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Reducing Inappropriate Imaging Orders For Lower Back Pain Using MRI And CT Checklists: A Quality Improvement Study In Saskatchewan, Canada

Maryam Madani Larijani, Amir Azizian, Tracey Carr, Andreea Badea and Gary Groot

Purpose: The objectives of this quality improvement study were: a) to develop Checklists for healthcare professionals to improve appropriateness of lumbar spine imaging orders and referrals in concordance with Choosing Wisely recommendations and guidelines; and b) to trial the Checklists, assessing their impact on reducing inappropriate imaging orders in Saskatchewan, Canada.

Methods: A Clinical Development Team developed and adopted evidence-based lumbar spine magnetic resonance imaging (MRI) and computed tomography (CT) Checklists (quality improvement interventions) into the radiology requisition for both lumbar spine MRI and CT in Saskatchewan. Using a pre-post study design, data were obtained from the Radiology Information System (RIS). Control charts compared monthly number of imaging requests pre- and post-Checklists from June 2014 to August 2017.

Results: Results showed a 23% reduction in the monthly average number of MRI requisitions one year after implementation of the lumbar spine MRI Checklist. On average, monthly volumes of lumbar spine CT requests decreased by 27% after implementation of the lumbar spine CT Checklist.

Conclusions: Implementation of the two Checklists with evidence-based clinical indications and guidelines to order imaging may reduce volume of inappropriate urgent to elective MRI and CT requisitions for adult outpatients. Our results may help the design of other local and national quality improvement studies (e.g., appropriate ordering of knee MRI imaging), by replicating the integration of a Checklist into the ordering process to mitigate inappropriate imaging requests.