Appropriateness of Spine-Related Imaging

2013 CADTH

Jason W. Busse, DC, PhDMcMaster UniversityDepts. of Anesthesia & Clinical Epidemiology & Biostatistics

Overview

Background

Systematic Reviews of Appropriateness Literature

Surveys of Canadian Spine Surgeons

Utilization data (Manitoba & Ontario)

Background

Diagnostic imaging is an essential component of Canadian healthcare

The proliferation of advanced technology has led to substantial perceived need for these technologies, thereby increasing the utilization of imaging services.

Background

To inform the current use, and inappropriate use, of spine-related imaging we conducted:

Two systematic reviews of the literature

Two surveys of Canadian spine surgeons

An analysis of utilization data in Manitoba and Ontario

Overview

Background

Systematic Reviews of Appropriateness Literature

Surveys of Canadian Spine Surgeons

Utilization data (Manitoba & Ontario)

Systematic Review: Methods

Eligible studies met either of the following criteria:

(1) reports data on the proportion of spine-related imaging that was inappropriate; or

(2) tests a strategy to improve the appropriateness of spine-related imaging

Literature Search Results (n=19,808)

CINAHL:1548 HealthSTAR: 4962EMBASE: 7119 Index to Chiropractic Literature: 72MEDLINE: 5783 The International Guideline Library: 324

370 potentially relevant studies selected for review of full text

7,172 duplicate articles

12,636 abstracts screened

40 publications included in our systematic review

1 unpublished paper from a team member (TEF)

Results for Inappropriate Imaging

22 unique cohorts from 21 studies reported on the proportion of inappropriate spine-related imaging:

USA - 12 studies

Canada - 2 studies

Norway - 2 studies

Australia - 2 studies

UK - 1 study

France - 1 study

Finland - 1 study (reporting 2 cohorts)

Results: Neck Imaging

Study Country of Study

Population Appropriateness criteria

Findings

Hoffman et al., 2000

USA X-rays for acute, blunt neck trauma(n=34,069)

The National Emergency X-Radiography Utilization Study (NEXUS) criteria

12.7% of X-rays were inappropriate

Sheikh et al., 2012

USA Acute, blunt neck trauma patients(n=1245)

American College of Radiology (ACR) Appropriateness criteria

100% of X-rays were inappropriate (433 of 433)

Results: Neck Imaging

Study Country of Study

Population Appropriateness criteria

Findings

Moak et al., 2011

USA Acute, blunt neck trauma patients(n=124)

NEXUS + dangerous mechanism of injury

7.4% of CT scans were inappropriate (9 of 122)

Griffith et al., 2011

USA CT scans for acute, blunt neck trauma(n=1589)

The National Emergency X-Radiography Utilization Study (NEXUS) criteria

20% of CT scans were inappropriate

Kokabi et al., 2011

Australia CT scans for acute, blunt neck trauma(n=106)

Goergen‟s criteria 53.8% of CT scans were inappropriate

Oikarinen et al., 2009

Finland CT scans of the neck (n=30)

Guidelines for imaging recommended by the European Commission

3% of CT scans were inappropriate

Results: Low Back

Study Country of Study

Population Appropriateness criteria

Findings

Oikarinen et al., 2009

Finland CT scans of the low back (n=30)

Guidelines for imaging recommended by the European Commission

77% of CT scans were inappropriate

Emery et al., 2013

Canada Patients referred for a low back MRI (n=500)

The RAND-UCLA appropriateness method, including a literature review, expert assessment and a chart review

56% of MRIs were inappropriate, and 29% were of uncertain value

Results: Low BackStudy Country

of StudyPopulation Appropriateness

criteriaFindings

Espeland et al., 1999

Norway Low back pain (LBP) patientsreferred for plain films (n=323)

Norwegian and British recommendations for the use of radiography

Proportion inappropriate:

Norwegian – 34% (42% uncertain)British – 46%(18% uncertain)

Espeland et al., 2001

Norway LBP patientsreferred for plain films (n=99)

Norwegian and British recommendations for the use of radiography

Proportion inappropriate:*

Norwegian – 71%British – 60%

Ammendoliaet al., 2007

Canada Acute LBP (n=1241); 481 were referred for x-ray

The U.S. Agency for Health Care Policy and Research (AHCPR) guidelinesA modified version of the AHCPR guidelinesThe radiography guidelines by Simmons et al

Proportion of Inappropriate x-rays:

21.8% - AHCPR

47.3% - mAHCPR

12.7% - Simmons

* Patients who received inappropriate plain films rated imaging as more important than those who received appropriate imaging

Conclusions

The literature on appropriateness of spine-related imaging is challenging due to the application of multiple standards

There were 22 different appropriateness criteria reported in 21 studies

Only 4 of which were reported in more than 1 study

All studies agree that inappropriate imaging occurs, but the size of the problem depends on the clinical population and the criteria applied.

