Use of Imaging Studies for Low Back Pain
Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.
National Committee for Quality Assurance
National Committee for Quality Assurance
National Quality Forum
Finalized Date/Time
Physician Performance Measure (Measures) and related data specifications were developed by the National Committee for Quality Assurance (NCQA).
The Measures are copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices). Commercial use is defined as the sale, licensing, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial use of the Measures requires a license agreement between the user and NCQA. NCQA is not responsible for any use of the Measures.
(c) 2008 -2014 National Committee for Quality Assurance. All Rights Reserved.
Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any CPT or other codes contained in the specifications.
CPT(R) contained in the Measure specifications is copyright 2004-2013 American Medical Association. LOINC(R) copyright 2004-2013 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2013 International Health Terminology Standards Development Organisation. ICD-10 copyright 2013 World Health Organization. All Rights Reserved.
None
None
None
Low back pain is a pervasive problem that affects three quarters of adults at some time in their lives (Chou, 2012). It ranks among the top ten reasons for patient visits to internists and is the most common and expensive reason for work disability in the U.S. Low back pain is second only to upper respiratory problems as a symptom-related reason for visits to a physician (Jarvik and Deyo 2002; U.S. Preventive Services Task Force 2004).
Each year in the United States low back pain is experienced by 25 to 50 percent of adults, making it one of the most common reasons for seeking health care services (Haldeman, 2008). Low back pain results in high indirect costs from disability, lost time from work, and decreased productivity while at work, and is the number one cause for activity limitations in younger adults (Chou, 2012). The costs associated with health care services for spine pain (primarily low back pain) in the U.S. increased from $45.9 billion in 1997 to $102.6 billion in 2004 (Martin, 2008).
American College of Physicians and the American Pain Society (Chou et al. 2007)
Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence).
Institute for Clinical Systems Improvement (2012)
Clinicians should not recommend imaging (including computed tomography [CT], magnetic resonance imaging [MRI] and x-ray) for patients with non-specific low back pain (Strong Recommendation, Moderate Quality Evidence).
•Low back pain assessment should include a subjective pain rating, functional status, patient history including notation of presence or absence of "red flags," psychosocial indicators, assessment of prior treatment and response, employment status, and clinician's objective assessment.
•Reduce or eliminate imaging for diagnosis of non-specific low back pain in patients 18 years and older.
•First-line treatment should emphasize patient education and a core treatment plan, that includes encouraging activity, use of heat, no imaging, cautious and responsible use of opioids, anti-inflammatory and analgesic over-the-counter medications and return to work assessment.
•Patients with acute or subacute low back pain should be advised to stay active and continue ordinary daily activity as tolerated.
•Use opioids cautiously and responsibly in the presence of acute or subacute low back pain.
U.S. Preventive Services Task Force (USPSTF) (2004)
The USPSTF concludes that the evidence is insufficient to recommend for or against the routine use of interventions to prevent low back pain in adults in primary care settings. (I recommendation)
Higher score indicates better quality
NQF ID Number
Disclaimer
These performance Measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications.
THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.
Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
eMeasure Identifier
166
measureStartDate
measureEndDate
Chou, R., A. Qaseem, V. Snow, D. Casey, J.T. Cross Jr., P. Shekelle, D.K. Owens, and the Clinical Efficacy Assessment Subcommittee of the American College of Physicians and the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel. 2007. “Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society.” Ann Intern Med 147(7):478-491.
Chou R, et al. Radiologic Clinics of North America. Appropriate Use of Lumbar Imaging for Evaluation of Low Back Pain. 2012 Jul, Vol. 50, No. 4: 569-85.
Haldeman S, Dagenais S. A supermarket approach to the evidence informed management of chronic low back pain. Spine J 2008;8: 1–7.
Institute for Clinical Systems Improvement. 2012. “Health Care Guideline: Adult Low Back Pain” Bloomington: Institute for Clinical Systems Improvement.
Jarvik, J.G., and R.A. Deyo. 2002. “Diagnostic evaluation of low back pain with emphasis on imaging.” Ann Intern Med 137:586-597.
Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA 2008;299: 656–64.
U.S. Preventive Services Task Force. 2004. “Primary care interventions to prevent low back pain in adults.” (February) http://www.uspreventiveservicestaskforce.org/uspstf/uspsback.htm
This measure applies to the first episode of low back pain during the measurement period.
The outpatient or emergency department visit in the Initial Patient Population needs to occur during the first 337 days of the measurement period (337 days allows 28 days for the numerator event). This visit must be the first visit for low back pain during the measurement period.
Transmission Format
TBD
Initial Patient Population
Patients 18-50 years of age with a diagnosis of low back pain during an outpatient or emergency department visit
Denominator
Equals Initial Patient Population
Denominator Exclusions
Exclude patients with a diagnosis of cancer any time in their history or patients with a diagnosis of recent trauma, IV drug abuse, or neurologic impairment during the 12-month period prior to the outpatient or emergency department visit.
Exclude patients with a diagnosis of low back pain within the 180 days prior to the outpatient or emergency department visit.
Numerator
Patients without an imaging study conducted on the date of the outpatient or emergency department visit or in the 28 days following the outpatient or emergency department visit
Numerator Exclusions
Not Applicable
Denominator Exceptions
None
Measure Population
Not Applicable
Measure Observations
Not Applicable
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex.
None
Population criteria
-
Initial Patient Population =
- AND: FIRST: "Occurrence A of Diagnosis, Active: Low Back Pain" starts during "Measurement Period"
- AND: "Patient Characteristic Birthdate: birth date" >= 18 year(s) starts before start of "Measurement Period"
- AND: "Patient Characteristic Birthdate: birth date" < 50 year(s) starts before start of "Measurement Period"
- AND:
- OR: "Occurrence A of Diagnosis, Active: Low Back Pain" starts during ("Encounter, Performed: Office Visit" <= 337 day(s) starts after start of "Measurement Period")
- OR: "Occurrence A of Diagnosis, Active: Low Back Pain" starts during ("Encounter, Performed: Emergency Department Visit" <= 337 day(s) starts after start of "Measurement Period")
- OR: "Occurrence A of Diagnosis, Active: Low Back Pain" starts during ("Encounter, Performed: Face-to-Face Interaction" <= 337 day(s) starts after start of "Measurement Period")
-
Denominator =
- AND: "Initial Patient Population"
-
Denominator Exclusions =
- AND:
- OR: "Diagnosis, Active: Low Back Pain" <= 180 day(s) starts before start of "Occurrence A of Diagnosis, Active: Low Back Pain"
- OR:
- OR: "Diagnosis, Active: All Cancer"
- OR: "Diagnosis, Inactive: All Cancer"
- OR: "Diagnosis, Resolved: All Cancer"
- starts before or during "Measurement Period"
- OR:
- OR: "Diagnosis, Active: Trauma"
- OR: "Diagnosis, Active: IV Drug Abuse"
- OR: "Diagnosis, Active: Neurologic impairment"
- <= 365 day(s) starts before or during "Measurement Period"
-
Numerator =
- AND NOT:
- OR: "Diagnostic Study, Performed: X-Ray of Lower Spine"
- OR: "Diagnostic Study, Performed: MRI of Lower Spine"
- OR: "Diagnostic Study, Performed: CT Scan of Lower Spine"
- <= 28 day(s) starts after start of "Occurrence A of Diagnosis, Active: Low Back Pain"
-
Denominator Exceptions =
- None
Occurrence A of Diagnosis, Active: Low Back Pain
Measurement Period
Patient Characteristic Birthdate: birth date
Measurement Period
Patient Characteristic Birthdate: birth date
Measurement Period
Occurrence A of Diagnosis, Active: Low Back Pain
