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Understanding overuse of diagnostic imaging for patients with low back pain in the Emergency Department: a qualitative study
  1. Johan Blokzijl1,2,3,
  2. Rachael H Dodd3,4,
  3. Tessa Copp3,4,
  4. Sweekriti Sharma2,3,
  5. Elise Tcharkhedian5,
  6. Christiane Klinner2,
  7. Chris G Maher2,3,
  8. Adrian C Traeger2,3
  1. 1 Physical Therapy Sciences, Program in Clinical Health Sciences, University Medical Centre Utrecht Brain Centre, Utrecht, Netherlands
  2. 2 Institute for Musculoskeletal Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
  3. 3 Wiser Healthcare, Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
  4. 4 Sydney Health Literacy Lab, Sydney School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
  5. 5 Liverpool Hospital, Liverpool, New South Wales, Australia
  1. Correspondence to Dr Adrian C Traeger, School of Public Health, The University of Sydney, Sydney, NSW 2050, Australia; adrian.traeger{at}sydney.edu.au

Abstract

Background Overuse of lumbar imaging in the Emergency Department is a well-recognised healthcare challenge. Studies to date have not provided robust evidence that available interventions can reduce overuse. For an intervention aimed at reducing imaging to be effective, insight into how both patients and clinicians view lumbar imaging tests is essential.

Aim To explore factors that might influence overuse of lumbar imaging in the Emergency Department.

Methods Participants were recruited from three hospitals in Sydney, Australia between April and August 2019. We conducted focus groups and/or interviews with 14 patients and 12 clinicians. Sessions were audio-recorded and transcribed verbatim. Data were analysed using framework analysis by a team of four researchers with diverse backgrounds.

Results Patients described feeling that the decision about lumbar imaging was made by their Emergency Department clinician and reported little involvement in the decision-making process. Other potential drivers of lumbar imaging overuse from the patients’ perspective were strong expectations for lumbar imaging, a reluctance to delay receiving a diagnosis, and requirements from third parties (eg, insurance companies) to have imaging. Emergency Department clinicians suggested that the absence of an ongoing therapeutic relationship, and the inability to manage perceived patient pressure could drive overuse of lumbar imaging. Suggested protective factors included: involving patients in the decision, ensuring clinicians have the ability to explain the reasons to avoid imaging and collaborative approaches to care both within the Emergency Department and with primary care.

Conclusion and key findings We found several factors that could contribute to overuse of lumbar imaging in the Emergency Department. Solutions to overuse of lumbar imaging in the Emergency Department could include: (1) strategies to involve patients in decisions about imaging; (2) training and support to provide thorough and well explained clinical assessment for low back pain; and (3) systems that support collaborative approaches to care.

  • imaging
  • musculo-skeletal
  • emergency department
  • qualitative research
  • quality improvement

Data availability statement

No data are available. No data are available as it is not possible to fully anonymise the qualitative data.

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Data availability statement

No data are available. No data are available as it is not possible to fully anonymise the qualitative data.

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Footnotes

  • Handling editor Margaret Samuels-Kalow

  • Twitter @JohanBlokzijl1, @RachaelHDodd, @TessaCopp, @SweekritiSharma, @CGMMaher, @adrian_traeger

  • Contributors ACT, CK and CGM conceived and designed the study, and obtained research funding. ACT and CGM supervised the conduct of the study and data collection. ACT, SS, CK, ET contributed to data collection. JB, ACT, RHD and TC contributed to the analysis and interpretation of the data. JB drafted the manuscript, and all authors contributed substantially to its revision. ACT takes responsibility for the paper as a whole.

  • Funding This work was supported by a National Health and Medical Research Council Programme Grant APP1113532 and a Kickstart Grant from The University of Sydney. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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