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Glenn Pransky Director, Center for Disability Research,

Liberty Mutual Research Institute Associate Professor, Univ of MA Medical School

Inappropriate MRI for LBP – Causes, Consequences

and Prevention

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Today

Who gets early MRI for LBP and why

Some MRI’s are not a good idea

Consequences of inappropriate, early MRI

Preventing these iatrogenic effects

Many thanks to my colleagues Barbara Webster, YoonSun Choi, Manuel Cifuentes and Ann Bauer who created and led important investigations

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Disclosure

Employee of Liberty Mutual Research Institute

No financial interest

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• Center for Injury Epidemiology • Center for Physical Ergonomics • Center for Behavioral Sciences • Center for Disability Research

Liberty Mutual Research Institute for Safety generating knowledge to help people live safer and more secure lives

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Spinal Magnetic Resonance Imaging (MRI)

No radiation exposure- safer than x-ray Shows more anatomic information - soft

tissues including disc, ligaments, and spinal canal contents

Technologically appealing to patients and physicians

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But MRI for LBP is problematic

Often finds ‘abnormalities’ that are not likely to be significant or alter treatment

Focuses patients and providers on ineffective, invasive treatment

Expensive

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MRI abnormalities of uncertain clinical significance

Abnormalities found in 20-57% of asymptomatic subjects (Jarvik and Deyo)

54% disc bulge, 59% DDD, 21% disc herniation in < 60yo asymptomatic men (Boden, 1990)

MRIs monitored over time show that progression of degenerative changes not associated with LBP history over time (Boos et al, Jarvik et al, Waris et al)

And those with degenerative changes are at no greater risk for long-term problems

Chronic LBP patients have similar pain and function at 12 mo regardless of DDD, bulges, high-intensity zone, or end plate changes (Kleinstruck, Spine 2006)

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Study on MRI to reassure LBP patients

246 pts, ALBP or radiculopathy All had MRI < 48hrs; randomized to receive results

soon, or delayed > 6 weeks Conservative Rx (6 weeks) – no early surgical cases Clinical outcome, self-efficacy, function at 6 weeks

was similar for unblinded and blinded patients. General health of the blinded group improved more

than for the unblinded group (P = .008) Concluded that early MRI does NOT reassure

patients or providers

Ash LM, Modic MT, Obuchowski NA et al, 2008

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Early lumbar MRI – iatrogenic impacts

Misinterpretation of findings by the patient leads to disease perception and assumption that symptoms reflect structural problem

(Kilo and Larson; Abenhaim et al)

Requests for more intensive interventions or delay in initiation of functional restoration program (Fordyce; Roland and van Tulder)

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Evidence-based guidelines for acute LBP

“In the absence of “red flags”, MRI should be reserved for patients with significant radicular pain, persisting (not significantly improving) after one month of conservative management, and who are candidates for surgery or epidural steroid injection” (Chou et al. 2007; Hegmann 2008; Koes et al. 2001)

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Red flags

Malignancy, infection, trauma Risk factors – IV drug use, diabetes,

immunosuppression Fever, weight loss, bony tenderness High ESR, low hematocrit Cauda equina syndrome Represent less than 0.5% of all acute LBP

cases in workers X-ray a better initial approach with

most red flags?

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What are the iatrogenic consequences in WC?

National sample of LM WC claims, to determine the impact of inappropriate (guideline – noncompliant) early MRI

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Methods

Selection criteria (N = 3213 cases)

New 2006 LBP claims, no claim in prior year No concurrent conditions in first 15 days post-

onset ≥1 day paid lost time in first 10 days post-onset

Exposure Early MRI (≤28 days) Timely MRI (>28 days – 6 mo.) No MRI Analysis:

Propensity grouping; Cox regression and generalized linear regression models

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Severity Measures

Early opioid use (yes/no first 15 days and amount)

Maximum severity before MRI (based on ICD-9 codes)

Average weekly medical costs pre-MRI Time on disability pre-MRI

(days to first MRI)

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Results (Webster, Bauer, Choi et al, Spine, 2013)

Early MRI utilization was quite high overall (21.7%), 18.2% of them had repeat MRI Females less likely to get early MRI

MRI done on average second week post-onset NO red flag indication for early-MRI (cauda

equina syndrome, cancer, fracture, infection) 22.0% of early-MRI cases underwent surgery

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Results – Time on disability Daily proportion of cases on disability by propensity/MRI subgroup

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0.1

0.2

0.3

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0.7

0.8

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0 100 200 300 400 500 600 700 800

Days of Disability Post Lumbar MRI

Surv

ival

Dis

trib

utio

n Fu

nctio

n

High Prop - Early MRI

Low Prop - Early MRI

High Prop - No MRI

Low prop - No MRI

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Results – going off disability Cox Proportional Model for Rate of RTW Post-MRI

MRI Group P value RTW Rate 95% CL*

No MRI (Low propensity) <0.0001 3.0 2.6, 3.4

No MRI (High propensity) <0.0001 2.9 2.3, 3.5

Early MRI (High propensity) 0.0943 1.2 1.0, 1.4

Early MRI (Low propensity) 1.0 * CL = Confidence Limit Controlled for: age, gender, job tenure, pre-MRI medical costs and disability, days to first MRI, early opioid use and MEA dose, maximum severity pre-MRI, and state.

