Jacobs Josephine C, Jarvik Jeffrey G, Chou Roger, Boothroyd Derek, Lo Jeanie, Nevedal Andrea, Barnett Paul G
Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Menlo Park, CA, USA.
Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.
J Gen Intern Med. 2020 Dec;35(12):3605-3612. doi: 10.1007/s11606-020-06181-7. Epub 2020 Sep 28.
Contrary to guidelines, magnetic resonance imaging (MRI) is often ordered in the first 6 weeks of new episodes of uncomplicated non-specific low back pain.
To determine the downstream consequences of early imaging.
Retrospective matched cohort study using data from electronic health records of primary care clinics of the U.S. Department of Veterans Affairs.
Patients seeking primary care for non-specific low back pain without a red flag condition or an encounter for low back pain in the prior 6 months (N = 405,965).
MRI of the lumbar spine within 6 weeks of the initial primary care visit.
Covariates included patient demographics, health history in the prior year, and baseline pain. Outcomes were lumbar surgery, prescription opioid use, acute health care costs, and last pain score recorded within 1 year of the index visit.
Early MRI was associated with more back surgery (1.48% vs. 0.12% in episodes without early MRI), greater use of prescription opioids (35.1% vs. 28.6%), a higher final pain score (3.99 vs. 3.87), and greater acute care costs ($8082 vs. $5560), p < 0.001 for all comparisons.
Reliance on data gathered in normal clinical care and the potential for residual confounding despite the use of coarsened exact matching weights to adjust for baseline differences.
The association between early imaging and increased utilization was apparent even in a setting largely unaffected by incentives of fee-for-service care. Reduced imaging cost is only part of the motivation to improve adherence with guidelines for the use of MRI. Early scans are associated with excess surgery, higher costs for other care, and worse outcomes, including potential harms from prescription opioids.
与指南相悖的是，在新发无并发症的非特异性腰痛发作的前6周内，经常会安排磁共振成像（MRI）检查。
确定早期成像的下游后果。
采用美国退伍军人事务部初级保健诊所电子健康记录数据进行的回顾性匹配队列研究。
因非特异性腰痛寻求初级保健且无警示情况或在过去6个月内未曾因腰痛就诊的患者（N = 405,965）。
初次初级保健就诊后6周内进行腰椎MRI检查。
协变量包括患者人口统计学特征、前一年的健康史以及基线疼痛情况。结局指标为腰椎手术、处方阿片类药物使用情况、急性医疗费用以及在索引就诊后1年内记录的最后疼痛评分。
早期MRI检查与更多的背部手术相关（早期MRI检查的发作中为1.48%，无早期MRI检查的发作中为0.12%）、更多地使用处方阿片类药物（35.1%对28.6%）、更高的最终疼痛评分（3.99对3.87）以及更高的急性医疗费用（8082美元对5560美元），所有比较的p值均<0.001。
依赖于正常临床护理中收集的数据，尽管使用了粗化精确匹配权重来调整基线差异，但仍存在残余混杂的可能性。
即使在很大程度上不受按服务收费医疗激励影响的环境中，早期成像与利用率增加之间的关联也很明显。降低成像成本只是提高MRI使用指南依从性的部分动机。早期扫描与过度手术、其他护理的更高成本以及更差的结局相关，包括处方阿片类药物的潜在危害。
