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Inappropriate Ordering of Lumbar Spine Magnetic Resonance Imaging: Are Providers Choosing Wisely?
Risha Gidwani, DrPH; Patricia Sinnott, PhD; Tigran Avoundjian, MPH; Jeanie Lo, MPH; Steven M. Asch, MD MPH; and Paul G. Barnett, PhD
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Inappropriate Ordering of Lumbar Spine Magnetic Resonance Imaging: Are Providers Choosing Wisely?

Risha Gidwani, DrPH; Patricia Sinnott, PhD; Tigran Avoundjian, MPH; Jeanie Lo, MPH; Steven M. Asch, MD MPH; and Paul G. Barnett, PhD
This article analyzes use of lumbar spine magnetic resonance imaging in a national sample of patients with low back pain.

Objectives: To analyze inappropriate use of magnetic resonance imaging (MRI) for patients with low back pain in a healthcare system with no financial incentives for overuse.

Study Design: We used administrative data to assess the appropriateness of lumbar spine (LS) MRI in the Veterans Health Administration.

Methods: All veterans who received LS MRI in the outpatient setting in fiscal year 2012 were included. We based our assessments of appropriateness on CMS criteria, which have been endorsed by the National Quality Forum. Generalized estimating equations were used to evaluate characteristics of inappropriate scans.

Results: Of the 110,661 LS MRIs performed, 31% were classified as inappropriate. Most scans that were considered appropriate were characterized as such because they were preceded by conservative therapy (53%). "Red flag" conditions were responsible for a much smaller percentage of scans being considered appropriate; 13% of scans were preceded by conservative therapy and were performed in patients with a red flag condition, while only 4% of scans were considered appropriate because of red flag conditions only. Scans ordered in the emergency department and in urgent care, primary care, and internal medicine clinics were most likely to be classified as inappropriate. Resident physicians were significantly less likely than other provider types to order inappropriate LS MRIs (odds ratio, 0.80; P <.0001). Approximately 24% of providers ordered 74% of inappropriate scans.

Conclusions: We found that 31% of LS MRIs were inappropriate in a healthcare system largely absent of financial and other incentives for ordering. The problem of inappropriate ordering of LS MRI is concentrated in a small number of providers; any provider-facing interventions to reduce inappropriate order should therefore be targeted, rather than aimed at all providers who order LS MRI.

Am J Manag Care. 2016;22(2):e68-e76
Take-Away Points
Using CMS criteria, we found that 31% of lumbar spine magnetic resonance imaging (LS MRI) performed in fiscal year 2012 was inappropriate. This high level of inappropriate ordering is particularly striking in a system largely free of financial and other incentives for ordering, suggesting that nonpecuniary factors play a role in these inappropriate ordering choices. We found a high concentration of inappropriate ordering among few providers. Results indicate that efforts to reduce inappropriate use of LS MRI should involve cultural change, as well as patient and provider education, rather than financial incentives alone, and that provider-facing efforts should be targeted instead of universal.
Most Americans will experience low back pain (LBP) at some point in their adult lives.1 Many patients with LBP receive imaging to explore the cause of their pain2; advances in imaging technology have revealed unprecedented anatomical detail for LBP patients. The underlying difficulty is that, for many patients, anatomical and functional abnormalities do not correlate well, and thus imaging can fail to guide treatment of the primary complaint.3-8 In one study of individuals who underwent magnetic resonance imaging (MRI), approximately 90% were detected to have a degenerated or bulging disc, 36% had a herniated disc, and 21% had spinal stenosis—but all patients were asymptomatic.4 For most patients, LBP resolves on its own9-10; even sophisticated imaging of the lumbar spine (LS) for nonchronic pain does not improve outcomes.11

Overuse of LS MRI is suspected to be a large problem; multiple societies have prioritized it as a quality-of-care measure or a measure of prudent stewardship of resources. The American College of Physicians and the American Association of Neurological Surgeons recommend against the use of LS MRI for nonspecific or nonpersistent LBP in their Choosing Wisely campaign.12,13 The National Quality Forum (NQF), a nonprofit entity that sets national priorities for quality measurement, has endorsed a CMS measure regarding inappropriate use of imaging in LBP.14

