Clinical Decision Support Decreases Volume of Imaging for Low Back Pain in an Urban Emergency Department

Abstract

Purpose: To determine whether point-of-care clinical decision support can effectively reduce inappropriate medical imaging of patients who present to the emergency department (ED) with low-back pain (LBP).

Materials and methods: This was a prospective, single-center study of lumbar imaging referrals made by 43 emergency physicians at a major acute care center. Each physician saw at least 10 LBP cases in both pre- and post-intervention periods. A point-of-care checklist of accepted red flags for LBP was designed by a working group of physicians and embedded in the computerized order entry form for lumbar imaging. We compared imaging rates of LBP and physician variation in imaging ordering before and after the implementation of the checklist. We then measured the potential harms of reduced imaging.

Results: After intervention, the proportion of LBP patients with an imaging order fell significantly (median: 22% to 17%; mean: 23% to 18%; P = .0002) compared with pre-intervention baseline. The percentage of patients without imaging who were later imaged at a hospital outpatient clinic within 30 days was 2.3% before intervention and 2.2% after (P = .974). In addition, the proportion of patients discharged from the ED without imaging who returned to the ED within 30 days was 8.2% before intervention and 6.9% after (P = .170). One minor thoracic spine compression fracture was missed, but management was not impacted. No serious diagnoses were missed.

Conclusion: Clinical decision support integrated in electronic order entry forms can safely and effectively reduce imaging orders for LBP patients in the ED.

Keywords: Choosing Wisely; Low back pain; appropriateness; clinical decision support; diagnostic imaging; emergency department.