1. Advanced Imaging for Low Back Pain
When to Image Based on Choosing Wisely® and ACR Appropriateness Criteria®
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2. What Is R-SCAN?
Collaborative activity for referring clinicians and radiologists to improve patient care through clinical improvement
R-SCAN Collaboration Goals:
Ensure patients receive the most appropriate imaging exam at the most appropriate time based on evidence-based appropriate use criteria
Reduce unnecessary imaging tests focused on imaging Choosing Wisely® topics
Lower the cost of care
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Use this slide as a reminder / intro to what the program is about and its benefits.
Website is
For example, if your facility tends to order many CT exams for suspected pulmonary embolism, you might select that topic to ensure you’re ordering appropriately.
As far as a time commitment, staff time dedicated to an R-SCAN project ranges from 15 to 30 hours over a three- to six-month period.
You can also gain experience using a clinical decision support (CDS) tool; gaining experience with CDS now will help referring clinicians be prepared for the implementation of federal reimbursement requirements for CDS consultation prior to ordering advanced imaging. This alternative to pre-authorization reduces time and expense for practices and patients when imaging is the next step in the diagnostic process.

3. Why Participate? R-SCAN Offers:
Data-driven system for moving toward value-based imaging and patient care
Opportunity to focus on highly relevant imaging exams to improve utilization
Collaborators can fulfill their Improvement Activity requirements under the MIPS
Easy way to practice with clinical decision support (CDS) technology
In preparation for PAMA
Free and immediate access to Web-based tools and CME activities
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Participants earn improvement activity credits.
More here:
Information about Protecting Access to Medicare Act here:

4. Problem: Overutilization of Imaging for Low Back Pain
Most low back pain cases are self-limited and do not require imaging1
Numerous studies suggest that many radiographic, CT and MRI studies for low back are inappropriately ordered2,3
The problem statement will be in all templates, but customized for the specific topic.
More information on the issue here:
Davis, P.C., Wippold, F.J. II, Brunberg, J.A. et al. ACR Appropriateness Criteria on low back pain. J Am Coll Radiol. 2009; 6: 401–407.
Lehnert, B.E. and Bree, R.L. Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support? J Am Coll Radiol. 2010; 7: 192–197.
Emery, D.J., Shojania, K.G., Forster, A.J., Mojaverian, N., and Feasby, T.E. Overuse of magnetic resonance imaging. JAMA Intern Med. 2013; 173: 823–825. 

5. Using Evidence to Guide Imaging Ordering
Choosing Wisely campaign
Collaborative effort between ABIM Foundation and over 70 medical specialty societies
Helps patients and medical professionals avoid wasteful or unnecessary medical tests, treatments and procedures
Many medical associations agree that imaging is inappropriate for low back pain in many situations, including:
American College of Physicians
American College of Emergency Physicians
American Academy of Family Physicians
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Choosing Wisely includes 150 patient-friendly resources and more than 500 specialty societies provided recommendations.
Learn more:

6. Using Evidence to Guide Imaging Ordering
ACR Appropriateness Criteria®
Assist referring physicians and other providers in making the most appropriate imaging or treatment decisions for specific clinical conditions
Employs input of physicians from other medical specialties and societies to provide important clinical perspectives
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See next slide for more info on the AC 6

7. ACR Appropriateness Criteria: The Facts
178 clinical imaging topics
Over 875 clinical variants 
Basic access is free
Learn more at acr.org/ac
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New Appropriateness Criteria topics are added annually. 7

8. ACR Appropriateness Criteria for Low Back Pain
Clinical Scenario: Low Back Pain
Variant 1: Acute, subacute or chronic uncomplicated low back pain or radiculopathy. No red flags. No prior management. Variant 2: Acute, subacute or chronic uncomplicated low back pain or radiculopathy. One or more of the following: low velocity trauma, osteoporosis, elderly individual or chronic steroid use. Variant 3: Acute, subacute or chronic low back pain or radiculopathy. One or more of the following: suspicion of cancer, infection or immunosuppression. Variant 4: Acute, subacute or chronic low back pain or radiculopathy. Surgery or intervention candidate with persistent or progressive symptoms during or following 6 weeks of conservative management. Variant 5: Low back pain or radiculopathy. New or progressing symptoms or clinical findings with history of prior lumbar surgery. Variant 6: Low back pain with suspected cauda equina syndrome or rapidly progressive neurologic deficit.
The AC variants for the specific R-SCAN topic will be in all templates.
The major clinical indications – or “variants” are considered for each Appropriateness Criteria topic. Explain how AC works and what the variants are… 8

9. Appropriateness Criteria Rating by Value
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Exams associated with imaging for the individual clinical indications are rated according to their value as determined by the members of the Appropriateness Criteria panels. The panels use the following approach for determining the exams rating, or value:
1. The guideline authors conduct a systematic search of scientific literature, identify most relevant articles and develop initial ratings.
2. A larger panel reviews and carries out rating rounds.
3. Topics updated every 3 years, or more frequently where needed. 9