The reasons for overuse of imaging are not well understood. Fee-for-service financial incentives have been suggested as a potential reason for overuse of lumbar spine imaging,15 as have malpractice concerns16 and cultural factors.17 In this study, we explored inappropriate use of LS MRI in a US healthcare system—one largely free of financial incentives for overuse, and in which physicians are largely insulated from malpractice concerns—to understand whether inappropriate ordering occurs in the absence of these financial or legal influences. The federal government accepts liability for any instances of medical negligence or wrongdoing on the part of the Department of Veterans Affairs (VA) providers; concerns over malpractice or incentives to practice defensive medicine are therefore much lower for VA providers compared with providers in the larger US healthcare environment. It is also not well understood whether inappropriate ordering is equally distributed across providers, or concentrated among relatively few high-ordering providers; this information carries important implications for quality improvement activities. Here, we use NQF-endorsed CMS criteria to evaluate inappropriate ordering of LS MRI across the entire VA, including the patient-, provider-, and system-level factors associated with the practice.

To study the appropriateness of this imaging modality, we identified the population of veterans who received an outpatient LS MRI in VA in fiscal year (FY) 2012. If patients received more than 1 LS MRI, we retained information regarding the first MRI. Additionally, we searched VA inpatient and outpatient data from FY 2010 to FY 2012 to evaluate the care and condition of these veterans prior to receipt of LS MRI. CMS criteria pertain to LS MRIs with a diagnosis of LBP on the MRI claim; because VA MRIs do not have associated diagnosis codes, we evaluated all LS MRIs. We considered the clinic visit with the ordering provider that immediately preceded the scan to be the ordering visit.

We evaluated the appropriateness of LS MRI according to the NQF-endorsed CMS measure #0514 (“MRI Lumbar Spine for Low Back Pain”),14 with slight modifications (Figure). This measure classifies an LS MRI as appropriate if it was: 1) preceded by conservative therapy, or 2) conducted in a patient who has a “red flag” condition. CMS considers physical therapy or chiropractic care in the 60 days prior to the scan, or an evaluation and management visit occurring between 28 to 60 days prior to the scan, to be conservative therapy. Physical therapy, chiropractic care, and evaluation and management visits were identified by Current Procedural Terminology codes specified by the NQF-endorsed CMS measure.14 We classified an evaluation and management (E&M) visit as conservative therapy only if the scan was not ordered during that visit.

We made minor modifications to the CMS criteria regarding red flag conditions. The CMS measure excludes LS MRIs occurring in patients with red flag conditions from the denominator; here, we included them but considered them to be appropriate in order to present a complete view of all LS MRIs in VA. CMS red flag conditions include trauma in the 45 days preceding the scan; LS surgery in the 90 days preceding the scan; or intravenous drug abuse, neurologic impairment, cancer, HIV diagnosis, or diagnosis of unspecified immune deficiency in the 365 days preceding the scan. The measure includes all cancer; we excluded primary skin and primary prostate cancer as these types of neoplasms would not cause lumbar compression and rarely have an impact on spine pain. Additionally, there are concerns regarding a high false-positive rate for prostate cancer due to overuse of prostate-specific antigen (PSA) screening. To the CMS red flag conditions, we added intraspinal abscess or compression fracture in the 30 days prior to the scan, and osteomyelitis in the previous 365 days. All red flag conditions were identified through International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes in inpatient and outpatient data sets.

From these data, we identified which LS MRI scans were considered inappropriate. LS MRIs were considered inappropriate in patients who did not have a red flag condition in the time frame of interest and those who did not receive appropriate conservative therapy.

