The aim of the pilot study was to reduce the number of inappropriate lumbar spine x-rays being undertaken for patients with non-specific low back pain. It aimed to change the spinal pathway to ensure that the referral recommendations in the NICE guideline for the early management of low back pain in adults was being implemented for patients with non-specific low back pain.
As a consequence of implementing the change the aim was to ensure that the patient’s journey was effective, their management was timely and they were not being exposed to unnecessary radiation which would not change their management.
This example was originally submitted to demonstrate practice against NICE guideline CG88. The guideline has now been updated and replaced by NG59. The example has been reviewed and practice described remains consistent with the updated guideline.
Aims and objectives
Aim: To reduce the number of inappropriate lumbar spine x-rays being undertaken in the Princess of Wales Locality.
The purpose of the pilot study was to ensure that guidelines were being adhered too, ensuring a safe and efficient patient journey.
Reasons for implementing your project
An audit carried out in the Radiology department at the Princess of Wales Hospital highlighted inappropriate lumbar spine X-rays being undertaken for non-specific low back pain against recommendations of NICE guidelines (Low back pain in over 16's). The specific relevant recommendations in the updated guideline NG59 are recommendation 1.1.4 "Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica".
A total of 100 consecutive non trauma lumbar x-ray requests from Primary Care GPs were audited for a 3 month period . The audit found that 73% of X-rays undertaken were inappropriate. The average age of the patients who underwent the x-rays was 52.1.
The audit highlighted that patients were being exposed too unnecessary radiation and timing delays for appropriate management at an estimated financial cost to the Health board of £55,546. The audit highlighted that a change in the spinal pathway was required in - order to ensure that patients with non-specific low back pain were seen by the most appropriate professional in a timely manner. Avoiding exposing them to harmful unnecessary radiation at a cost to the Health board that did not change their management.
How did you implement the project
In order to put the NICE guidance into practice the following steps were undertaken:
The Radiology department in conjunction the MCAS team (Musculoskeletal Assessment Service) met with the Director of primary care and a lead GP for the Local Advisory committee to discuss the proposed pilot study.
Agreement was sought for change and for the pilot study to proceed. The group looked at the spinal pathway that was in place and made some modifications ensuring that those patients with non-specific low back pain were directed to the Physiotherapy Walk in service in the first instance rather than for imaging.
Any requests for x-rays made by GP’s were rejected and the radiology department sign posted the referrals directly to Physiotherapy for assessment and management. If more advanced assessment and imaging was required the patients were directed to the Musculoskeletal Assessment Service (MCAS) from Physiotherapy. A letter was formulated by the group and sent to all the GPs in the locality informing them of the pilot study with a copy of pathway for the management of mechanical low back pain. A representative from the MCAS team (Jane Griffiths) and the Radiology Department (Dr Dawn Howes) presented the pilot study to the local PT4l (GP meeting), the Physiotherapy MCAS and Radiology departments to inform staff of the pilot study.
Posters were produced to display in GP waiting rooms, physiotherapy and radiology departments to educate patients as to the reasoning not to x-ray the lumbar spine for non-specific low back pain. The main problem that we faced was that numerous GP’s were concerned that serious pathology would be missed. Re-assurances were given by Radiology and MCAS that this pathway was for those presenting with non-specific low back pain. It was also highlighted to the GP’s that x-rays requested for serious pathology are negatively reassuring as they often do not pick up sinister pathology until it is advanced. Urgent access to the MCAS service was offered to GP’s for patients they had concerns about. This section of the pathway is still currently being reviewed.
The pilot study was introduced on the 1st June 2015 for a 3 month period. The project incurred cost for the production of the posters (made in house and printed by project leads) and posting information to local GP’s. These costs were minimal and met by the radiology and MCAS teams.
Following the introduction of the pilot study a re-audit was undertaken to monitor any changes that occurred as a result of the introduction of the modified pathway. This showed that 91% of lumbar spine x-rays requested from primary care were appropriate as opposed to 18% during the time of the initial audit.
The average age of those having a lumbar spine x-ray increased to 69 and the overall number of lumbar spine x-rays requested drastically reduced.
By reducing the number of inappropriate x-rays carried out this ensured no harm was being done exposing patients to unnecessary radiation, patients were seen in a timely manner and their management was not delayed waiting for results of imaging which would not have influenced their treatment.
The reduction in imaging has led to a cost saving for the health board. The aim now is to feed back the information to the GP forums and other departments involved. We also hope to extend the project Health board wide. The results met our expectations as we were aware that best practice was not in place and that by making modifications to the spinal pathway patients journeys would be more efficient.
Key learning points
Based on our experience it’s advisable to meet with all relevant parties/stakeholders before the introduction of the change to ensure that everyone is on board with the implementation of the changes.
It is also advisable to do further work educating patients as to the negative effects of requesting imaging for non-specific low back pain and why the tests are not recommended.
Changing the beliefs and expectations of the patients would I feel be the most effective way of reducing unnecessary investigations.