Encounter, Performed: Office Visit
Measurement Period
Occurrence A of Diagnosis, Active: Low Back Pain
Encounter, Performed: Emergency Department Visit
Measurement Period
Occurrence A of Diagnosis, Active: Low Back Pain
Encounter, Performed: Face-to-Face Interaction
Measurement Period
Initial Patient Population
Initial Patient Population
Diagnosis, Active: Low Back Pain
Occurrence A of Diagnosis, Active: Low Back Pain
Diagnosis, Active: All Cancer
Diagnosis, Inactive: All Cancer
Diagnosis, Resolved: All Cancer
Measurement Period
Diagnosis, Active: Trauma
Diagnosis, Active: IV Drug Abuse
Diagnosis, Active: Neurologic impairment
Measurement Period
Denominator
Diagnostic Study, Performed: X-Ray of Lower Spine
Diagnostic Study, Performed: MRI of Lower Spine
Diagnostic Study, Performed: CT Scan of Lower Spine
Occurrence A of Diagnosis, Active: Low Back Pain
Data criteria (QDM Data Elements)
-
"Diagnosis, Active: All Cancer" using "All Cancer Grouping Value Set (2.16.840.1.113883.3.464.1003.108.12.1011)"
-
"Diagnosis, Active: IV Drug Abuse" using "IV Drug Abuse Grouping Value Set (2.16.840.1.113883.3.464.1003.106.12.1003)"
-
"Diagnosis, Active: Low Back Pain" using "Low Back Pain Grouping Value Set (2.16.840.1.113883.3.464.1003.113.12.1001)"
-
"Diagnosis, Active: Neurologic impairment" using "Neurologic impairment Grouping Value Set (2.16.840.1.113883.3.464.1003.114.12.1012)"
-
"Diagnosis, Active: Trauma" using "Trauma Grouping Value Set (2.16.840.1.113883.3.464.1003.113.12.1036)"
-
"Diagnosis, Inactive: All Cancer" using "All Cancer Grouping Value Set (2.16.840.1.113883.3.464.1003.108.12.1011)"
-
"Diagnosis, Resolved: All Cancer" using "All Cancer Grouping Value Set (2.16.840.1.113883.3.464.1003.108.12.1011)"
-
"Diagnostic Study, Performed: CT Scan of Lower Spine" using "CT Scan of Lower Spine Grouping Value Set (2.16.840.1.113883.3.464.1003.113.12.1035)"
-
"Diagnostic Study, Performed: MRI of Lower Spine" using "MRI of Lower Spine Grouping Value Set (2.16.840.1.113883.3.464.1003.113.12.1034)"
-
"Diagnostic Study, Performed: X-Ray of Lower Spine" using "X-Ray of Lower Spine Grouping Value Set (2.16.840.1.113883.3.464.1003.113.12.1033)"
-
"Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1010)"
-
"Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"
-
"Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"
-
"Patient Characteristic Birthdate: birth date" using "birth date LOINC Value Set (2.16.840.1.113883.3.560.100.4)"
Diagnosis, Active: All Cancer
Diagnosis, Inactive: All Cancer
Diagnosis, Resolved: All Cancer
Patient Characteristic Birthdate: birth date
Diagnostic Study, Performed: CT Scan of Lower Spine
Encounter, Performed: Emergency Department Visit
Encounter, Performed: Face-to-Face Interaction
Diagnosis, Active: IV Drug Abuse
Low Back Pain
Diagnostic Study, Performed: MRI of Lower Spine
Diagnosis, Active: Neurologic impairment
Encounter, Performed: Office Visit
Diagnosis, Active: Trauma
Diagnostic Study, Performed: X-Ray of Lower Spine
Diagnosis, Active: Low Back Pain
Reporting Stratification
- None
Supplemental Data Elements
-
"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity CDCREC Value Set (2.16.840.1.114222.4.11.837)"
-
"Patient Characteristic Payer: Payer" using "Payer SOP Value Set (2.16.840.1.114222.4.11.3591)"
-
"Patient Characteristic Race: Race" using "Race CDCREC Value Set (2.16.840.1.114222.4.11.836)"
-
"Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex AdministrativeSex Value Set (2.16.840.1.113762.1.4.1)"
Patient Characteristic Ethnicity: Ethnicity
Patient Characteristic Sex: ONC Administrative Sex
Patient Characteristic Payer: Payer
Patient Characteristic Race: Race