Observational Study of the Downstream Consequences of Inappropriate MRI of the Lumbar Spine
Observational Study of the Downstream Consequences of Inappropriate MRI of the Lumbar Spine
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DOI：
10.1007/s11606-020-06181-7
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发表时间：
2020-09-28
影响因子：
5.7
通讯作者：
Barnett, Paul G.
中科院分区：
文献类型：
--
作者：
Jacobs, Josephine C.;Jarvik, Jeffrey G.;Barnett, Paul G.
背景与指南相反，磁共振成像（MRI）通常在无并发症的非特异性腰痛新发发作的前6周进行。目的确定早期成像的下游后果。设计回顾性配对队列研究，使用美国退伍军人事务部初级保健诊所的电子健康记录数据。参与者寻求非特异性腰痛初级护理的患者，在过去6个月内没有红旗病症或遇到腰痛（N= 405，965）。初次初级保健访视前6周内腰椎暴露MRI。主要测量协变量包括患者人口统计学资料、前一年的健康史和基线疼痛。结果是腰椎手术，处方阿片类药物的使用，急性医疗保健费用，并在索引访问的1年内记录的最后一次疼痛评分。早期MRI与更多的背部手术（1.48% vs. 0.12%，无早期MRI的发作）、更多的处方阿片类药物使用（35.1% vs. 28.6%）、更高的最终疼痛评分（3.99 vs. 3.87）和更高的急性护理费用（8082 vs. 5560）相关，所有比较p< 0.001。局限性依赖于在正常临床护理中收集的数据，尽管使用粗化的精确匹配权重来调整基线差异，但仍存在残留混杂的可能性。结论：早期影像学检查与提高利用率之间的关联是明显的，即使在很大程度上不受按服务收费的激励的情况下。降低成像成本只是提高MRI使用指南依从性的部分动机。早期扫描与过度手术，其他护理费用较高和更差的结果有关，包括处方阿片类药物的潜在危害。
Background Contrary to guidelines, magnetic resonance imaging (MRI) is often ordered in the first 6 weeks of new episodes of uncomplicated non-specific low back pain. Objective To determine the downstream consequences of early imaging. Design Retrospective matched cohort study using data from electronic health records of primary care clinics of the U.S. Department of Veterans Affairs. Participants Patients seeking primary care for non-specific low back pain without a red flag condition or an encounter for low back pain in the prior 6 months (N= 405,965). Exposure MRI of the lumbar spine within 6 weeks of the initial primary care visit. Main Measures Covariates included patient demographics, health history in the prior year, and baseline pain. Outcomes were lumbar surgery, prescription opioid use, acute health care costs, and last pain score recorded within 1 year of the index visit. Key Results Early MRI was associated with more back surgery (1.48% vs. 0.12% in episodes without early MRI), greater use of prescription opioids (35.1% vs. 28.6%), a higher final pain score (3.99 vs. 3.87), and greater acute care costs ($8082 vs. $5560),p< 0.001 for all comparisons. Limitations Reliance on data gathered in normal clinical care and the potential for residual confounding despite the use of coarsened exact matching weights to adjust for baseline differences. Conclusions The association between early imaging and increased utilization was apparent even in a setting largely unaffected by incentives of fee-for-service care. Reduced imaging cost is only part of the motivation to improve adherence with guidelines for the use of MRI. Early scans are associated with excess surgery, higher costs for other care, and worse outcomes, including potential harms from prescription opioids.