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Emergency Physicians Choose Wisely When Ordering Plain Radiographs for Low Back Pain Patients

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      Abstract

      Objectives

      The Choosing Wisely Canada (CWC) Emergency Medicine group recommends avoidance of lumbosacral radiographs for patients with non-traumatic low back pain (LBP) in the absence of red flags. The objective of this study was to evaluate imaging practices of emergency physicians (EPs) in four Calgary emergency departments (EDs) and identify patient, physician, and environmental factors associated with over-ordering of radiographs for low-risk LBP patients.

      Methods

      Data was retrospectively collected from patients, ages 18–50 and Canadian Triage and Acuity Scale (CTAS) codes 2–5, who presented with non-traumatic LBP to Calgary EDs from April 1, 2014 to March 31, 2016. Patients considered high risk, specifically with partial thromboplastin time (PTT) > 40 seconds or international normalized ratio (INR) > 1.2 seconds, any consult, admission to hospital, and history of cancer, were excluded. The primary outcome was to establish the overall usage of lumbosacral radiographs. The secondary outcome was to identify factors that influenced lumbosacral spine imaging.

      Results

      Data from 2128 low-risk patients showed that 14.8% of the patients received lumbosacral radiographs. Variation among 132 physicians in X-ray ordering ranged from 0% to 90.9%. There were site-specific differences in ordering patterns [Rockyview General Hospital (RGH) = 21.6% > South Health Campus (SHC) = 15.6% > Peter Lougheed Centre (PLC) = 13.1% > Foothills Medical Centre (FMC) = 9.7%, p < 0.001]. Canadian College of Family Physicians-Emergency Medicine (CCFP-EM) licensed physicians ordered more X-rays compared to Fellow of the Royal College of Physicians of Canada (FRCPC) licensed physicians (16.6% vs. 11.1%, p < 0.001). Older physicians and physicians with more experience ordered more X-rays than their younger and less experienced colleagues.

      Conclusion

      Considerable variation exists in the ordering practices of Calgary EPs. Overall, EPs seem to be choosing wisely in terms of ordering plain radiographs for non-traumatic LBP.

      Related collections

      Most cited references 20

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      Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society.

      RECOMMENDATION 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence). RECOMMENDATION 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). RECOMMENDATION 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence). RECOMMENDATION 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). RECOMMENDATION 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence). RECOMMENDATION 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs. RECOMMENDATION 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits-for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).
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        Measuring the global burden of disease.

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          Expenditures and health status among adults with back and neck problems.

          Back and neck problems are among the symptoms most commonly encountered in clinical practice. However, few studies have examined national trends in expenditures for back and neck problems or related these trends to health status measures. To estimate inpatient, outpatient, emergency department, and pharmacy expenditures related to back and neck problems in the United States from 1997 through 2005 and to examine associated trends in health status. Age- and sex-adjusted analysis of the nationally representative Medical Expenditure Panel Survey (MEPS) from 1997 to 2005 using complex survey regression methods. The MEPS is a household survey of medical expenditures weighted to represent national estimates. Respondents were US adults (> 17 years) who self-reported back and neck problems (referred to as "spine problems" based on MEPS descriptions and International Classification of Diseases, Ninth Revision, Clinical Modification definitions). Spine-related expenditures for health services (inflation-adjusted); annual surveys of self-reported health status. National estimates were based on annual samples of survey respondents with and without self-reported spine problems from 1997 through 2005. A total of 23 045 respondents were sampled in 1997, including 3139 who reported spine problems. In 2005, the sample included 22 258 respondents, including 3187 who reported spine problems. In 1997, the mean age- and sex-adjusted medical costs for respondents with spine problems was $4695 (95% confidence interval [CI], $4181-$5209), compared with $2731 (95% CI, $2557-$2904) among those without spine problems (inflation-adjusted to 2005 dollars). In 2005, the mean age- and sex- adjusted medical expenditure among respondents with spine problems was $6096 (95% CI, $5670-$6522), compared with $3516 (95% CI, $3266-$3765) among those without spine problems. Total estimated expenditures among respondents with spine problems increased 65% (adjusted for inflation) from 1997 to 2005, more rapidly than overall health expenditures. The estimated proportion of persons with back or neck problems who self-reported physical functioning limitations increased from 20.7% (95% CI, 19.9%-21.4%) to 24.7% (95% CI, 23.7%-25.6%) from 1997 to 2005. Age- and sex-adjusted self-reported measures of mental health, physical functioning, work or school limitations, and social limitations among adults with spine problems were worse in 2005 than in 1997. In this survey population, self-reported back and neck problems accounted for a large proportion of health care expenditures. These spine-related expenditures have increased substantially from 1997 to 2005, without evidence of corresponding improvement in self-assessed health status.
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            Author and article information

            Affiliations
            [1 ] Medicine, University of Ottawa, Ottawa, CAN
            [2 ] Medicine, University of Calgary, Calgary, CAN
            [3 ] Alberta Health Services, University of Calgary, Calgary, CAN
            [4 ] Information Technology, University of Calgary, Calgary, CAN
            [5 ] Emergency Medicine, University of Calgary, Calgary, CAN
            Author notes
            Journal
            Cureus
            Cureus
            2168-8184
            Cureus
            Cureus (Palo Alto (CA) )
            2168-8184
            10 August 2018
            August 2018
            : 10
            : 8
            6181247 10.7759/cureus.3126
            Copyright © 2018, Hiranandani et al.

            This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

            Categories
            Emergency Medicine
            Quality Improvement

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