1013 — Overuse of Lumbar Spine MRI in VA: A National Analysis

Gidwani R, HERC, Ci2i, Stanford University; Sinnott P, HERC; Avoundjian T, Ci2i; Lo J, HERC; Asch SM, Ci2i, Stanford University; Barnett PG, HERC, Stanford University;

Objectives:
Overuse of lumbar spine magnetic resonance imaging (MRI) is suspected to be a large problem; multiple medical and healthcare societies have prioritized it as a quality of care measure or a measure of prudent stewardship of resources. Here, we analyze overuse of lumbar spine MRI in a national population of persons receiving outpatient lumbar spine MRI in the Department of Veterans Affairs (VA) healthcare system.

Methods:
We evaluated the appropriateness of scans for all persons receiving lumbar spine MRI in Fiscal Year 2012. Our assessments of appropriateness were based on Center for Medicare and Medicaid Services (CMS) administrative data-based criteria. These criteria have been endorsed by the National Quality Forum (NQF). Generalized estimating equations were used to evaluate characteristics of inappropriate scans.

Results:
Of the 110,661 lumbar spine MRIs performed, 31% were classified as inappropriate. Black patients were less likely to have an inappropriate scan compared to White patients (adjusted OR = 0.80, p < 0.0001). Scans ordered in Emergency Departments, Urgent Care, Primary Care and Internal Medicine clinics were most likely to be classified as inappropriate. Resident physicians were significantly less likely than other provider types to order inappropriate lumbar spine MRI adjusted OR 0.80, p < 0.0001). Approximately 24% of providers ordered 74% of inappropriate scans.

Implications:
We found 31% of lumbar spine MRIs were inappropriate in a health care system largely absent financial incentives for ordering. This suggests non-pecuniary factors play an important role in ordering behavior in VA. The problem of overuse of lumbar spine MRI is not widespread; it is concentrated in a small number of providers. Further research to explore the reasons for overuse in VA, including the relative importance of lack of awareness of guidelines, concerns about patient satisfaction or reassurance, and/or gatekeeping arrangements practiced by orthopedic surgery or neurosurgery clinics, will be informative for quality improvement.

Impacts:
Any provider-facing interventions to reduce overuse of lumbar spine MRI should be targeted rather than aimed at all providers who order such images.