• Jeffrey G Jarvik, Bryan A Comstock, Kathryn T James, Andrew L Avins, Brian W Bresnahan, Richard A Deyo, Patrick H Luetmer, Janna L Friedly, Eric N Meier, Daniel C Cherkin, Laura S Gold, Sean D Rundell, Safwan S Halabi, David F Kallmes, Katherine W Tan, Judith A Turner, Larry G Kessler, Danielle C Lavallee, Kari A Stephens, and Patrick J Heagerty.
• Department of Radiology, University of Washington, USA; Department of Neurological Surgery, University of Washington, USA; Department of Health Services, University of Washington, USA; Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, USA. Electronic address: jarvikj@uw.edu.
• Contemp Clin Trials. 2015 Nov 1; 45 (Pt B): 157-163.

BackgroundDiagnostic imaging is often the first step in evaluating patients with back pain and likely functions as a "gateway" to a subsequent cascade of interventions. However, lumbar spine imaging frequently reveals incidental findings among normal, pain-free individuals suggesting that treatment of these "abnormalities" may not be warranted. Our prior work suggested that inserting the prevalence of imaging findings in patients without back pain into spine imaging reports may reduce subsequent interventions. We are now conducting a pragmatic cluster randomized clinical trial to test the hypothesis that inserting this prevalence data into lumbar spine imaging reports for studies ordered by primary care providers will reduce subsequent spine-related interventions.Methods/DesignWe are using a stepped wedge design that sequentially randomizes 100 primary care clinics at four health systems to receive either standard lumbar spine imaging reports, or reports containing prevalence data for common imaging findings in patients without back pain. We capture all outcomes passively through the electronic medical record. Our primary outcome is spine-related intervention intensity based on Relative Value Units (RVUs) during the following year. Secondary outcomes include subsequent prescriptions for opioid analgesics and cross-sectional lumbar spine re-imaging.DiscussionIf our study shows that adding prevalence data to spine imaging reports decreases subsequent back-related RVUs, this intervention could be easily generalized and applied to other kinds of testing, as well as other conditions where incidental findings may be common. Our study also serves as a model for cluster randomized trials that are minimal risk and highly pragmatic.Copyright © 2015 Elsevier Inc. All rights reserved.

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