Watchful waiting to reduce low-value spinal imaging: randomized clinical trial

Context: Acute back pain is a common reason for primary care visits and often results in low-value spinal imaging.

Objective: To determine the effect of a standardized patient-delivered intervention on low-value imaging among primary care patients with acute low back pain.

Study Design: Randomized clinical trial (NCT 04255199).

Setting: 10 primary care clinics in Sacramento, CA.

Population: Primary care clinicians were randomized 1:1 to intervention or control (n=53 clinicians).

Intervention: From 5/2021 to 3/2022, intervention clinicians received 3 simulated office visits with standardized patient instructors (SPIs) portraying patients with acute uncomplicated back pain. SPI instruction was guided by a 3-step model: 1) set the stage for deferred imaging by building trust, 2) convey empathy, and 3) communicate optimism while advocating watchful waiting without imaging. Control clinicians received no intervention.

Outcome measures: The primary outcome, assessed over 18 months of follow-up, was lumbar spinal imaging completion within 90 days of acute low back pain visits. Secondary outcomes were: cervical spine imaging completion after acute neck pain visits; any imaging completion after an adult visit; percent of adult patients with “top-box” patient experience ratings; and use of targeted communication skills during audio-recorded SP evaluation visits at 9-12 months.

Results: After adjustment for pre-randomization rates, intervention and control clinicians had similar rates of ordering lumbar imaging for patients with acute back pain during follow-up [15.7% vs. 17.3%; adjusted ratio of post- vs pre-period odds ratios (aOR 1.00, 95% CI: 0.72-1.40)]. Adjusted follow-up period rates of imaging for acute neck pain and overall imaging were not significantly different in intervention and control clinicians. Intervention and control clinicians had similar percentages of adult visits with “top-box” patient experience ratings during follow-up [88.4% vs. 88.8%; adjusted pre-post difference-in-difference: -1.3% (-3.3%, 0.6%)]. During audio-recorded SP visits, intervention clinicians had significantly better ratings than controls on eliciting the patient’s perspective [adjusted standardized difference (aSD): 0.42 (0.03-0.81)] and conveying empathy [aSD 0.85 (0.40-1.30)].

Conclusions: A simulated office visit intervention encouraging a watchful waiting approach to spinal imaging did not affect low-value imaging rates during follow-up or patient experience ratings.