Advanced Imaging for Low Back Pain When to Image Based on Choosing Wisely® and ACR Appropriateness Criteria® Standard template

What Is R-SCAN? Collaborative activity for referring clinicians and radiologists to improve patient care through clinical improvement R-SCAN Collaboration Goals: Ensure patients receive the most appropriate imaging exam at the most appropriate time based on evidence-based appropriate use criteria Reduce unnecessary imaging tests focused on imaging Choosing Wisely® topics Lower the cost of care Standard template Use this slide as a reminder / intro to what the program is about and its benefits. Website is www.rscan.org. For example, if your facility tends to order many CT exams for suspected pulmonary embolism, you might select that topic to ensure you’re ordering appropriately. As far as a time commitment, staff time dedicated to an R-SCAN project ranges from 15 to 30 hours over a three- to six-month period. You can also gain experience using a clinical decision support (CDS) tool; gaining experience with CDS now will help referring clinicians be prepared for the implementation of federal reimbursement requirements for CDS consultation prior to ordering advanced imaging. This alternative to pre-authorization reduces time and expense for practices and patients when imaging is the next step in the diagnostic process.

Why Participate? R-SCAN Offers: Data-driven system for moving toward value-based imaging and patient care Opportunity to focus on highly relevant imaging exams to improve utilization Collaborators can fulfill their Improvement Activity requirements under the MIPS Easy way to practice with clinical decision support (CDS) technology In preparation for PAMA Free and immediate access to Web-based tools and CME activities Standard Template Participants earn improvement activity credits. More here: https://rscan.org/images/PDFs/RSCAN_Improvement-Flyer_v4.Web_09-11-17pdf.pdf Information about Protecting Access to Medicare Act here: https://www.acr.org/Advocacy/eNews/20170421-Issue/20170421-ACR-Answers-Frequent-Questions-About-CDS-Mandate

Problem: Overutilization of Imaging for Low Back Pain Most low back pain cases are self-limited and do not require imaging1 Numerous studies suggest that many radiographic, CT and MRI studies for low back are inappropriately ordered2,3 The problem statement will be in all templates, but customized for the specific topic. More information on the issue here: http://www.jacr.org/article/S1546-1440(16)30565-8/fulltext Davis, P.C., Wippold, F.J. II, Brunberg, J.A. et al. ACR Appropriateness Criteria on low back pain. J Am Coll Radiol. 2009; 6: 401–407. Lehnert, B.E. and Bree, R.L. Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support? J Am Coll Radiol. 2010; 7: 192–197. Emery, D.J., Shojania, K.G., Forster, A.J., Mojaverian, N., and Feasby, T.E. Overuse of magnetic resonance imaging. JAMA Intern Med. 2013; 173: 823–825. 

Using Evidence to Guide Imaging Ordering Choosing Wisely campaign Collaborative effort between ABIM Foundation and over 70 medical specialty societies Helps patients and medical professionals avoid wasteful or unnecessary medical tests, treatments and procedures Many medical associations agree that imaging is inappropriate for low back pain in many situations, including: American College of Physicians American College of Emergency Physicians American Academy of Family Physicians Standard template Choosing Wisely includes 150 patient-friendly resources and more than 500 specialty societies provided recommendations. Learn more: www.choosingwisely.org

Using Evidence to Guide Imaging Ordering ACR Appropriateness Criteria® Assist referring physicians and other providers in making the most appropriate imaging or treatment decisions for specific clinical conditions Employs input of physicians from other medical specialties and societies to provide important clinical perspectives Standard template See next slide for more info on the AC 6

ACR Appropriateness Criteria: The Facts 178 clinical imaging topics Over 875 clinical variants  Basic access is free Learn more at acr.org/ac Standard template New Appropriateness Criteria topics are added annually. 7

ACR Appropriateness Criteria for Low Back Pain Clinical Scenario: Low Back Pain Variant 1: Acute, subacute or chronic uncomplicated low back pain or radiculopathy. No red flags. No prior management. Variant 2: Acute, subacute or chronic uncomplicated low back pain or radiculopathy. One or more of the following: low velocity trauma, osteoporosis, elderly individual or chronic steroid use. Variant 3: Acute, subacute or chronic low back pain or radiculopathy. One or more of the following: suspicion of cancer, infection or immunosuppression. Variant 4: Acute, subacute or chronic low back pain or radiculopathy. Surgery or intervention candidate with persistent or progressive symptoms during or following 6 weeks of conservative management. Variant 5: Low back pain or radiculopathy. New or progressing symptoms or clinical findings with history of prior lumbar surgery. Variant 6: Low back pain with suspected cauda equina syndrome or rapidly progressive neurologic deficit. The AC variants for the specific R-SCAN topic will be in all templates. The major clinical indications – or “variants” are considered for each Appropriateness Criteria topic. Explain how AC works and what the variants are… 8

