Inappropriate ordering of lumbar spine magnetic resonance imaging: are providers Choosing Wisely?

Objectives: To analyze inappropriate use of magnetic resonance imaging (MRI) for patients with low back pain in a healthcare system with no financial incentives for overuse.

Study Design: We used administrative data to assess the appropriateness of lumbar spine (LS) MRI in the Veterans Health Administration.

Methods: All veterans who received LS MRI in the outpatient setting in fiscal year 2012 were included. We based our assessments of appropriateness on CMS criteria, which have been endorsed by the National Quality Forum. Generalized estimating equations were used to evaluate characteristics of inappropriate scans.

Results: Of the 110,661 LS MRIs performed, 31% were classified as inappropriate. Most scans that were considered appropriate were characterized as such because they were preceded by conservative therapy (53%). "Red flag" conditions were responsible for a much smaller percentage of scans being considered appropriate; 13% of scans were preceded by conservative therapy and were performed in patients with a red flag condition, while only 4% of scans were considered appropriate because of red flag conditions only. Scans ordered in the emergency department and in 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 LS MRIs (odds ratio, 0.80; P < .0001). Approximately 24% of providers ordered 74% of inappropriate scans.

Conclusions: We found that 31% of LS MRIs were inappropriate in a healthcare system largely absent of financial and other incentives for ordering. The problem of inappropriate ordering of LS MRI is concentrated in a small number of providers; any provider-facing interventions to reduce inappropriate order should therefore be targeted, rather than aimed at all providers who order LS MRI.