10. Alignment of Appropriateness Criteria and Choosing Wisely
An AC example for the specific R-SCAN topic will be in all templates.
All low back pain imaging variants and clinical scenarios: 10

11. When to Use Lumbar Spine Imaging
Red Flag Symptoms
Age >70
Unremitting (>6 weeks) or worsening pain
History of malignancy
Sensory disturbances
Weight loss
Weakness, numbness
History of abdominal aortic aneurysm
Radicular symptoms
Trauma
Pseudoclaudication
Fever or recent infection
Abnormal reflexes
Immunosuppression
New bowel or bladder dysfunction
Prior surgery
Abnormal sphincter tone
Prolonged corticosteroid use or known osteoporosis
When to do the imaging will be included in all templates, but content customized.
Order lumbar spine imaging when red flags are present

12. When Not to Image for Low Back Pain
Patients with “nonspecific” low back pain:
Acute (<6 weeks)
No historical features that suggest a particular underlying condition
No radicular symptoms or pseudoclaudication
Normal neurologic exam
When not to do the imaging will be included in all templates, but content customized.
Lumbar spine imaging in these settings is associated with a high risk of detecting incidental findings unrelated to the patient’s current symptoms and expose the patient to a surgical procedure with positive outcomes unlikely.

13. R-SCAN and Clinical Decision Support
ACR Select® is a web-based version ACR Appropriateness Criteria, comprising over 3,000 clinical scenarios and 15,000 imaging indications
ACR Select® provides evidence-based decision support for the appropriate utilization of medical imaging procedures
R-SCAN participants gain free access to a customized, web-based version the ACR Select, an important first step for aligning ordering patterns with appropriate use criteria
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One of R-SCAN’s many free tools is the ACR Select CDS product, a digital version of the ACR Appropriateness Criteria
Specifically, the team uses CDS to rate the value of exams ordered for one of R-SCAN’s Choosing Wisely topics before and after an educational program is carried out.
All R-SCAN participants have free access to the web-based tool to explore the Appropriateness Criteria guidelines for other imaging topics.
Consulting clinical decision support will be a requirement for the ordering of advanced imaging for Medicare patients starting in 2019, so R-SCAN provides a good way to check out this technology. 13

14. Getting Started With R-SCAN rscan.org Standard template
To access ACR Select, visit the RSCAN site and click on “Start your project” 14

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Log in with an ACR username/password
If you don’t have an ACR username and password, the R-SCAN team can provide one. 15

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Click on “Practice with ACR Select” 16

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Check out the instructions for how to enter data and then click on the “Enter case data” button to explore the AC guidelines and exam ratings. 17

18. 1 3 4 2 6 5 Standard template Here’s an example:
Enter a patient’s age and gender
Select the body area of interest
Search on a clinical indication
Select the indication that’s the best match
Review the appropriateness score and note the associated cost and radiation exposure
Select the exam. 5 6 18

19. R-SCAN Low Back Pain Educational Resources
Visit: rscan.org
Click: Resources
Click: Topic-specific Resources
Podcasts
Imaging Order Simulation activity
Articles
Materials to share with patients
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Note: A library of educational materials is available for each R-SCAN Choosing Wisely topic. 19

20. R-SCAN Resources With CME
Podcast
A radiologist and referring physician discuss strategies of image ordering related to low back pain; approved for .5 CME
Learn more
Imaging Order Simulation Activity
Test your knowledge in selecting the best imaging exam for low back pain with various indications
Free with CME
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21. Key Points: Talking With Patients
Choosing Wisely: When Imaging Is Not Needed
Imaging won’t help you feel better or improve faster
Imaging is expensive, costing hundreds or thousands of dollars
Imaging can also lead to unnecessary surgery and treatments
X-rays and CT scans use radiation
Customized
Other important notes when speaking to patients:

22. Case 1
45-year-old man with a past medical history of hypertension reports 3 weeks of nagging, low back pain
Pain is:
Dull, moderate
Does not radiate
Somewhat relieved by over counter analgesics
Worse with long periods of sitting or standing
Better when lying down
Questions:
What is your differential diagnosis?
What other questions would you ask?
What is the focus of your physical exam?
Each template will include a few case examples.

23. Case 1 (continued) No reports of: Questions:
Weight loss
History of abdominal aortic aneurysm
Neurological symptoms
Fevers or chills
Escalating pain
Neurologic exam is completely normal
Questions:
Does this patient require imaging of the low back?
Why or why not?
Each template will include a few case examples.

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26. Summary Non-specific low back pain is common and usually self-limited
Certain features of history and exam help distinguish back pain likely due to specific pathology
Imaging is usually not indicated for patients with non-specific back pain
Not only is imaging costly, but it can result in additional interventions
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27. Questions?