Effect of Clinical Decision Support-Generated Report Cards Versus Real-Time Alerts on Primary Care Provider Guideline Adherence for Low Back Pain Outpatient Lumbar Spine MRI Orders

AJR Am J Roentgenol. 2019 Feb;212(2):386-394. doi: 10.2214/AJR.18.19780. Epub 2018 Nov 26.


Objective: The purpose of this study is to determine whether the type of feedback on evidence-based guideline adherence influences adult primary care provider (PCP) lumbar spine (LS) MRI orders for low back pain (LBP).

Materials and methods: Four types of guideline adherence feedback were tested on eight tertiary health care system outpatient PCP practices: no feedback during baseline (March 1, 2012-October 4, 2012), randomization by practice to either clinical decision support (CDS)-generated report cards comparing providers to peers only or real-time CDS alerts at order entry during intervention 1 (February 6, 2013-December 31, 2013), and both feedback types for all practices during intervention 2 (January 14, 2014-June 20, 2014, and September 4, 2014-January 21, 2015). International Classification of Disease codes identified LBP visits (excluding Medicare fee-for-service). The primary outcome of the likelihood of LS MRI order being made on the day of or 1-30 days after the outpatient LBP visit was adjusted by feedback type (none, report cards only, real-time alerts only, or both); patient age, sex, race, and insurance status; and provider sex and experience.

Results: Half of PCPs (54/108) remained for all three periods, conducting 9394 of 107,938 (8.7%) outpatient LBP visits. The proportion of LBP visits increased over the course of the study (p = 0.0001). In multilevel hierarchic regression, report cards resulted in a lower likelihood of LS MRI orders made the day of and 1-30 days after the visit versus baseline: 38% (p = 0.009) and 37% (p = 0.006) for report cards alone, and 27% (p = 0.020) and 27% (p = 0.016) with alerts, respectively. Real-time alerts alone did not affect MRI orders made the day of (p = 0.585) or 1-30 days after (p = 0.650) the visit. No patient or provider variables were associated with LS MRI orders being generated on the day of or 1-30 days after the LBP visit.

Conclusion: CDS-generated evidence-based report cards can substantially reduce outpatient PCP LS MRI orders on the day of and 1-30 days after the LBP visit. Real-time CDS alerts do not.

Keywords: clinical decision support; evidence-based guideline adherence feedback; low back pain; lumbar spine MRI.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Ambulatory Care*
  • Clinical Decision-Making / methods*
  • Computer Systems
  • Decision Support Systems, Clinical*
  • Feedback
  • Female
  • Guideline Adherence / statistics & numerical data*
  • Humans
  • Low Back Pain / diagnostic imaging*
  • Magnetic Resonance Imaging / statistics & numerical data*
  • Male
  • Middle Aged
  • Practice Patterns, Physicians' / statistics & numerical data*
  • Prescriptions / statistics & numerical data*
  • Primary Health Care*
  • Spine / diagnostic imaging*