Effort to stop primary care providers from ordering low-value imaging hits brick wall

An effort to stop primary care providers from ordering unnecessary imaging exams has hit a brick wall, with the project failing to break through. 

Researchers with the University of California, Davis, detailed their randomized clinical trial in JAMA Network Open Wednesday. Acute lower back pain is a common reason for visiting a PCP, with these encounters often leading to spine imaging that offers little diagnostic value. 

Family physician Joshua J. Fenton, MD, and colleagues experimented with having an instructor conduct a fake patient encounter with PCPs. During the visit, they delivered feedback and guidance to docs while pretending to be a patient with acute uncomplicated back pain. 

But the encounter appeared to have little impact on low-value imaging order rates or patient experience ratings, signaling that education alone is insufficient to address this problem. 

“Although the intervention was rated highly by clinicians and was associated with more empathic communication during an announced follow-up standardized patient visit, the findings indicate that educational interventions emphasizing clinician communication are unlikely to reduce rates of low-value spinal imaging among primary care clinicians,” Fenton, with the UC Davis Center for Healthcare Policy and Research, and co-authors wrote Nov. 6. 

The study recruited a total of 53 physicians and advanced-practice providers across 10 adult primary or urgent care facilities in Sacramento. Clinicians were randomized 1:1 to experience the intervention or serve as the control. Those in the former cohort received three fake office visits from a standardized patient instructor, posing as a patient with acute uncomplicated back pain. At each encounter, instructors provided clinician feedback guided by a three-step model:

1. Set the stage for deferred imaging by building trust. 
2. Convey empathy. 
3. Communicate optimism while advocating for “watchful waiting” without any imaging. 

Researchers then tracked clinicians for 18 months of follow-up. A total of 25 clinicians were in the intervention group and 28 more served as the control, receiving no visits from instructors. Patients in the intervention group experienced similar rates of lumbar imaging (16%) to those who served as controls (17%). Adjusted follow-up rates of imaging for acute neck pain and overall imaging were not significantly different among either group, the authors noted. Clinicians also had similar patient experience ratings. However, providers in the intervention group had significantly better ratings related to eliciting the patient’s perspective and conveying empathy. 

While the intervention failed, the randomized study potentially “provides important insights to inform future strategies for reducing low-value care,” physicians wrote in a corresponding editorial. 

“Whereas previous interventions to de-implement unnecessary tests and treatments have focused on passive patient or clinician education, the innovative intervention design of utilizing standardized patients to deliver the educational intervention represents a potentially more active, engaging approach,” Nicole M. Mott, MD with the Center for Clinical Management Research, VA Ann Arbor Healthcare System in Michigan, and colleagues wrote Nov. 6. “Furthermore, this method simulates actual conversations between patients and clinicians about forgoing unnecessary care, which is ultimately the goal of the Choosing Wisely campaign.”

They believe the results underscore the need for additional tools beyond education to reduce low-value imaging. What those might be, however, is unclear. They noted that success in cutting low-value care has been “underwhelming” up to this point. 

“Slow progress may be due to how difficult it is to change the patient and clinician behaviors that result in low-value care,” the editorialists added. “The entrenched nature of many types of low-value care highlights the need for more novel, potent, and multifaceted approaches to reduce such services.”