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Results – Medical utilization Generalized Multivariate Regression Model Comparing Post-MRI

Medical Expenditures

MRI Group

P value

Difference (US$)

95% CL*

No MRI (Low propensity) <0.0001 -13578 -16630, -10526

No MRI (High propensity) <0.0001 -16549 -23874, -9223

Early MRI (High propensity) 0.206 -5010 3961, -12773

Early MRI (Low propensity) 0.00 * CL = Confidence Limit Controlled for: age, gender, job tenure, pre-MRI medical costs and disability, days to first MRI, early opioid use and MEA dose, maximum severity pre-MRI, and state.

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Results – surgery Generalized Multivariate Regression Model Examining the Risk to

Undergo Surgery Post-MRI

MRI Group

P value

Risk ratio

95% CL*

No MRI (Low propensity) <0.0001 0.03 0.01, 0.05

No MRI (High propensity) <0.0001 0.1 0.05, 0.20

Early MRI (High propensity) 0.1776 0.8 0.53, 1.12

Early MRI (Low propensity) 1.0

* CL = Confidence Limit Controlled for: age, gender, job tenure, pre-MRI medical costs and disability, days to first MRI, early opioid use and MEA dose, maximum severity pre-MRI, and state.

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Summary (Webster et al, JOEM, 2010)

Ordering MRIs prematurely resulted in: prolonged disability increased total medical costs higher risk for surgery

Much greater iatrogenic impact than early opioids or other factors (severity or demographics)

Increased medical utilization suggested ‘cascade’ effect of services

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“Cascade” – 6 months post-MRI

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%Epidurals

Other Injections

EMG / NCV

Advanced Imaging

Surgery

Fusion

No MRI, Nonspecific LBP (N = 1546)

No MRI, Radiculopathy (N = 271)

Early MRI, Nonspecific LBP (N = 458)

Early MRI, Radiculopathy (N = 324)

Timely MRI, Nonspecific LBP (N = 214)

Timely MRI, Radiculopathy (N = 209)

Webster, Choi,Bauer et al, Spine, 2014

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Geographic variation in inappropriate MRI use?

Individual predictors - age, gender, job tenure, and industry

State-level predictors - economic factors, physician supply and practice variables, workers compensation system features, and access to MRI testing Generalized linear mixed models - evaluate

within and between state variability Compared 6 highest and 6 lowest MRI

utilization states

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Early MRI by state and severity

Low rate states High rate states

State CA CT HI MA NH VT AR FL GA NC PA TX All

Low severity % with early MRI 9.8 11.9 4.2 13.8 13.4 2.2 53.3 46.8 39.1 41.3 42.1 32.5 21.5

High severity % with early MRI 40.7 40.7 17.4 35.7 31.3 20.8

69.0 77.0 62.3 62.9 64.6 66.2 52.5

Overall % early MRI 14.9 17.6 6.8 20.1 17.4 6.0 58.4 57.6 46.4 47.2 48.6 47.4 29.7

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Results

Higher state rates of early MRI explained by: Rate of non-hospital MRI sites Lower state median income Accounted for 84% of between-state variation Mostly in low severity cases

12.5% of all observed variability Individual and other state predictors - non-

significant at state level (but higher severity dx. did predict individual utilization)

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X-ray vs early MRI for acute LBP

↑consults (73% vs 49%) ↑surgery (6% vs 2%) ↑cost but equivalent 12 month

symptoms, function, satisfaction Jarvik JAMA 2003

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Diagnostic and treatment trends for LBP

Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off?

J Am Board Fam Med. 2009; 22(1): 62–68

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How can we address this problem?

Improved MRI results reporting Patient education and communication Physician education and selection

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Results

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Patient communication

Analogous to requests for opioids in LBP? Qualitative study of how patients responded to

similar physician decisions about discontinuing opioids (Matthias MS, Krebs EE, Bergman AA, EJP, 2014)

- Some patients attributed limiting or denying opioids to physicians' distrust or lack of caring

- Others attributed these limitations to acting out of genuine concern for patients' health

Outcome DIRECTLY related to physician – patient communication and relationship as described by patients

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Pt. education – Natural History of LBP (thanks to Mike Erdil)

Spontaneous recovery in 40-50% in 1-2 weeks, 80-90% 6 weeks, 13% continued LBP 6 mo (Quebec Spine 1987, AHCPR 1994, Mehling Spine 2012)

Rapid recovery 6 weeks acute LBP followed by plateau, low levels pain and disability 1 yr (Menezes CMAJ 2012)

Recurrence 20-80%, 54% by 6 mo, but most function with it (Mehling Spine 2012)

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Physician education and selection

Evidence for academic detailing is moderate at best

High-use physicians – highly aberrant practices compared to usual care

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Conclusion

Common and increasing problem Multiple drivers – patient requests, tech

focus, economic drivers Significant negative consequences, esp

in WC Multifaceted approach needed for

prevention Occupational health experts can lead

the charge

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Questions?