy Cohort (n = 21,445)Control Cohort (n = 2240)P-Value
      Sex
       Female, n (%)14,950 (69.7%)1283 (57.3%)<.0001
      Denotes statistical significance.
      Age (years: average ± SD)53.0 ± 15.650.5 ± 15.8<.0001
      Denotes statistical significance.
      Race/ethnicity, n (%)<.0001
      Denotes statistical significance.
       Caucasian13,563 (63.2%)1259 (56.2%)
       Black/African American3785 (17.7%)274 (12.2%)
       Hispanic2080 (9.7%)190 (8.5%)
       Asian614 (2.9%)27 (1.2%)
       Other1403 (6.5%)490 (21.9%)
      Denotes statistical significance.
      Overall, 920 (4.3%) LBP-related primary care visits were associated with an LS-MRI ordered from the primary care practice on the day of visit in the study cohort. During the study period, we observed a decreased intensity in the use of LS-MRI among patients with LBP in the study cohort. In the preintervention phase, 5.3% of LBP visits (443/8437) were associated with an LS-MRI order; after our CDS-enabled interventions were implemented, utilization decreased by a relative 30.2% (P <.0001), to a rate of 3.7% of LBP-related primary care visits (n = 477/13,008). The approximately 30% relative decrease in LS-MRI utilization intensity in the study cohort postintervention persisted even after accounting for baseline demographic differences in age, sex, and race between the study and control cohorts (adjusted odds ratio 0.68, P <.0001) (Table 2).
      Table 2Results of Logistic Regression on the Use of Magnetic Resonance Imaging Controlling for Patient Characteristics in Study Cohort
      VariableOdds Ratio95% CIP-Value
      Primary outcome measure: LS-MRI utilization
       Patient age (by year)1.008 per year1.004-1.013.0002
      Denotes statistical significance.
       Patient sex (reference = female)1.231.07-1.42.004
      Denotes statistical significance.
       Race/ethnicity (reference = Caucasian).150
      Asian0.990.65-1.45
      Black/African American0.790.65-0.95
      Hispanic1.050.83-1.31
      Other0.980.74-1.28
       Intervention0.680.59-0.77<.0001
      Denotes statistical significance.
      Secondary outcome measure: MRI of any body part utilization
       Patient age (by year)1.008 per year1.005-1.012<.0001
      Denotes statistical significance.
       Patient sex (reference = female)1.261.11-1.42.0004
      Denotes statistical significance.
       Race/ethnicity (reference = Caucasian).178
      Asian1.110.77-1.55
      Black/African American0.830.69-0.98
      Hispanic1.060.86-1.30
      Other1.010.79-1.28
       Intervention0.670.59-0.75<.0001
      Denotes statistical significance.
      CI = confidence; LS = lumbar spine; MRI = magnetic resonance imaging.
      Denotes statistical significance.
      In the study cohort, 1251 (5.3%) LBP-related primary care visits were associated with an order for an MRI of any body part; 73.5% of these MRIs were for lumbar-spine (920/1251). In the preintervention phase, 6.5% of LBP visits (n = 546/8437) were associated with an MRI of any body part order; after intervention, the utilization of MRI of any body part decreased by a relative 30.8% (P <.0001), to a rate of 4.5% of LBP-related primary care visits (n = 584/13,008). In contrast, in the control cohort of NAMCS-surveyed visits, the use of MRI of any body part did not change significantly (P = .712) over the same time frame (Figure 2). Similar to the primary outcome measure, the approximately 30% relative decrease in MRI of any body part utilization intensity in the study cohort postintervention persisted even after accounting for baseline demographic differences in age, sex, and race between the study and control cohorts (adjusted odds ratio 0.67, P <.0001) (Table 2).
      Figure thumbnail gr2
      Figure 2Comparison of MRI utilization before and after implementation of intervention.
      Table 3 depicts results for the tertiary outcome measures in the study cohort. There was a statistically significant relative increase of 22.7% (2.2% vs 2.7%) in the rate of LS-MRI ordered by outpatient specialists (eg, orthopedics, neurosurgery, rheumatology) within 30 days of a patient's index primary care visit (P = .0292), which suggests that some of the LS-MRI use may have simply shifted to ordering by specialists. However, the overall percentage of LBP-related visits that resulted in an LS-MRI within 30 days of the index visit remained significantly different in the pre- and postintervention periods, even after accounting for examinations that were ordered by specialists (8.9% vs 7.8%, relative 12% decrease, P = .0023).
      Table 3Analysis of Tertiary Outcome Measures in the Study Cohort
      Due to the design of the National Ambulatory Medical Care Survey, tertiary outcome measure was not possible in the control cohort.
      Outcome MeasurePreinterventionPostintervention% ChangeP-Value
      Lumbar spine MRI ordered by any outpatient providers within 30 days of index primary care visit753 (8.9%)1009 (7.8%)−12.3.0023
      Denotes statistical significance.
      Lumbar spine MRI ordered by specialty clinics within 30 days188 (2.2%)352 (2.7%)+22.7.0292
      Denotes statistical significance.
      Lumbar Spine MRI ordered by primary care outpatient providers within 30 days565 (6.7%)657 (5.1%)−23.9<.001
      Denotes statistical significance.
      Follow-up PCP visit within 30 days855 (10.1%)1224 (9.4%)−6.9.080
      Denotes statistical significance.
      Guideline adherence rate in the use of lumbar spine MRI based on manual chart review78/100 (78%)96/100 (96%)+23.1.0002
      Denotes statistical significance.
      MRI = magnetic resonance imaging; PCP = primary care physician.
      Due to the design of the National Ambulatory Medical Care Survey, tertiary outcome measure was not possible in the control cohort.
      Denotes statistical significance.
      In the study cohort preintervention, 78% of LS-MRI orders were adherent to the evidence-based guideline, compared with 96% after intervention (P = .0002). There was 89% (89/100) concordance between users' input into the CPOE system and the PCP clinic notes. The majority of the nonconcordance was due to incomplete documentation (n = 7 of 100; 7%) of clinical information in clinic notes compared with LS-MRI order. In 4/100 instances (4%), discordance was noted with conflicting clinical information entered in clinic notes compared with LS-MRI order.

