Choosing Wisely: imaging recommendations

Transcription

1 Choosing Wisely: imaging recommendations Michele Maiers, DC, MPH, PhD This is the ACA Your Hands On Partner (ACA) All rights reserved. This presentation may not be reproduced or transmitted in any form or by any

2 Chiropractic has an Image Problem

3 Chiropractic has an Image Problem Policy makers Reservations about quality, consistency Do not know how to include chiropractic Do not think about including chiropractic

4 Joining the Choosing Wisely campaign is an important way to address these barriers

5 Choosing Wisely NOT intended to prohibit any particular treatment in all scenarios NOT intended to dictate care decisions NOT to be used to establish coverage decisions or exclusions

6 Choosing Wisely Encourages Conversation Shared decision making Informed consent Empowered patients Welfare of patient comes first

7 ACA Committee on Quality Assurance and Accountability Criteria for topics a) Common to the practice of chiropractic b) Use should be questioned and discussed Recommendations 1) Supported by clinical research 2) High value, cost effective, improved patient outcomes *CMS Performance Measures

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9 1. Do not obtain spinal imaging for patients with acute low back pain during the six (6) weeks after onset in the absence of red flags. History of cancer Suspected fracture Progressive neurologic symptoms Infection Contraindication to SMT (e.g. osteoporosis, axial spondyloarthritis, tumors)

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11 Routine Imaging to Identify Pathology? Back pain presenting to primary care: 0.7% primary metastatic cancer 0.01% spinal infection 0.04% cauda equine syndrome 4% vertebral compression fracture <5% inflammatory back disease *almost all have identifiable risk factors Deyo, RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268: Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imagin. Ann Intern Med. 2002;137: Underwood MR, Dawes P. Inflammatory back pain in primary care. BR J Rheumatol. 1995;34:

12 Jarvik JG, et al. Association of early imaging for back pain with clinical outcomes in older adults. JAMA. 2015;313(11)

13 Identify spinal abnormalities? Brinjikji W, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol Apr; 36(4):

14 1. Do not obtain spinal imaging for patients with acute low back pain during the six (6) weeks after onset in the absence of red flags. Instead Render imaging on a case by case basis Consider in the presence of red flags, or if improvement does not occur after 6 weeks of care

15 2. Do not perform repeat imaging to monitor patients progress. No established relationship between changes in alignment/ structural characteristics and outcome Increases harm (e.g. cost, ionizing radiation, dependency)

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18 Nominal Risk of X rays? Accumulated average radiation exposure Lumbar x rays=6 th highest contributor to radiation exposure Annual dose lumbar x rays 75X chest xray Highest risk for women, esp. gonad exposure Cost Additional procedures (each with their own risk) Advanced imaging increases risk of surgery Fazel, R, et al. Exposure to low dose ionizing radiation from medical imaging procedures in the United States. N Engl J Med. 2009;361(9):

19 Empower Patients with a Diagnosis? Unintended harms related to labeling Smaller improvement to general health More pain/ worse overall health status at 3 months Why? Catastrophizing Fear avoidance behavior Maladaptive strategies Ash LM, et al. Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol. 2008;29: Kendrick D, et al. Radiography of the lumbar spine in primary care patients with low back pain: randomized controlled trial. BMJ. 2001;322:400 5.

20 2. Do not perform repeat imaging to monitor patients progress. Instead Consider when symptoms change notably, disease progression occurs, or patients do not respond to care Current evidence supports repeat imaging to monitor idiopathic scoliosis

21 ACA and the Choosing Wisely program believe that decisions about care should be made based upon best available evidence, clinical judgment of the doctor, and preferences and goals of the patient This is how evidenced based care works

22 Providers are Under Pressure Patient expectations affect clinical decisions Patients more satisfied when imaging received Believe it is necessary, despite clinical benefit Defensive medicine Conversation is key! Schers H, et al. Implementation barriers for general practice guidelines on low back pain in a qualitative study. Spine. 2001;26: Kendrick D, et al. Radiography of the lumbar spine in primary care patients with low back pain: randomized controlled trial. BMJ. 2001;322: Deyo RA, et al. Reducing roentgenography use. Can patient expectations be altered? Arch Intern Med. 1987;147: Palmlof L, et al. Expectations of recovery: a prognostic factor in patients with neck pain undergoing manual therapy treatment. Eur J Pain. 2016;20(9): Bishop, MD, et al. The influence of clinical equipoise and patient preferences on outcomes of conservative manual interventions for spinal pain: an experimental study. J Pain Res. 2017;10:

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