Study: Modification and Reinitiation of Lower Back Imaging Orders After Evidence-Based Collaborative Consultation

February 5, 2019

An article titled, “Modification and Reinitiation of Lower Back Imaging Orders After Evidence-Based Collaborative Consultation” was published by Academic Radiology on December 20, 2018. Academic Radiology is the official journal of the Association of University Radiologists.

The study’s lead author, Adam C. Powell, Ph.D., and his team sought to assess the extent to which collaborative consultation impacted decisions to perform lower back imaging. A Centers for Medicare & Medicaid Services quality measure and the Choosing Wisely guidelines of the American Academy of Family Physicians, the American Society of Anesthesiologists, and the North American Spine Society suggest that in most cases, physicians should wait at least 28 days after a patient has experienced the onset of low back pain before ordering imaging, as back pain often resolves with time and no intervention. The study explored four interaction sequences between ordering and consulting physicians in a non-denial prior authorization program. Ordering physicians were asked to modify orders during a consultation with a board-certified physician if their orders did not appear to meet best practice guidelines. If the original orders were not reinitiated, it could imply that the modified orders met clinical objectives.

Order records and claims data pertaining to approximately 3.5 years, between 2014 and 2017, were used to conduct the analysis.  Orders were included if they featured computed tomography (CT) or magnetic resonance imaging (MRI) of the lower back. The analysis explored the rate at which orders were modified or reinitiated within 28 days.

The study examined 538,768 orders, which led to 6,855 collaborative consultations. The data indicated that the majority of orders undergoing consultation were not modified, and that there was infrequent reinitiation of modified orders within 28 days. The specialty of the physician appeared to have a significant association with the likelihood of order modification, with primary care physicians (PCPs) more likely to agree to modify orders than non-PCPs. Reinitiation of imaging orders within 28 days of their withdrawal may have sometimes been consistent with evidence-based practice, since sufficient time may have elapsed so that imaging actually was at least 28 days after the initial onset of pain.

Based upon the findings of the study, the authors concluded that nondenial prior authorization of low back imaging orders provides “physicians the freedom to decide how to proceed with their orders,” while also reducing the likelihood of “the potentially harmful downstream interventions that have been shown to be associated with the nonindicated early imaging, as well as radiation exposure.”

In response to the findings, Dr. Powell remarked, “This study, along with a study on reinitiation of neuroimaging orders that we published in 2015, demonstrates the performance of a nondenial approach to prior authorization. When physicians voluntarily agree to modify their orders, they typically stick to what they have agreed. These studies demonstrate the success of a nondenial approach in managing imaging for two unrelated areas of the body.”

To read the full article, please visit: https://www.academicradiology.org/article/S1076-6332(18)30540-3/fulltext

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