      Discussion

      Recent health care reform efforts aim to improve quality, reduce waste, and enhance value.
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      Clinical guidelines have been proposed as a way to increase clinical efficiency and minimize inappropriate care.
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      However, wide gaps between evidence and practice exist,
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      and significant implementation barriers persist.
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      In our study, we found that implementing a multifaceted intervention including education using CDS and accountability tools was associated with a 32%-33% decrease in LS-MRI and MRI of any body part use intensity while improving guideline-adherent practice. Given national promotion of adoption and meaningful use of HIT,
      • Buntin M.B.
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      • Blumenthal D.
      Health information technology: laying the infrastructure for national health reform.
      these findings support the notion that HIT-enabled interventions using CDS can help improve quality and reduce waste by promoting evidence-based practice for diagnostic imaging.
      Comparing with previous studies of imaging CDS, we observed a slightly greater improvement in guideline adherence than others.
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      In a time-series study, making appropriateness guidelines available in a CPOE system in 2 European emergency departments decreased nonconforming radiology orders from 33.2% to 26.9% (P = .0001).
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      Blackmore et al
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      found that the use of imaging CDS was associated with a 23% decrease in the utilization rate of lumbar MRI for low back pain in a retrospective cohort study. Although HIT in the form of CDS likely played a critical role in our intervention, we believe our higher guideline adherence rates were due to the combined effect of CDS and complementary accountability tools. These tools highlight to providers the importance of quality and value, and the quarterly practice variation reports and peer-to-peer consultation likely reinforced this message regularly.
      Although we found an adjusted 32% reduction in LS-MRI utilization on the same day as the index primary care visit postintervention, it is important to note that part of this decrease did not necessarily translate into reduction in use of LS-MRI in the 30-day interval after the index primary care visit. Our findings show that some patients still underwent LS-MRI studies, requested either through the PCPs or specialists, within 30 days of the index visit. Some of the studies that were ordered through primary care subsequently may represent care that is guideline adherent, performed in patients whose symptoms persisted despite conservative medical management. Yet, we also noted that the LS-MRI utilization rate actually increased, from 2.2% to 2.7% (P = .0292), when examining those ordered by a specialist. This shift of ordering pattern to specialty providers in which the intervention was not implemented may have offset some of the MRI use reductions ordered by PCPs. Further research is needed to examine the impact of our intervention in non-primary-care settings.
      Our study has several limitations. First, we could not measure the specific impact of individual components of our intervention (ie, CDS, quarterly reporting, and peer-to-peer consultation) on ordering behavior. However, we chose to implement a multifaceted intervention strategy, as previous research has found that interventions that target multiple behavioral factors are more likely to result in change.
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      Second, it is possible that our observed decrease in imaging use may not be solely due to our intervention, but also to confounders, such as increased public awareness of harm associated with inappropriate imaging, and the publication of the ACP guidelines during the study period. However, small-to-no decrease in imaging use was observed in the control cohort, which argues that guideline publication alone may not be an effective intervention for changing clinical practice.
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      Due to design of the NAMCS survey, body-specific imaging data (ie, LS-MRI) was not available. The difference in data collection methodology between the study and control cohorts (health records in the study cohort vs survey in the control cohort) represents another limitation. However, other studies over the same time period have found that MRI use in the Medicare population based on claims data
      • Sharpe Jr., R.E.
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      is consistent with that revealed in NAMCS surveys. Additionally, our study was performed at a single academic medical center; thus, the generalizability of our findings in other settings is unclear. Furthermore, we used billing data in cohort identification, which may not have captured all eligible patients. Only orders placed through our institution were included, potentially underestimating imaging for our patients at outside institutions. However, such occurrences are estimated to be small and are thus unlikely to influence our findings. Finally, we did not assess the impact of our intervention on patient or provider satisfaction, which will be an important topic for future enquiry to help define best practices for implementing CDS-enabled interventions.

