A large number of primary care practitioners continue to order lumbar spine magnetic resonance imaging (LS-MRI) scans for low back pain despite practice guidelines opposing such imaging. Reasons cited for ordering an LS-MRI included lenient radiology review, patient travel constraints, and “being pressed for time,” according to study results published in the Journal of General Internal Medicine.
A team of researchers interviewed Veterans Affairs Administration primary care practitioners (PCPs) to distinguish and understand factors associated with ordering unnecessary LS-MRIs for acute, uncomplicated low back pain. A total of 55 PCPs, categorized as having either high (n=22) or low (n=33) rates of guideline concordance regarding ordering LS-MRIs, were interviewed about their use and the reasoning behind their decisions. Of the 22 clinicians who were high-concordance practitioners, 19 were physicians and 3 were nurse practitioners. Of the 33 individuals in the low-concordance group, 16 were physicians, 15 were nurse practitioners, and 2 were physician assistants.
Clinicians with both high and low guideline concordance reported that LS-MRIs were needed for specialty care referrals. One high-concordance PCP told interviewers that when he worked for the Department of Defense, he rarely ordered MRIs; imaging tests were ordered by the anesthesiologist or physiatrist. But since moving to the Veterans Administration, he said the process was completely flipped and MRIs were ordered by the PCPs. A low-concordance PCP discussed the need to order MRIs for patients on long-term opioids. “I inherited patients on narcotics…. When I’m referring to pain management for epidural injection, you have to order [an] MRI. I ordered a lot because I was getting people off pain meds and [on the] treatment they needed.”
The clinicians interviewed also discussed how environmental factors, such as stringency of radiology utilization review (eg, more stringent, fewer MRIs approved), management of patient travel burdens, and time constraints affected trends in ordering imaging.
Moreover, disagreement with LS-MRI guidelines was more common in the low-concordant group. “For example, some low-concordant PCPs imaged veterans more often because they thought clinical guidelines did not account for veteran’s unique needs; this supports research on how provider guideline concordance is affected by perceptions of applicability to patients,” noted the researchers.
Patient factors, such as belief in the value of imaging and pressure on providers, were similarly reported by high and low guideline-concordant clinicians; however their reports on how provider-level factors, such as guideline familiarity and agreement, belief in the value of LS-MRI, and how often they acquiesced to patient requests differed.
The study results highlight a diverse number of factors that contribute to the ordering of unnecessary LS-MRIs, suggesting that “de-implementation efforts should incorporate multifaceted strategies rather than a single strategy,” the investigators concluded. Such strategies would need to address institutional issues, clinician and patient education strategies, and sensitivity to patient needs.
“Research and clinical guidelines do not discuss ordering LS-MRI to address patient preferences and needs,” the investigators concluded. “Yet, this raises questions about the role of patient perceptions in LS-MRI overuse and how to incorporate patient preferences and needs when de-implementing low-value care to improve health equity, which could be explored in future research,” they concluded.
Nevedal AL, Lewis ET, Wu J, et al. Factors influencing primary care providers’ unneeded lumbar spine MRI orders for acute, uncomplicated low-back pain: a qualitative study [published online December 12, 2019]. J Gen Intern Med. doi:10.1007/s11606-019-05410-y