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  • JAMA: Equipment Ownership, Prior Imaging Behavior Predict High Rates of Low-Value Imaging for LBP, Headache

    In brief:

    • Researchers analyzed data from 100,977 providers (primary care physicians, chiropractors, and specialists including orthopedic surgery, neurosurgery, back and spine surgery, physical medicine, and rheumatology) to track prevalence of low-value imaging for uncomplicated back pain and headache as identified in the Choosing Wisely campaign
    • Study looked at predictors of higher rates of low-value imaging, including whether the provider owned imaging equipment
    • Clinicians were more likely to order imaging if they owned the equipment or if they had ordered imaging for a previous patient with the same symptoms
    • Equipment ownership was a "consistent independent predictor" of increased use of low-value imaging
    • Authors call for more clinician education on avoiding low-value imaging

    Despite evidence showing that imaging for low back pain (LBP) and uncomplicated headache is not necessary, too many health care providers still order these services for their patients, who incur greater financial costs. In a new study published in JAMA Internal Medicine, researchers identified several factors associated with higher rates of low-value imaging—including whether the providers owned the imaging equipment.

    Using 4 years' worth of claims data from 1 insurer, authors analyzed clinician characteristics as predictors for imaging for uncomplicated back pain and headache—2 low-value services identified by the Choosing Wisely campaign guidelines as inappropriate for imaging.

    The study included 100,977 providers divided into 3 categories: primary care physicians, chiropractors, and providers in specialties including orthopedic surgery, neurosurgery, back and spine surgery, physical medicine, and rheumatology.

    Low back pain. Primary care physicians were 1.81 times more likely to order low-value imaging for back pain if they had ordered it for a prior patient than those who didn't order earlier imaging. Chiropractors and specialists were nearly 3 times more likely to do so.

    All clinician types were more likely to order imaging for low back pain if they owned the equipment, but chiropractors (7.76) and specialists (4.96) had the greatest increased odds, compared with primary care physicians, who had increased odds of 2.06.

    Headache. For headache, clinicians who ordered imaging for a previous patient were twice as likely to do so for the next patient than those who had not made a previous order. Clinicians who owned the imaging equipment had 1.88 times higher odds of ordering low-value imaging for headache than those who didn't own equipment.

    High rate of low-value back imaging as a predictor of low-value headache imaging. Primary care physicians who had high rates of low-value back pain imaging were 1.78 times more likely to order low-value headache imaging than those whose low back pain imaging rates were low.

    Ownership of imaging equipment. Clinician ownership of imaging equipment was a "consistent independent predictor of low-value imaging across clinician type and imaging scenario," authors write. Primary care physicians with the highest rates of low-value back imaging were also 1.53 times more likely to order low-value headache imaging if they owned the imaging equipment.

    Authors believe the findings have direct implications for patients, who shoulder a greater cost share with the additional services. For example, the study found that patients with private insurance were more likely to be referred for low back and headache imaging if their provider had higher rates of imaging and/or owned the imaging. This was especially true among chiropractors and specialists.

    According to authors, underlying factors may include "discomfort with clinical uncertainty, overestimating the benefits of testing, group practice trends, and other practice-related factors," as well as "the pervasive fear of malpractice."

    Researchers also pinpoint the challenges regarding equipment ownership in the changing payment environment and consolidation of practices and health systems. "Previous legislation has limited imaging equipment ownership and clinician self-referral; however, exceptions have been made for patient convenience and evolving practice models," authors write. "As a result, these laws may be less effective than intended. Although there are payment programs that hold health care provider groups responsible for the cost of care, early evidence shows that their effectiveness at reducing low-value care has been modest, even among self-selected provider groups."

    Still, authors note, to optimize patient care and cost, "stakeholders should design clinician-targeted interventions to reduce low-value care."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.