Now that winter has arrived, low back pain diagnoses may appear more often as patients can potentially injure themselves shoveling or from slips and falls on ice and snow. Clinical evidence indicates that in the absence of red flags (see exclusions below), diagnostic imaging (plain X-ray, MRI, CT scan) is not necessary for most cases of new-onset back pain1. BCBSRI utilizes the Clinical Guidelines for the Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guidelines from the American College of Physicians and the American Pain Society. The full guideline is available on the Annals of Internal Medicine website at www.annals.org/cgi/reprint/147/7/478.pdf and contains additional guidance for diagnosis and treatment. We track performance in this area using the HEDIS measure "Use of Imaging Studies in Low Back Pain (LBP)," which examines the percentage of members 18-50 years old with a primary diagnosis of new onset low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis2. The table below summarizes the HEDIS measure, population, and tips for improving performance.

Measure

Population: Numerator and Denominator

Tips for success

Use of Imaging Studies for Low Back Pain (LBP)

Numerator: Members from the denominator who had an imaging study with a diagnosis of low back pain and no exclusions.

Exclusions: HIV, spinal infection, organ transplant other than kidney transplant, cancer, trauma, neurologic impairment, prolonged use of corticosteroids, or IV drug abuse.

1. Avoid ordering diagnostic studies in the first six weeks of new onset back pain in the absence of red flags (e.g., cancer, recent trauma, neurologic impairment, or IV drug abuse).
2. Encourage conservative treatment (pain management, activity modification, physical therapy) for new onset low back pain without red flags. Remind patients that uncomplicated low back pain is typically a benign, self-limited condition, and that the majority of patients resume their usual activities in 30 days.
3. Use correct exclusion codes where necessary (e.g., code for cancer or other secondary diagnoses if these are why you are ordering the studies).

Denominator: Members 18-50 years old with a principal diagnosis of low back pain at either an outpatient or an emergency room visit.