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Family doctors ordered fewer imaging tests after changes to the physician fee schedule clarified that all tests for uncomplicated low back pain must be medically necessary


Changes to the Schedule of Benefits for Physician Services in 2012 clarified that imaging tests for uncomplicated low back pain must be medically necessary resulted in a change to family doctors’ ordering patterns for low back pain imaging, with little effect on specialists’ behavior, according to a new study from the Institute for Clinical Evaluative Sciences (ICES).

“We know that overuse of imaging tests adds to healthcare costs and exposes patients to unnecessary radiation with little benefit to patients. Guidelines in Canada, and around the world, have identified imaging for uncomplicated low back pain as a low value intervention that should not be performed unless there are concerning clinical features such as trauma, or a suspicion of infection or cancer,” says Dr. Ben Fine of the Department of Medical imaging at the University of Toronto and lead author of the study.

Dr. David Henry, co-author and adjunct scientist at ICES added “Overall, the restriction in coverage caused a larger decrease in the ordering practices of family practitioners than specialists and a larger and more sustained reduction in the use of lumbar spine X-rays and spine computed tomography (CT) than magnetic resonance imaging (MRI). It is important to understand that CT or MRI imaging of the back may lead to overdiagnosis, which means the detection of small abnormalities that are never going to harm the patient. Further investigation of these ‘incidentalomas’ may lead to complications, such as unnecessary surgery.”

In the study, published today in CMAJ Open, the researchers compared the numbers of x-ray, spine CT and single segment MRI studies ordered by family practitioners and specialists in the three years before and after the policy change in May 2012.

The researchers found:

  • In the first year after the policy change, there was a reduction of 28.7 per cent in the annual total number of lumbar X-rays, compared to the average ordered annually during the baseline period.
  • The numbers of lumbar spine X-ray and spine CT examinations ordered by family practitioners fell by 98,597 and 17,499 respectively in the year after the policy change.
  • The estimated costs to OHIP of lumbar spine X-rays fell from an annual average of $17 million between 2009/10 and 2011/12 to $12 million in the year after the policy restriction.

The researchers add that the most significant and most sustained effect of the policy change was the reduction in ordering of lumbar spine X-rays by family physicians. In contrast, the policy change had no measurable effect on ordering of X-rays spine CT and single segment MRI by specialists.

“Impact of restricting diagnostic imaging reimbursement for uncomplicated back pain in Ontario: a population-based interrupted time-series analysis,” was published today in CMAJ Open.

Author block: Benjamin Fine, Susan E. Schultz, Lawrence White and David Henry.

The Institute for Clinical Evaluative Sciences (ICES) is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy. For the latest ICES news, follow us on Twitter: @ICESOntario

The Department of Medical Imaging, University of Toronto, is the oldest academic imaging department in Canada and boasts over 200 faculty members, 60 residents and 90 fellows. It is affiliated with 17 hospital sites across Toronto. Departmental members are strongly committed to the academic imperatives of education and research and an agenda built around innovation, integration, impact, and an overall vision of improving health


Deborah Creatura
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