EHR nudge helps health system drop use of unnecessary lumbar X-rays by 53%

A simple nudge in the electronic health record has helped one New York hospital system cut the use of unnecessary X-ray imaging for lower back pain by 53% among inpatients.

Researchers with NYC Health + Hospitals detailed their quality improvement July 27 in the Journal of the American College of Radiology [1]. One previous study estimated that Medicare spends upward of $300 million on wasteful scans of the lumbar spine, which provide no benefit to the patient and can result in cascading diagnostics and treatments.

The organization’s System High Value Care Council led the charge, gathering input from radiology, internal and emergency medicine, quality, patient safety and informatics. Organizers keyed in on three specific exams—X-ray and noncontrast CT or MRI of the lumbar spine—for the quality improvement project.

“Our low-effort EHR intervention successfully reduced lumbar X-ray across all clinical settings in the largest safety net institution across the country,” Surafel Tsega, MD, senior director of informatics, and co-authors concluded. “We additionally reduced lumbar CTs in the inpatient and ambulatory settings. Variation in reduction was seen among individual sites. Future initiatives can expand on this model by offering a more robust analysis of the reduction in potentially unnecessary lumbar imaging.”

The EHR update involved three elements: (1) an advisory statement within the order title, advocating against routine imaging for low-back pain in the first six weeks, absent any red flags such as suspicion of cancer. (2) In addition, the advisory also appeared in the process instructions within the order. (3) NYC Health + Hospitals also replaced its original list of 24 appropriate imaging indications with a shorter one. The updated version was based on the American College of Radiology’s Imaging Wisely criteria, along with input from subject matter experts at the health system.

Tsega et al. analyzed data from the year leading up to the intervention’s implementation in June 2022, along with the 28 weeks that followed. The quality improvement initiative spanned across 70 different ambulatory clinics in New York, along with 11 teaching hospitals. Across all clinical environments, there were statistically significant drops in low-value back imaging. This included a 52.9% drop in the use of lumbar X-ray among inpatients, 23.7% for ambulatory encounters, and 17.3% in the emergency department. However, there was no statistically significant decrease in the ordering of lumbar CT and MRI exams on the inpatient or ambulatory side, and use of computed tomography for back pain actually increased in the ED.

Experts noted much higher baseline ordering rates for X-ray, which may have impacted the results.

“We speculate that, prior to our intervention, clinicians may have considered X-rays low cost, less harmful and easier to obtain compared to CTs or MRIs,” the authors wrote. “This may have resulted in excessive use of X-rays as a first-line evaluation for back pain. This instance of supply-sensitive overuse (utilization of healthcare resources based on availability more than medical necessity), may have created greater opportunities in reducing potentially unnecessary imaging for X-rays, as compared to CT or MRI.”