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    Original Investigation
    July 13, 2020

    Assessment of Primary Care Clinician Concordance With Guidelines for Use of Magnetic Resonance Imaging in Patients With Nonspecific Low Back Pain in the Veterans Affairs Health System

    Author Affiliations
    • 1Veterans Affairs Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California
    • 2Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
    • 3Department of Radiology, University of Washington, Seattle
    • 4Department of Neurological Surgery, University of Washington, Seattle
    • 5Department of Health Services, University of Washington, Seattle
    • 6Department of Clinical Epidemiology and Medical Informatics, Oregon Health & Science University, Portland
    • 7Department of Medicine, Oregon Health & Science University, Portland
    • 8Quantitative Research Unit, Stanford University Medical School, Stanford, California
    JAMA Netw Open. 2020;3(7):e2010343. doi:10.1001/jamanetworkopen.2020.10343
    Key Points español 中文 (chinese)

    Question  What are rates of concordance with guidelines for the use of magnetic resonance imaging in patients with nonspecific low back pain among primary care clinicians in the US Department of Veterans Affairs (VA)?

    Findings  In this cohort study of 1 285 405 primary care visits of 920 547 patients, an early magnetic resonance imaging scan of the lumbar spine was performed in 2.42% of primary care episodes for uncomplicated low back pain in VA primary care clinics.

    Meaning  Results of this study suggest that the use of magnetic resonance imaging in nonspecific low back pain by VA primary care clinicians is lower than rates that have been reported for US patients with commercial insurance.


    Importance  Magnetic responance imaging (MRI) of the lumbar spine that is not concordant with treatment guidelines for low back pain represents an unnecessary cost for US health plans and may be associated with adverse effects. Use of MRI in the US Department of Veterans Affairs (VA) primary care clinics remains unknown.

    Objective  To assess the use of MRI scans during the first 6 weeks (early MRI scans) of episodes of nonspecific low back pain in VA primary care sites and to determine if historical concordance can identify clinicians and sites that are the least concordant with guidelines.

    Design, Setting, and Participants  Retrospective cohort study of electronic health records from 944 VA primary care sites from the 3 years ending in 2016. Data were analyzed between January 2017 and August 2019. Participants were patients with new episodes of nonspecific low back pain and the primary care clinicians responsible for their care.

    Exposures  MRI scans.

    Main Outcomes and Measures  The proportion of early MRI scans at VA primary care clinics was assessed. Clinician concordance with published guidelines over 2 years was used to select clinicians expected to have low concordance in a third year.

    Results  A total of 1 285 405 new episodes of nonspecific low back pain from 920 547 patients (mean [SD] age, 56.7 [15.8] years; 93.6% men) were attributed to 9098 clinicians (mean [SD] age, 52.1 [10.1] years; 55.7% women). An early MRI scan of the lumbar spine was performed in 31 132 of the episodes (2.42%; 95% CI, 2.40%-2.45%). Historical concordance was better than a random draw in selecting the 10% of clinicians who were subsequently the least concordant with published guidelines. For primary care clinicians, the area under the receiver operating characteristic curve was 0.683 (95% CI, 0.658-0.701). For primary care sites, the area was under this curve was 0.8035 (95% CI, 0.754-0.855). The 10% of clinicians with the least historical concordance were responsible for just 19.2% of the early MRI scans performed in the follow-up year.

    Conclusions and Relevance  VA primary care clinics had low rates of use of early MRI scans. A history of low concordance with imaging guidelines was associated with subsequent low concordance but with limited potential to select clinicians most in need of interventions to implement guidelines.