Effectiveness of interventions designed to reduce the use of imaging for low-back pain: a systematic review.
BACKGROUND
Rates of imaging for low-back pain are high and are associated with increased health care costs and radiation exposure as well as potentially poorer patient outcomes. We conducted a systematic review to investigate the effectiveness of interventions aimed at reducing the use of imaging for low-back pain.


METHODS
We searched MEDLINE, Embase, CINAHL and the Cochrane Central Register of Controlled Trials from the earliest records to June 23, 2014. We included randomized controlled trials, controlled clinical trials and interrupted time series studies that assessed interventions designed to reduce the use of imaging in any clinical setting, including primary, emergency and specialist care. Two independent reviewers extracted data and assessed risk of bias. We used raw data on imaging rates to calculate summary statistics. Study heterogeneity prevented meta-analysis.


RESULTS
A total of 8500 records were identified through the literature search. Of the 54 potentially eligible studies reviewed in full, 7 were included in our review. Clinical decision support involving a modified referral form in a hospital setting reduced imaging by 36.8% (95% confidence interval [CI] 33.2% to 40.5%). Targeted reminders to primary care physicians of appropriate indications for imaging reduced referrals for imaging by 22.5% (95% CI 8.4% to 36.8%). Interventions that used practitioner audits and feedback, practitioner education or guideline dissemination did not significantly reduce imaging rates. Lack of power within some of the included studies resulted in lack of statistical significance despite potentially clinically important effects.


CONCLUSIONS
Clinical decision support in a hospital setting and targeted reminders to primary care doctors were effective interventions in reducing the use of imaging for low-back pain. These are potentially low-cost interventions that would substantially decrease medical expenditures associated with the management of low-back pain.
Department of Health Professions (Jenkins, Hancock), Macquarie University, Sydney, Australia; School of Rehabilitation Therapy (French), Queen's University, Kingston, Ont.; The George Institute for Global Health (Maher), Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Chiropractic (Engel), Macquarie University, Sydney, Australia; Australian School of Advanced Medicine (Magnussen), Macquarie University, Sydney, Australia hazel.jenkins@mq.edu.au.
Hazel J
HJ
Jenkins
Department of Health Professions (Jenkins, Hancock), Macquarie University, Sydney, Australia; School of Rehabilitation Therapy (French), Queen's University, Kingston, Ont.; The George Institute for Global Health (Maher), Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Chiropractic (Engel), Macquarie University, Sydney, Australia; Australian School of Advanced Medicine (Magnussen), Macquarie University, Sydney, Australia.
Mark J
MJ
Hancock
Department of Health Professions (Jenkins, Hancock), Macquarie University, Sydney, Australia; School of Rehabilitation Therapy (French), Queen's University, Kingston, Ont.; The George Institute for Global Health (Maher), Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Chiropractic (Engel), Macquarie University, Sydney, Australia; Australian School of Advanced Medicine (Magnussen), Macquarie University, Sydney, Australia.
Simon D
SD
French
Department of Health Professions (Jenkins, Hancock), Macquarie University, Sydney, Australia; School of Rehabilitation Therapy (French), Queen's University, Kingston, Ont.; The George Institute for Global Health (Maher), Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Chiropractic (Engel), Macquarie University, Sydney, Australia; Australian School of Advanced Medicine (Magnussen), Macquarie University, Sydney, Australia.
Chris G
CG
Maher
Department of Health Professions (Jenkins, Hancock), Macquarie University, Sydney, Australia; School of Rehabilitation Therapy (French), Queen's University, Kingston, Ont.; The George Institute for Global Health (Maher), Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Chiropractic (Engel), Macquarie University, Sydney, Australia; Australian School of Advanced Medicine (Magnussen), Macquarie University, Sydney, Australia.
Roger M
RM
Engel
Department of Health Professions (Jenkins, Hancock), Macquarie University, Sydney, Australia; School of Rehabilitation Therapy (French), Queen's University, Kingston, Ont.; The George Institute for Global Health (Maher), Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Chiropractic (Engel), Macquarie University, Sydney, Australia; Australian School of Advanced Medicine (Magnussen), Macquarie University, Sydney, Australia.
John S
JS
Magnussen
D020000:Decision Support Systems, Clinical; D003952:Diagnostic Imaging / Q000191:economics / Q000706:statistics & numerical data*; D005246:Feedback; D017048:Health Care Costs; D006300:Health Services Misuse / Q000517:prevention & control*; D006801:Humans; D033181:Information Dissemination; D017116:Low Back Pain / Q000175:diagnosis*; D008485:Medical Audit; D017410:Practice Guidelines as Topic; D011320:Primary Health Care; D017010:Reminder Systems