How is Appropriateness Defined?

Largely through a series of rules to ensure close to 100% sensitivity for all and any “clinically significant lesions”

This permits „rules‟ with very low specificity

In most cases, the association with measures of direct patient-importance is unknown

Are There Effective Interventions?

We identified 18 studies that have explored interventions to improve the appropriateness of imaging for spine-related complaints:

USA - 8 studies

UK - 6 studies

Canadian - 1 study

Australia - 1 study

Ireland - 1 study

Norway - 1 study

Study Population Intervention Control Findings

Stiell et al., 2009

11 824 patients with blunt trauma to the head or neck at one of 12 hospitals (Canada)

Active strategies to implement the Canadian C-Spine Rule, including education, policy, and real time reminders on radiology requisitions

Usual care

25% reduction in cervical spine x-rays

Interventions: Outcomes

All studies reported on the change in proportion of appropriate imaging studies

Only one study reported healthcare outcomes and this observed a non-significant change in pain at three and six months follow-up for an organisational intervention

Conclusions

Passive interventions to modify imaging rates (distribution of educational materials, media campaigns), have shown inconsistent results

Interventions focussing on active decision aids appear more promising

Very little focus on patient-important outcomes.

Overview

Background

Systematic Review of Appropriateness Literature

Surveys of Canadian Spine Surgeons

Utilization data (Manitoba & Ontario)

CSS Survey #1

On August 27, 2012, we administered an 8-item survey to all 100 surgeon members of the Canadian Spine Society (CSS), with active surgical practices, that inquired about demographic variables and imaging practices related to patients referred for spine-related complaints

55% response rate.

CSS Survey #1

84% required imaging studies to accompany any spine-related referral

MRI

30%

MRI + Xray

19% Xray

16%

MRI + CT + Xray

14%

MRI + CT

14%

CT + Xray

5% CT 2%

Surgeon‟s Comments (survey #1)

“MRI is the imaging modality of choice because of the great safety profile, due to lack of ionizing radiation, and the large amount of information you can get from this modality. Provinces should invest in having more of these machines available for patient evaluations”

“MRI is the gold-standard for imaging of the spine. We went through this same debate for CT scans about 15 years ago. It is useless to resist. Patients want them. Referring physicians want them…Regulating or restricting it only makes the system less efficient”

Surgeon‟s Comments (survey #1)

“Too many unnecessary expensive evaluations done that will not alter treatment”

“The vast majority of investigations are not indicated, or if indicated do not change management, resulting in inordinately long waiting times to obtain scan in those where they are indicated for management”

CSS Survey #2 In January, 2012, we administered a 28-item

survey to all active 100 surgeon members of the CSS that inquired about patient screening efficiency, typical wait times for both assessment and surgery, indicators for assessment by a surgeon, and attitudes towards the use of non-physician clinicians to screen low back and leg patients referred for surgical assessment.

85% response rate.

CSS Survey #2

Approximately a third of spine surgeons turned away more than 20% of low back or low back related leg pain patients that were referred to their practice

Only 29.5% of respondents reported that their screening efficiency for low back or low back related leg pain patients was optimal, with 41.6% screening more than 10 patients to identify a single surgical candidate.

CSS Survey #2

Most spine surgeons (77.6%; 66 of 85) were either willing to work with LBP clinicians to screen their low back or low back related leg pain patients (n=54) or were already doing so (n=12)

Respondents largely (85%+) endorsed findings that would necessitate surgical assessment: signs or symptoms associated with a „red flag‟ condition, leg dominant pain, and low back or low back related leg pain that was consistent with imaging or neurological findings.

