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Financial incentives alone don’t drive overuse of lumbar spine MRIs

L4-l5-disc-herniationBetween 30 and 50 percent of lumbar spine MRIs are inappropriate, according to new research led by VA and Stanford health economist Risha Gidwani, DrPH. The study, published recently in The American Journal of Managed Care, examined all lumbar spine MRIs prescribed in the entire Department of Veterans Affairs system in fiscal year 2012.

"This imaging modality is widely used, and in many cases, used inappropriately," Gidwani said.

These MRI scans are used to diagnose the source of lower back pain, a condition that sidelines millions of Americans each year. But the best treatments for most cases of lower back pain are conservative — many cases resolve on their own or with appropriate exercise within weeks, the team writes. In addition, radiographic findings on MRIs are often unrelated to patient symptoms and MRIs can lead to unnecessary treatments that don't help patients feel better. Extra scans also rack up costs and lead to inefficient allocation of resources, Gidwani said.

Organizations including the American College of Physicians and the American Association of Neurological Surgeons have drawn attention to the need to reduce inappropriate use of MRIs in their Choosing Wisely campaign. The Centers for Medicaid and Medicare Services also developed guidelines that identify inappropriate lumbar spine MRIs. These guidelines specify what conditions warrant an immediate MRI, including HIV, trauma, cancer or spinal surgery. In all other cases, the guidelines recommend visits with a physician to evaluate and manage the condition, physical therapy or chiropractic care in the 28 to 60 days before ordering an MRI.

Several hypotheses have been suggested to explain the overuse of lumbar spine MRIs, Gidwani said. Fee-for-service physicians could be trying to add to their bottom line or physicians could be practicing defensive medicine, seeking to avoid lawsuits, she said. To investigate this, her team studied ordering decisions in the VA, where physicians are salaried and largely shielded from malpractice concerns.

Using the most conservative parameters — where even a visit to any physician for any reason preceding an MRI is considered management for lower back pain — the researchers found 31 percent of lumbar spine MRIs were inappropriate. Within the VA alone, those inappropriate scans cost $13.6 million. By limiting the definition of "appropriate" to only cases where the physician appointment had a billing code for "lower back pain," the percentage of inappropriate scans skyrocketed to 53 percent. The real figure lies somewhere in the middle, Gidwani said.

"It's possible, and even probable, this percentage is even higher outside the VA," Gidwani said. "This study provides evidence this needs to be studied in different healthcare environments where financial incentives may exacerbate the problem."

The team did not detect any geographic patterns in overuse of lumbar spine MRIs, but they did find a small group of physicians was responsible for many of the inappropriate scans: 24 percent of providers ordered 74 percent of inappropriate scans. They also found several intriguing patterns. For example, black patients were more likely to receive an inappropriate scan. Members of the team are further investigating the drivers of these patterns, which could help healthcare leaders improve education and monitoring of the appropriate use of MRIs.

Previously: Medicare payment reform shown to cut costs and improve patient care, Stanford study: Medical procedures more expensive where physicians cluster in large medical practices and When physicians work together, costs can rise
Image by Edave

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