Appropriateness Criteria Rating by Value Standard template Exams associated with imaging for the individual clinical indications are rated according to their value as determined by the members of the Appropriateness Criteria panels. The panels use the following approach for determining the exams rating, or value: 1. The guideline authors conduct a systematic search of scientific literature, identify most relevant articles and develop initial ratings. 2. A larger panel reviews and carries out rating rounds. 3. Topics updated every 3 years, or more frequently where needed. 9

Alignment of Appropriateness Criteria and Choosing Wisely An AC example for the specific R-SCAN topic will be in all templates. https://acsearch.acr.org/docs/69483/Narrative/ All low back pain imaging variants and clinical scenarios: https://acsearch.acr.org/docs/69483/Narrative/ 10

When to Use Lumbar Spine Imaging Red Flag Symptoms Age >70 Unremitting (>6 weeks) or worsening pain History of malignancy Sensory disturbances Weight loss Weakness, numbness History of abdominal aortic aneurysm Radicular symptoms Trauma Pseudoclaudication Fever or recent infection Abnormal reflexes Immunosuppression New bowel or bladder dysfunction Prior surgery Abnormal sphincter tone Prolonged corticosteroid use or known osteoporosis When to do the imaging will be included in all templates, but content customized. Order lumbar spine imaging when red flags are present

When Not to Image for Low Back Pain Patients with “nonspecific” low back pain: Acute (<6 weeks) No historical features that suggest a particular underlying condition No radicular symptoms or pseudoclaudication Normal neurologic exam When not to do the imaging will be included in all templates, but content customized. Lumbar spine imaging in these settings is associated with a high risk of detecting incidental findings unrelated to the patient’s current symptoms and expose the patient to a surgical procedure with positive outcomes unlikely.

R-SCAN and Clinical Decision Support ACR Select® is a web-based version ACR Appropriateness Criteria, comprising over 3,000 clinical scenarios and 15,000 imaging indications ACR Select® provides evidence-based decision support for the appropriate utilization of medical imaging procedures R-SCAN participants gain free access to a customized, web-based version the ACR Select, an important first step for aligning ordering patterns with appropriate use criteria Standard template One of R-SCAN’s many free tools is the ACR Select CDS product, a digital version of the ACR Appropriateness Criteria Specifically, the team uses CDS to rate the value of exams ordered for one of R-SCAN’s Choosing Wisely topics before and after an educational program is carried out. All R-SCAN participants have free access to the web-based tool to explore the Appropriateness Criteria guidelines for other imaging topics. Consulting clinical decision support will be a requirement for the ordering of advanced imaging for Medicare patients starting in 2019, so R-SCAN provides a good way to check out this technology. 13

Getting Started With R-SCAN rscan.org Standard template To access ACR Select, visit the RSCAN site and click on “Start your project” 14

Standard template Log in with an ACR username/password If you don’t have an ACR username and password, the R-SCAN team can provide one. 15

Standard template Click on “Practice with ACR Select” 16

Standard template Check out the instructions for how to enter data and then click on the “Enter case data” button to explore the AC guidelines and exam ratings. 17

1 3 4 2 6 5 Standard template Here’s an example: Enter a patient’s age and gender Select the body area of interest Search on a clinical indication Select the indication that’s the best match Review the appropriateness score and note the associated cost and radiation exposure Select the exam. 5 6 18

R-SCAN Low Back Pain Educational Resources Visit: rscan.org Click: Resources Click: Topic-specific Resources Podcasts Imaging Order Simulation activity Articles Materials to share with patients Standard template Note: A library of educational materials is available for each R-SCAN Choosing Wisely topic. 19

R-SCAN Resources With CME Podcast A radiologist and referring physician discuss strategies of image ordering related to low back pain; approved for .5 CME Learn more Imaging Order Simulation Activity Test your knowledge in selecting the best imaging exam for low back pain with various indications Free with CME Standard template

Key Points: Talking With Patients Choosing Wisely: When Imaging Is Not Needed Imaging won’t help you feel better or improve faster Imaging is expensive, costing hundreds or thousands of dollars Imaging can also lead to unnecessary surgery and treatments X-rays and CT scans use radiation Customized Other important notes when speaking to patients: http://www.choosingwisely.org/patient-resources/imaging-tests-for-back-pain/

Case 1 45-year-old man with a past medical history of hypertension reports 3 weeks of nagging, low back pain Pain is: Dull, moderate Does not radiate Somewhat relieved by over counter analgesics Worse with long periods of sitting or standing Better when lying down Questions: What is your differential diagnosis? What other questions would you ask? What is the focus of your physical exam? Each template will include a few case examples.

Case 1 (continued) No reports of: Questions: Weight loss History of abdominal aortic aneurysm Neurological symptoms Fevers or chills Escalating pain Neurologic exam is completely normal Questions: Does this patient require imaging of the low back? Why or why not? Each template will include a few case examples.

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Summary Non-specific low back pain is common and usually self-limited Certain features of history and exam help distinguish back pain likely due to specific pathology Imaging is usually not indicated for patients with non-specific back pain Not only is imaging costly, but it can result in additional interventions Standard template, but content will be customized

Questions?