      Conclusion

      A multifaceted intervention of evidence CDS, supplemented by near-real-time technology-enabled consequences for overriding CDS and quarterly practice pattern variation reporting, may be a valuable strategy to reduce potentially inappropriate imaging.

      Appendix

      TableICD-9 Inclusion Codes for Cohort Identification
      ICD-9 CodeDescription
      307.89Psychogenic backache
      721.3Lumbosacral spondylosis w/o myelopathy
      721.5Kissing spine (Baastrup disease)
      721.6Ankylosing vertebral hyperostosis
      721.7Traumatic spondylopathy
      721.8Other allied disorders of spine
      721.9Spondylosis of unspecified site w/o myelopathy
      722.1Displacement of thoracic or lumbar disc w/o myelopathy
      722.2Degeneration of intervertebral disc, site unspecified
      722.3Schmorl's bides
      722.5Degeneration of thoracic or lumbar intervertebral disc
      722.6Degeneration of intervertebral disc, site unspecified
      722.9Other and unspecified disc disorder of unspecified region
      724Other and unspecified disorders of back
      724.0Spinal stenosis, not cervical
      724.1Pain in thoracic spine
      724.2Lumbago
      724.3Sciatica
      724.4Back pain with radiation, unspecified
      724.5Backache, unspecified
      724.6Disorders of sacrum (including lumbosacral junction)
      733.10Pathologic fractures, unspecified site
      733.13Pathologic fractures: vertebrae
      733.93Stress fracture of other bone
      738.4Acquired spondylolisthesis
      738.5Other acquired deformity of back or spine
      739.2Nonallopathic lesions-thoracic, not elsewhere classified
      739.3Nonallopathic lesions-lumbar, not elsewhere classified
      739.4Nonallopathic lesions-sacral, not elsewhere classified
      756.11Spondylolysis
      756.12Spondylolisthesis
      846.0Lumbosacral sprain
      846.1Sacroiliac (ligament) sprain
      846.2Sacrospinatus (ligament) sprain
      846.3Sacrotuberous (ligament) sprain
      846.8Other specified sites of sacroiliac region sprain
      846.9Unspecified site of sacroiliac region sprain
      847.2Thoracic sprain
      847.3Sacral sprain
      847.9Sprain—unspecified site of back
      ICD = International Classification of Diseases.

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