Effect of Electronic Clinical Decision Support on Imaging for the Evaluation of Acute Low Back Pain in the Ambulatory Care Setting

World Neurosurg. 2020 Feb;134:e874-e877. doi: 10.1016/j.wneu.2019.11.031. Epub 2019 Nov 13.


Objectives: To assess the effectiveness of a clinical decision support tool consisting of an electronic medical record best practice alert (BPA) on the frequency of lumbar imaging in patients with acute low back pain in the ambulatory care setting, and to explore why providers order imaging outside of clinical guidelines.

Methods: On March 23, 2016, we implemented a BPA pop-up alert that informed the ordering physician of the Choosing Wisely recommendation to not order imaging within the first 6 weeks of low back pain in the absence of red flags. We calculated imaging rates 1 year before and after implementation of the BPA. To override the BPA, providers could ignore the alert or explain their rationale for ordering imaging using either preset options or a free-text submission. We tracked preset options and manually reviewed 125 free-text submissions.

Results: Significant decreases in both total imaging rate (9.6% decrease; P = 0.02) and magnetic resonance imaging rate (14.9% decrease; P < 0.01) were observed after implementation of the BPA. No change was found in the rates of X-ray or computed tomography scan orders. Almost two-thirds (64%) of the providers used preset options in overriding the BPA, and 36% of the providers entered a free-text submission. Among those providers using a free-text submission, 56% entered a non-guideline-supported rationale.

Conclusions: The present study demonstrates the effectiveness of a simple, low-cost clinical decision support tool in reducing imaging rates for patients with acute low back pain. We also identify reasons why providers order imaging outside of clinical guidelines.

Keywords: Best practice alert; CT; Inappropriate imaging; Low back pain; MRI; X-ray.

MeSH terms

  • Acute Pain / diagnostic imaging*
  • Adolescent
  • Adult
  • Aged
  • Ambulatory Care
  • Decision Support Systems, Clinical*
  • Electronic Health Records
  • Female
  • Guideline Adherence
  • Humans
  • Low Back Pain / diagnostic imaging*
  • Magnetic Resonance Imaging / economics
  • Magnetic Resonance Imaging / statistics & numerical data*
  • Male
  • Middle Aged
  • Practice Guidelines as Topic
  • Practice Patterns, Physicians'
  • Radiography / economics
  • Radiography / statistics & numerical data
  • Tomography, X-Ray Computed / economics
  • Tomography, X-Ray Computed / statistics & numerical data*
  • Young Adult