Clinicians’ Perceptions of Barriers to Avoiding Inappropriate Imaging for Low Back Pain—Knowing Is Not Enough

Overuse of imaging for low back pain (LBP) is a considerable problem. Approximately 31% of lumbosacral magnetic resonance imaging (MRI) scans performed were deemed inappropriate in the Department of Veterans Affairs (VA),¹ and similar rates of inappropriate MRI use have been seen outside of the VA.² Seven Choosing Wisely (CW) campaign recommendations support not ordering imaging tests for patients with nonspecific LBP.³ Our objective was to determine what clinicians perceive to be barriers to following the CW recommendations to avoid ordering imaging tests for nonspecific LBP.

We invited a national random sample of VA nonresident clinicians (physicians, nurse practitioners, and physician assistants) to participate in an online survey from October 6, 2014 to December 8, 2014. The survey included demographic questions and a hypothetical scenario in which a 45-year-old woman with nonspecific LBP without red flag symptoms requested a computed tomographic (CT) or MRI scan. After reading the scenario, respondents were asked how they would respond to the patient’s request and factors that influenced their decision to obtain imaging. Using a 4-point scale, respondents also rated their own difficulty in following the CW recommendations to avoid imaging for nonspecific LBP in the first 6 weeks, and how they perceive patients’ willingness to accept this recommendation. We created a multivariable logistic regression model to identify provider characteristics associated with perceived difficulty in following this recommendation. The VA Ann Arbor Healthcare System institutional review board approved the study, which included a waiver of written informed consent signed by participants, who were not compensated for their participation, but who were entered into a lottery for a chance to win 1 of 30 $100 Amazon gift cards.

Of the 1224 eligible clinicians, 579 returned usable surveys (response rate, 47.3%; numbers vary owing to item nonresponse). Among the respondents, 305 (56.2%) were women, 379 (69.5%) were physicians, 130 (23.9%) were nurse practitioners, and 36 (6.6%) were physician assistants.

Only 18 clinicians (3.3%) thought the patient in the scenario would benefit from having at CT or MRI scan (Table 1). In addition, 420 clinicians (77.1%) reported they would worry that ordering imaging would result in future unnecessary tests or procedures. However, a similar number of clinicians (414, 75.7%) felt they would be unable to refer the patient to a specialist for further evaluation without obtaining imaging first. More than half of clinicians (316, 57.8%) worried that the patient would be upset if she did not receive imaging, and 141 clinicians (25.8%) felt they would not have time to discuss the risks and benefits of imaging with the patient. Furthermore, 149 (27.3%) clinicians expressed worry that not ordering an imaging test could leave them vulnerable to a malpractice claim.

While only 81 (14.8%) clinicians felt it would be difficult for them to follow the CW recommendation to not order imaging, 341 (62.9%) believed it would be difficult for most patients to accept the CW recommendation. In the multivariable regression model (Table 2), clinicians who were within 10 years of completing training who felt they would not have time to discuss risks and benefits, and who worried about liability were more likely to have difficulty accepting the CW recommendation (Table 2).

Most VA clinicians agreed with the CW recommendations against ordering imaging for nonspecific LBP, but several perceived barriers may prevent clinicians from following the recommendations in practice. Clearly for these clinicians, knowing is not enough. Reduction in low-value diagnostic testing for LBP will require efficient patient education interventions to address patient demands within the limited time constraints of clinicians. Furthermore, greater attention to referral requirements is needed to assure that clinicians are able to follow evidence-based recommendations, while still being able to refer patients to specialty clinics. We will not be able to eliminate inappropriate imaging until the barriers such as those identified by the clinicians respondents are addressed.

Corresponding Author: Erika D. Sears, MD, MS, Veterans Affairs Center for Clinical Management Research, 2215 Fuller Rd, Ann Arbor, MI 48105 (endavis@med.umich.edu).

Correction: This article was corrected online on November 14, 2016 to correct a typographical error in reference 3.

Published Online: October 17, 2016. doi:10.1001/jamainternmed.2016.6364

Author Contributions: Drs Sears and Prenovost had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Caverly, Kullgren, Fagerlin, Zikmund-Fisher, Prenovost, Kerr.

Acquisition, analysis, or interpretation of data: Sears, Caverly, Kullgren, Zikmund-Fisher, Prenovost, Kerr.

Drafting of the manuscript: Sears.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Sears, Prenovost.

Obtained funding: Kerr.

Administrative, technical, or material support: Sears.

Study supervision: Sears, Caverly, Kerr.

Conflict of Interest Disclosures: Dr Kullgren has received consulting fees from the SeeChange Health and HealthMine. No other disclosures were reported.

Funding/Support: Dr Caverly was supported by the Veterans Affairs (VA) Advanced Fellowship Program in Health Services Research and Development (HSR&D). Dr Kerr was supported in part by the Veterans Health Administration’s PACT Demonstration Laboratory. Dr Kullgren is the recipient of the VA HSR&D Career Development Award at the VA Medical Center, Ann Arbor, Michigan.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study, including collection, management, analysis, and interpretation of the data, or the decision to publish.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US Government.