We also investigated patient-, provider- and facility-level characteristics associated with inappropriate scans, as well as any regional differences in proportion of inappropriate scans. Patient-level characteristics included age, gender, and race. Provider-level variables included ordering provider type (attending physician, resident, physician’s assistant, and advanced practice nurse/nurse practitioner) and the clinic in which the scan was ordered (internal medicine/primary care, physical medicine and rehabilitation; neurology, neurosurgery, orthopedics, pain medicine, “other” medicine services, miscellaneous other medicine services, chiropractic care, and emergency department [ED] and urgent care). Other medicine services refer to various primary and specialty care clinics separate from the other categories of care (eg, geriatrics, oncology, hospice, dementia clinic).  Miscellaneous other services refer to all ancillary and support services (eg, cast clinic, social work, telephone triage).  The facility-level variable included complexity, defined in 5 levels (1a, 1b, 1c, 2, and 3; from most to least complex).

Characteristics of inappropriate scans were evaluated using generalized estimating equations to account for clustering of patients within facilities. Our generalized estimating equations employed a logit link, a binomial distribution family, and an independent correlation structure. We ran sensitivity analyses in which we evaluated facility-level physical therapy penetration—defined as physical therapy visits per 1000 pro-rated patients—and in which, we evaluated alternative definitions of conservative therapy. Specifically, we required the conservative therapy visits to have an accompanying diagnosis of low back pain. Post estimation commands were used to compare outcomes among different levels of each categorical level; for example, to compare residents with each other provider type, physician’s assistants to each other provider type, etc. All analyses were conducted in SAS version 9.2 (SAS Institute, Inc, Cary, North Carolina). 

In FY 2012, 110,661 LS MRIs were ordered in the outpatient setting by 16,273 unique providers. Most patients received 1 LS MRI; only 3.7% of patients received more than 1. Each provider ordered a median of 3 LS MRIs and a mean of 6.8 LS MRIs. Of the 110,661 total scans, 33,998 (30.7%) were classified as inappropriate; these patients had no red flag conditions coded and did not receive conservative therapy in a VA facility prior to their scan (Table 1). The majority of scans classified as appropriate were done so because the patient was deemed to have received prior conservative therapy (65.3%). Another 16.6% of LS MRIs were classified as appropriate because the patient had a red flag condition. (Note that the numbers add up to more than 100% because patients could have had both a red flag condition and have received conservative therapy.)

Table 2 describes the demographics of the population, which on average, was male, white, and middle-aged. The greatest proportion of scans (42%) was ordered for patients seen at the most-complex (level 1a) facilities. However, the greatest proportion of inappropriate scans (36%) was ordered for patients seen at the least-complex facilities (level 3) (Table 2). The number of scans ordered varied greatly by clinic setting, with the greatest percentage of scans ordered by the primary care/internal medicine clinic (62%), and the fewest percentage ordered by neurosurgery and orthopedics (6% combined). The greatest percentage of total scans (69%) was ordered by medical doctors or doctors of osteopathy, and the lowest was ordered by physicians’ assistants (8%). We did not find meaningful regional variation in proportion to scans considered inappropriate.

Results from generalized estimating equations revealed that patients aged under 35 years were more likely to have an inappropriate scan than those of all other ages (P <.0001) (Table 3). Black patients were less likely to have an inappropriate scan compared with white patients (odds ratio [OR], 0.80; P <.0001). Scans ordered at the lowest-complexity facility (level 3) were more likely to be inappropriate compared with those ordered at the highest-complexity facilities (OR, 1.27; P = .0096). These multivariate results also show the ED or urgent care clinic to be the settings most strongly associated with an inappropriate scan (OR, 1.42; P <.0001, with reference category of primary care/internal medicine clinic). In fact, ED/urgent care providers were more likely than providers practicing in any other clinic to order inappropriate scans (Table 3). Primary care/internal medicine clinics were also associated with a high likelihood of ordering inappropriate scans; all other clinic settings were less likely to order inappropriate scans than the primary care/internal medicine clinic (Table 3). Neurology, neurosurgery, and orthopedic clinics all practiced similarly; after adjusting for covariates, each was equally likely to order an inappropriate scan compared with the others (Table 3). Medical doctors (MDs), doctors of osteopathy (DOs), nurses, and physician’s assistants were also equally likely to order an inappropriate scan; however, residents were less likely to order an inappropriate LS MRI scan compared with MD/DOs (OR, 0.80; P <.0001) (Table 3).

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