Imaging Wisely Campaign: Initiative to Reduce Imaging for Low Back Pain Across a Large Safety Net System

Objectives: Low back pain is a common clinical presentation that often results in expensive and unnecessary imaging that may lead to undue patient harm, including unnecessary procedures. We present an initiative in a safety net system to reduce imaging for low back pain. Methods: This quality improvement study was conducted across 70 ambulatory clinics and 11 teaching hospitals. Three electronic health record changes, using the concept of a nudge, were introduced into orders for lumbar radiography (x-ray), lumbar CT, and lumbar MRI. The primary outcome was the number of orders per 1,000 patient-days or encounters for each imaging test in the inpatient, ambulatory, and emergency department (ED) settings. Variation across facilities was assessed, along with selected indications. Results: Across all clinical environments, there were statistically significant decreases in level differences pre- and postintervention for lumbar x-ray (-52.9% for inpatient encounters, P < .001; -23.7% for ambulatory encounters, P < .001; and -17.3% for ED only encounters, P < .01). There was no decrease in ordering of lumbar CTs in the inpatient and ambulatory settings, although there was an increase in lumbar CTs in ED-only encounters. There was no difference in lumbar MRI ordering. Variation was seen across all hospitals and clinics. Discussion: Our intervention successfully decreased lumbar radiography across all clinical settings, with a reduction in lumbar CTs in the inpatient and ambulatory settings. There were no changes for lumbar MRI orders.