Causes and Consequences of Inappropriate MRI of the Lumbar Spine

背景：在退伍军人中，下腰痛是一个严重且日益严重的问题。它特别流行于 归来的老兵。在有致残疼痛的退伍军人中，这是他们最常见的部位 疼痛。在非复杂性下腰痛发作早期进行磁共振成像(MRI)是不可能的 有帮助，可能会导致不必要的手术和医疗程序，更多地使用止痛药，以及糟糕的 结果。退伍军人中不适当的腰椎MRI订单的百分比类似于 已经在医疗保险和商业保险索赔中得到了观察。退伍军人委员会与退伍军人管理局 用于疼痛、诊断服务和使用管理的国家计划办公室正在努力降低 退伍军人中不适当的LS-MRI成像。尝试实施高级成像指南 决策支持工具通常具有温和的短期效果。准则的传播和审计以及 反馈在改善对下腰痛治疗指南的遵从性方面并不有效。新的 需要了解遵守指南的障碍和促进者，才能设计有效的 实施努力。不适当的低位扫描与低价值的下游成本相关 治疗背部疼痛，但这还没有在退伍军人管理局进行研究。 目标：将研究无并发症下腰痛新发作的国家数据，以确定提供者 他们一直在订购大量不适当的扫描。对少数人进行了定性采访 提供商将识别与指南高度一致的提供商和那些 都不太协调。面谈将确定潜在的可修改因素，这些因素可以成为 计划以减少不适当的订购。VA利用率数据将评估不适当的关联 LS-MRI订购了患者疼痛，以及高成本、潜在低价值的服务：脊柱融合、椎板切除术、 硬膜外注射和处方鸦片类药物。 方法：使用国家VA在3年内评估LS-MRI检查顺序的适当性 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和/或特定服务或站点的提供商 不适当的点餐是很常见的。对这些提供商中的一小部分进行定性评估(和 将对遵循准则的供应商进行比较)，以确定潜在的可修改因素 与不适当的排序有关，例如常规的顺序集、缺乏指导方针的知识、信念 关于扫描的价值、对腰椎疼痛患者的知识和护理的可用性。最后， 不适当的订单对结果、护理和成本的影响将被研究。一组新的脑膜炎病例 不复杂的腰背痛将被识别出来。在前6周提供LS-MRI的剧集将 与其他发作进行比较，以了解患者报告的疼痛、成本或使用 腰背部手术。这些将包括脊柱融合、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 对其影响的公正评估。区域分析将确定许多早期的地理位置 提供的扫描具有不同的结果或不同的程序比率。倾向性权重和 工具变量方法也将被用来确保研究结果不被 早期MRI的非随机分配。这项研究将由两名国家腰痛和腰痛专家提供建议。 退伍军人管理局临床医生委员会致力于实施下腰痛和成像指南 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.