According to the Institute of Medicine, waste accounted for 30% of the $2.5 trillion spent in the United States on healthcare in 2009.
Low back pain is a common concern, and it is estimated that up to 84% of adults will experience this issue some time in their lives. Studies of Medicaid/Medicare data have revealed that among patients with a primary diagnosis of low back pain, 12%-14% received an X-ray, CT, or MRI Scan within 4 weeks of diagnosis (www.choosingwisely.org, 2014). Physicians usually perform tests for low back pain to determine the presence of serious underlying conditions or to satisfy the patient’s need. Imaging of the lower spine before 6 weeks of continued symptoms does not improve outcomes but increases the probability of further unnecessary tests and costs. The annual Medicare spending on such unwarranted imaging for low back pain is over $100 million.
Imaging may be warranted if the patient experiences no improvement in 6 weeks, when more complicating factors are present (eg, trauma and fracture), or when symptoms are present to indicate a serious underlying condition. Such imaging should be saved for patients in whom noninvasive, conservative regimens have failed and surgery or therapeutic injection is being considered.
The key reason for the overuse of imaging is the patient’s demand/lack of education of the risks involved with unnecessary imaging. There is a lack of recognition that most low back pain vanishes within 4 weeks with some simple measures. In a hypothetical study, 57.8% of the clinicians worried that the patient would be upset if he or she did not undergo a CT or MRI scan and 25.8% thought they would not have enough time during the visit to talk about risks and benefits of imaging with the patient. Physicians may also have inadequate education and awareness of guidelines at the point of care. They may have other concerns including financial incentives and legal liabilities. Finally, payers have low co-pays for diagnostic imaging services, because such services are considered to be of low value.
There are 3 steps to reduce unwarranted imaging: (1) Use a data-driven approach to isolate imaging services, benchmark physicians, and understand the sources of variation. (2) Run physician engagement programs using a nondisruptive and standardized approach, emphasizing the degree of overuse of low back pain imaging and its potential for harm. Assist the physicians, develop talking points for physicians to discuss with patients, and create online resources to house the tools and content. (3) Deliver efficient patient education interventions by disseminating materials to address patient demands.
We can help you understand your Episodes of Care using your cost and clinical data, unearth the improvement opportunities, engage your physicians, and deliver practice change. We look forward to opportunities to apply Variation IQ tools and processes to enhance the healthcare of your patients, while improving your operational efficiency and margins.
IOM (Institute of Medicine). 2010. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington, DC: The National Academies Press.
Imaging for Nonspecific Low Back Pain; Imaging for Low Back Pain – Clinical Recommendation – Choosing Wisely. www.choosingwisely.org
Sears ED, Caverly TJ, Kullgren JT, et al. Clinicians' perceptions of barriers to avoiding inappropriate imaging for low back pain-knowing is not enough. JAMA Intern Med. 2016;176(12):1866-1868.
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