Advanced Imaging for Low Back Pain When to

Advanced Imaging for Low Back Pain When to Image Based on Choosing Wisely® and ACR Appropriateness Criteria®

What Is R-SCAN? § Collaborative activity for referring clinicians and radiologists to improve patient care through clinical improvement § R-SCAN Collaboration Goals: § Ensure patients receive the most appropriate imaging exam at the most appropriate time based on evidence -based appropriate use criteria § Reduce unnecessary imaging tests focused on imaging Choosing Wisely® topics § Lower the cost of care 2

Why Participate? § R-SCAN Offers: § Data-driven system for moving toward value-based imaging and patient care § Opportunity to focus on highly relevant imaging exams to improve utilization § Collaborators can fulfill their Improvement Activity requirements under the MIPS § Easy way to practice with clinical decision support (CDS) technology § In preparation for PAMA § Free and immediate access to Web-based tools and CME activities 3

Problem: Overutilization of Imaging for Low Back Pain § Most low back pain cases are self-limited and do not require imaging 1 § Numerous studies suggest that many radiographic, CT and MRI studies for low back are inappropriately ordered 2, 3 1. Davis, P. C. , Wippold, F. J. II, Brunberg, J. A. et al. ACR Appropriateness Criteria on low back pain. J Am Coll Radiol. 2009; 6: 401– 407. 2. Lehnert, B. E. and Bree, R. L. Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support? J Am Coll Radiol. 2010; 7: 192– 197. 3. Emery, D. J. , Shojania, K. G. , Forster, A. J. , Mojaverian, N. , and Feasby, T. E. Overuse of magnetic resonance imaging. JAMA Intern Med. 2013; 173: 823– 825. 4

Using Evidence to Guide Imaging Ordering § Choosing Wisely campaign § Collaborative effort between ABIM Foundation and over 70 medical specialty societies § Helps patients and medical professionals avoid wasteful or unnecessary medical tests, treatments and procedures § Many medical associations agree that imaging is inappropriate for low back pain in many situations, including: § American College of Physicians § American College of Emergency Physicians § American Academy of Family Physicians 5

Using Evidence to Guide Imaging Ordering § ACR Appropriateness Criteria® § Assist referring physicians and other providers in making the most appropriate imaging or treatment decisions for specific clinical conditions § Employs input of physicians from other medical specialties and societies to provide important clinical perspectives 6

ACR Appropriateness Criteria: The Facts § § 7 178 clinical imaging topics Over 875 clinical variants Basic access is free Learn more at acr. org/ac

ACR Appropriateness Criteria for Low Back Pain Clinical Scenario: Low Back Pain 8 Variant 1: Acute, subacute or chronic uncomplicated low back pain or radiculopathy. No red flags. No prior management. Variant 2: Acute, subacute or chronic uncomplicated low back pain or radiculopathy. One or more of the following: low velocity trauma, osteoporosis, elderly individual or chronic steroid use. Variant 3: Acute, subacute or chronic low back pain or radiculopathy. One or more of the following: suspicion of cancer, infection or immunosuppression. Variant 4: Acute, subacute or chronic low back pain or radiculopathy. Surgery or intervention candidate with persistent or progressive symptoms during or following 6 weeks of conservative management. Variant 5: Low back pain or radiculopathy. New or progressing symptoms or clinical findings with history of prior lumbar surgery. Variant 6: Low back pain with suspected cauda equina syndrome or rapidly progressive neurologic deficit.

Appropriateness Criteria Rating by Value 9

Alignment of Appropriateness Criteria and Choosing Wisely 10 All low back pain imaging variants and clinical scenarios: https: //acsearch. acr. org/docs/69483/Narrative/

When to Use Lumbar Spine Imaging Red Flag Symptoms § § § § § 11 Age >70 History of malignancy Weight loss History of abdominal aortic aneurysm Trauma Fever or recent infection Immunosuppression Prior surgery Prolonged corticosteroid use or known osteoporosis § Unremitting (>6 weeks) or worsening pain § Sensory disturbances § Weakness, numbness § Radicular symptoms § Pseudoclaudication § Abnormal reflexes § New bowel or bladder dysfunction § Abnormal sphincter tone

When Not to Image for Low Back Pain § Patients with “nonspecific” low back pain: § § 12 Acute (<6 weeks) No historical features that suggest a particular underlying condition No radicular symptoms or pseudoclaudication Normal neurologic exam

R-SCAN and Clinical Decision Support § ACR Select® is a web-based version ACR Appropriateness Criteria, comprising over 3, 000 clinical scenarios and 15, 000 imaging indications § ACR Select® provides evidence-based decision support for the appropriate utilization of medical imaging procedures § R-SCAN participants gain free access to a customized, web-based version the ACR Select, an important first step for aligning ordering patterns with appropriate use criteria 13

Getting Started With R-SCAN rscan. org 14

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R-SCAN Low Back Pain Educational Resources 19 1. Visit: rscan. org 2. Click: Resources 3. Click: Topic-specific Resources § Podcasts § Imaging Order Simulation activity § Articles § Materials to share with patients

R-SCAN Resources With CME § Podcast § A radiologist and referring physician discuss strategies of image ordering related to low back pain; approved for. 5 CME § Learn more § Imaging Order Simulation Activity § Test your knowledge in selecting the best imaging exam for low back pain with various indications § Free with CME 20

Key Points: Talking With Patients § Choosing Wisely: When Imaging Is Not Needed § Imaging won’t help you feel better or improve faster § Imaging is expensive, costing hundreds or thousands of dollars § Imaging can also lead to unnecessary surgery and treatments § X-rays and CT scans use radiation 21

Case 1 § 45 -year-old man with a past medical history of hypertension reports 3 weeks of nagging, low back pain § Pain is: § Dull, moderate § Does not radiate § Somewhat relieved by over counter analgesics § Worse with long periods of sitting or standing § Better when lying down 22 § Questions: § What is your differential diagnosis? § What other questions would you ask? § What is the focus of your physical exam?

Case 1 (continued) § No reports of: § Weight loss § History of abdominal aortic aneurysm § Neurological symptoms § Fevers or chills § Escalating pain § Neurologic exam is completely normal 23 § Questions: § Does this patient require imaging of the low back? § Why or why not?

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Summary § Non-specific low back pain is common and usually self-limited § Certain features of history and exam help distinguish back pain likely due to specific pathology § Imaging is usually not indicated for patients with non-specific back pain § Not only is imaging costly, but it can result in additional interventions 26

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