Reducing Unnecessary Use of High Technology Imaging in Patients

Susan M. Szpunar, Steven E. Minnick, Louis D. Saravolatz, Kenneth Bollin, Jesse Heard, Mary Chase, Gayle Blackmer



We conducted a Performance Improvement-Continuing Medical Education (PI-CME) project addressing the appropriate use of high-technology imaging in patients with low back pain.


The project followed the three stages of PI-CME.  Stage A consisted of a retrospective chart review of patients with low back pain seen at two Internal Medicine and two Family Medicine clinics from 7/1/2009-12/31/2009. Charts were reviewed for the presence of “red flags” (symptoms indicating a more severe back condition) and the imaging studies that were ordered. Stage B included an educational session, confidential physician progress reports, and an interactive patient tool. Stage C consisted of two periods of post-intervention chart review, presentation of post intervention findings to physicians, and physician reflection.


At baseline, only three of 157 patients presenting with zero red flags had a high-technology image ordered (1.9%).  Over 70% of patients with three or more red flags had no imaging ordered.  The findings suggested that once the information from the medical record was taken into account, instead of over-utilization, physicians may have been under-utilizing imaging.  At each follow-up period, there were zero patients with no red flags who had a high-technology image ordered. The percent of patients with three or more red flags with no imaging ordered decreased over the project interval from 72% to 5.7% (p<0.0001).

Conclusions:  PI-CME is an effective tool for addressing practice gaps.  It engages physicians in an active, personal learning journey. Reliance on billing data alone can lead to erroneous findings with respect to utilization of services or guideline adherence. 

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