Causes and Consequences of Inappropriate MRI of the Lumbar Spine

背景：腰痛是退伍军人中一个重要且日益严重的问题。尤其是在 退伍军人归来在有致残性疼痛的退伍军人中，这是他们最常见的部位。 痛苦磁共振成像（MRI）进行了早期发作的无并发症腰痛， 有帮助，可能导致不必要的手术和医疗程序，更多地使用止痛药， 结果。不适合VA的腰椎MRI订单的百分比与 在医疗保险和商业保险索赔中被观察到。选择明智的委员会和VA 负责疼痛、诊断服务和使用管理的国家项目办公室正在努力降低 不适当的LS-MRI成像。尝试实施高级成像指南， 决策支持工具一般具有有限的短期效果。准则传播和审计， 反馈在改善对治疗腰痛的指导方针的依从性方面并不有效。新 需要了解遵守指南的障碍和促进因素，以设计有效的 执行工作。不适当的低回扫描与低价值的下游成本有关 治疗背痛，但这还没有在VA中进行研究。 目的：将研究新发无并发症腰痛的国家数据，以确定提供者 他们总是订购大量不合适的扫描定性访谈与少数 提供者将识别与指南高度一致的提供者和 不太一致访谈将确定潜在的可修改因素，这些因素可以作为 减少不适当的订购。VA利用率数据将评估不适当的 LS-MRI订单，患者疼痛，高成本，潜在低价值服务：脊柱融合术，椎板切除术， 硬膜外注射和处方鸦片 方法：将使用国家VA在3年内评价LS-MRI顺序的适当性 行政数据，以确定执行工作的潜在重点： 订购大量不适当扫描的提供商，和/或特定服务或网站， 不适当的排序是常见的。对其中少数供应商的定性评估（以及 遵循指南的供应商比较组），以确定潜在的可修改因素 与不适当的订购有关，如常规订单集，缺乏指导方针的知识，信念 关于扫描的价值，知识和对腰椎疼痛患者的护理的可用性。最后， 将研究不适当的医嘱对结果、护理和费用的影响。一组新病例 将确定无并发症的腰痛。在前6周内提供LS-MRI的Epperimeter将 与其他事件进行比较，以查看患者报告的疼痛、费用或使用 低背程序。这些将包括脊柱融合术，椎板切除术，硬膜外注射和阿片类药物 止痛药由于扫描不是随机分配的，因此将使用几种方法来提供 公正的评价其效果。区域分析将确定许多早期 提供的扫描具有不同的结果或不同的程序速率。倾向权重和 还将使用工具变量方法，以确保研究结果不受 早期MRI的非随机分配。这项研究将由两名国家腰痛专家和 一个由退伍军人管理局临床医生组成的委员会，致力于实施腰痛和成像指南 适当性

Background: Low back pain is a significant and growing problem in Veterans. It is especially prevalent in returning Veterans. Among returning Veterans who have disabling pain, it is the most frequent site of their pain. Magnetic Resonance Imaging (MRI) conducted early in an episode of uncomplicated low back pain is not helpful and may lead to unneeded surgeries and medical procedures, greater use of pain medications, and poor outcomes. The percentage of orders for MRI of the lumbar spine that are inappropriate in VA is similar to what has been observed in Medicare and commercial insurance claims. The VA Choosing Wisely Committee and VA national program offices for pain, diagnostic services, and utilization management are working to reduce rates of inappropriate LS-MRI imaging in VA. Attempts to implement guidelines for advanced imaging with decision support tools have generally had modest, short-term effects. Guideline dissemination and audit and feedback have not been effective in improving compliance with guidelines for treatment of low-back pain. New understanding of the barriers and facilitators to guideline adherence is needed to design an effective implementation effort. Inappropriate low back scans are associated with downstream costs from low value treatments for back pain, but this has not been studied in VA. Objectives: National data on new episodes of uncomplicated low-back pain will be studied to identify providers who consistently order a large number of inappropriate scans. Qualitative interviews with a small number of providers will identify differences between providers who are highly concordant with guidelines and those that are less than concordant. The interviews will identify potential modifiable factors that can be the basis of a program to reduce inappropriate ordering. VA utilization data will evaluate the association of inappropriate LS-MRI orders with patient pain, and high-cost, potentially low value services: spinal fusion, laminectomy, epidural injections, and prescription opiates. Methods: The appropriateness of LS-MRI orders will be evaluated over 3 years using national VA administrative data in order to identify a potential focus for implementation efforts: a consistent group of providers that orders a high number of inappropriate scans, and/or particular services or sites where inappropriate ordering is common. A qualitative assessment of a small number of these providers (and a comparison group of providers that follow guidelines) will be conducted to identify potential modifiable factors associated with inappropriate ordering, such as routine order sets, lack of knowledge of guidelines, beliefs about the value of scans, knowledge and availability of care for patients with pain of the lumbar spine. Finally, the effect of inappropriate orders on outcomes, care, and cost will be studied. A cohort of new cases of uncomplicated low-back pain will be identified. Episodes in which LS-MRI is provided in the first 6 weeks will be compared to other episodes to see if there are any differences in patient reported pain, cost, or the use of low-back procedures. These will include spinal fusion, laminectomy, epidural injections, and opioid prescriptions for pain. Since the scans are not randomly assigned, several methods will be used to provide an unbiased assessment of their effect. An areas analysis will determine if geographic locations where many early scans are provided have different outcomes or different rates of procedures. The propensity weighting and instrumental variables methods will also be used to make sure that study finding are not the confounded by the non-random assignment of early MRI. The study will be advised by two national experts on low-back pain and a committee of VA clinicians engaged in implementing guidelines for low back pain and imaging appropriateness.