CSS Survey #2

A majority of respondents (75.3%, 64 of 85) agreed they would be comfortable not assessing a low back or low back related leg pain patient referred to their practice if clear indications for surgery were ruled out by a LBP clinician

17.6% were unsure

7.1% would still want to assess the patient themselves

CSS Survey #2

“I do work with a nurse practitioner and she has screening clinics and also sees many of our non-surgical patients. I had a similar relationship in my previous job. It is invaluable having these people”

“We have a triage clinic now which doesn't require an MRI. Patients get a phone all from a spine nurse, and if potentially surgical, get an MRI...We phoned about 700 patients last year, and less than 10% were surgical”

Overview

Background

Systematic Review of Appropriateness Literature

Surveys of Canadian Spine Surgeons

Utilization data (Manitoba & Ontario)

Next steps

Questions

Spine imaging rates, Manitoba, 2001-2010

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

2001/2002 2002/2003 2003/2004 2004/2005 2005/2006 2006/2007 2007/2008 2008/2009 2009/2010 2010/2011

Rate

per

100,0

00 in

div

idu

als

Fiscal Year

Spine x-ray

CT Spine

MRI Spine

350% increase in MRI use

Spine imaging rates, Ontario, 2001-2010

0

1000

2000

3000

4000

5000

6000

2001/2002 2002/2003 2003/2004 2004/2005 2005/2006 2006/2007 2007/2008 2008/2009 2009/2010 2010/2011

Rate

per

10

0,0

00

in

div

idu

als

Fiscal Year

Spine x-ray

CT Spine

MRI Spine

Spine imaging costs, Manitoba, 2001-2010

$0

$1,000,000

$2,000,000

$3,000,000

$4,000,000

$5,000,000

$6,000,000

2001/2002 2002/2003 2003/2004 2004/2005 2005/2006 2006/2007 2007/2008 2008/2009 2009/2010 2010/2011

Cost

Fiscal Year

Annual spending on spine

imaging has doubled

Spine imaging costs, Ontario, 2001-2010

$-

$10,000,000

$20,000,000

$30,000,000

$40,000,000

$50,000,000

$60,000,000

$70,000,000

2001/2002 2002/2003 2003/2004 2004/2005 2005/2006 2006/2007 2007/2008 2008/2009 2009/2010 2010/2011

Cost

Fiscal year

Spine x-ray is still a major cost driver

Spine x-ray$2,005,997

(40%)

CT spine$1,015,624

(20%)

MRI spine$1,993,896

(40%)

Costs of Spine Imaging, by modality, Manitoba (2010)

CT spine use by neighbourhood income, Manitoba (2010)

0

200

400

600

800

1,000

1,200

1,400

1 (poor) 2 3 4 5 (rich)

Rat

e p

er 1

00

,00

0 in

div

idu

als

Neighbourhood income quintile

Rural

Urban

MRI spine use by neighbourhood income, Manitoba (2010)

0

200

400

600

800

1,000

1,200

1,400

1 (poor) 2 3 4 5 (rich)

Rat

e p

er

10

0,0

00

ind

ivid

ual

s

Neighbourhood income quintile

Rural

Urban

Lead up testing before MRI spine

x-ray then CT6%

CT then x-ray2%

x-ray only30%

CT only8%

none54%

Key findings

• MRI spine use has increased markedly since 2001, but spine x-ray still accounts for 40% of spine imaging costs in Manitoba

• “Lead-up” spine x-ray or CT spine before MRI spine accounts for as much as 16% of all spine x-ray and 14% of all CT spine procedures in Manitoba

• Most (70%) patients receive CT or MRI spine before surgical consult, but few (6.6%) patients receive spine surgery after CT or MRI spine

Conclusions

• True extent of inappropriate spinal imaging cannot be determined (claims data do not contain reason for imaging referral)

• Improved health system coordination for patients with spinal complaints may help to improve efficiency of spine imaging use– diagnostic imaging pathways (right test first)– standardized (and/or centralized and/or

multidisciplinary) assessment of patients with low back pain to streamline assessment and referral

The Study Team

Jason Busse Gordon H. Guyatt

Paul E. Alexander Y. Raja Rampersaud

Amane Abdul-Razzak Michael J. Goytan

John J. Riva Nancy Lloyd

Mostafa Alabousi Brie DeMone

John Dufton Tom E. Feasby

Regina Li Martin Reed

Yoan Kagoma Edward J. Mills

Madison Zhang Kristian Thorlund

Markus Faulhaber Holger Schünemann

Rachel Couban John You

Thank-you for Your Time

For further details you can reach me at: bussejw@mcmaster.ca

mailto:bussejw@mcmaster.ca