• Institute for Clinical Systems Improvement (ICSI). Adult low back pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2008 Nov. 66 p. [105 references]

Does not apply to this measure

This measure is used to assess the percentage of patients with a diagnosis of back pain for whom the physician ordered imaging studies during the six weeks after pain onset, in the absence of "red flag."

The priority aim addressed by this measure is to reduce unnecessary imaging in adult patients with low back pain in the absence of "red flag" indicators or progressive symptoms.

Acute low back pain; x-ray (anterior-posterior [AP], lateral [LAT]); computed tomography (CT) scan; magnetic resonance imaging (MRI); "red flag" indicators (see the "Denominator Inclusions/Exclusions" field in the Complete Summary)

Number of patients with acute low back pain who present to clinic with low back pain six weeks or less from onset of pain without "red flag" indicators (see the related "Denominator Inclusions/Exclusions" field in the Complete Summary)

Number of patients with acute low back pain or sciatica receiving imaging studies: anterior-posterior (AP) or lateral (LAT) x-rays, computed tomography (CT) scan, or magnetic resonance imaging (MRI)

• A clinical practice guideline or other peer-reviewed synthesis of the clinical evidence

Unspecified

Current routine use

Internal quality improvement

Physician Group Practices/Clinics

Physicians

Group Clinical Practices

Age greater than or equal to 18 years

Either male or female

Unspecified

Unspecified

Unspecified

Unspecified

Unspecified

Unspecified

Getting Better

Effectiveness

Users of care only

Adult patients age 18 and over in primary care who have symptoms of acute low back pain or sciatica

Identify patients with acute low back pain using diagnosis codes (see the "Denominator Inclusions/Exclusions" field). Patients should be included if the onset of symptoms was six weeks or less.

The medical record of each patient is reviewed to determine if the patient meets any of the "red flag" indicators (see the "Denominator Inclusions/Exclusions" field). If none of the "red flag" indicators is present, the chart is further reviewed for use of anterior-posterior (AP) or lateral (LAT) x-ray, computed tomography (CT) scan, or magnetic resonance imaging (MRI).

The suggested time period for data collection is a calendar month.

Patients associated with provider

Inclusions
Number of patients with acute low back pain who present to clinic with low back pain* six weeks or less from onset of pain without "red flag" indicators**

*Patients who are within six weeks of onset of low back pain and related symptoms, as identified by the following International Classification of Diseases, Ninth Revision (ICD-9) codes: 720.x, 721.x, 722.x, 724.xx, 847.2, 738.4, 738.5, 738.6, 846.x, 847.2, 847.2, 847.3, 847.4, 847.9.

**Magnetic resonance imaging (MRI) and computed tomography (CT) generally are not useful in the early evaluation and treatment of low back pain or sciatica unless the patient has major or progressive neurological symptoms, or there is a suspicion of cancer or infection.

Generally anterior-posterior (AP) or lateral (LAT) x-rays are not useful in the acute setting but may be warranted with:

• Unrelenting night pain or pain at rest (increased incidence of clinically significant pathology)
• History of or suspicion of cancer (rule out metastatic disease)
• Fever above 38 degrees C (100.4 degrees F) for greater than 48 hours
• Osteoporosis
• Other systemic diseases
• Neuromotor or sensory deficit
• Chronic oral steroids
• Immunosuppression
• Serious accident or injury (fall from heights, blunt trauma, motor vehicle accident) - this does not include twisting or lifting injury unless other risk factors are present (e.g., history of osteoporosis)
• Clinical suspicion of ankylosing spondylitis

Other conditions that may warrant AP or LAT x-rays:

• Over 50 years old (increased risk of malignancy, compression fracture)
• Failure to respond after six weeks of conservative therapy
• Drug or alcohol abuse (increased incidence of osteomyelitis, trauma, fracture)

Exclusions
See "Inclusions" above.

All cases in the denominator are equally eligible to appear in the numerator

Clinical Condition
Encounter

Time window is a single point in time

Inclusions
Number of patients with acute low back pain or sciatica receiving imaging studies: anterior-posterior (AP) or lateral (LAT) x-rays, computed tomography (CT) scan, or magnetic resonance imaging (MRI)

Exclusions
Unspecified

The measure results are somewhat or substantially under the control of the health care professionals, organizations and/or policymakers to whom the measure applies.

Encounter or point in time

Administrative data
Medical record

Individual Case

Unspecified

Rate

Better quality is associated with a lower score

Unspecified

Internal time comparison

Unspecified

Percentage of patients with a diagnosis of back pain for whom the physician ordered imaging studies during the six weeks after pain onset, in the absence of "red flag."

Institute for Clinical Systems Improvement

The following Minnesota health plans provide direct financial support: Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica, Metropolitan Health Plan, PreferredOne and UCare Minnesota. In-kind support is provided by the Institute for Clinical Systems Improvement's (ICSI) members.

Work Group Members: David C. Thorson, MD (Work Group Leader) (Family HealthServices Minnesota) (Sports Medicine); Jeff Bonsell, DC (HealthPartners Medical Group) (Chiropractic Medicine); Suzanne Hecht, MD (University of Minnesota Physicians) (Family Practice); Becky Mueller, DO (CentraCare) (Family Practice); Robb Campbell, MD, MPH (3M) (Occupational Medicine); Michael Goertz, MD, MPH (Park Nicollet Health Services) (Occupational Medicine); Ola Kuku, MD, MPH (Allina Medical Clinic) (Occupational Medicine); Glenn Buttermann, MD (Midwest Spine Institute) (Orthopedic Surgery); Adam Locketz, MD (Midwest Spine Institute) (Physical Medicine and Rehabilitation); Randy Shelerud, MD (Mayo Clinic) (Physical Medicine and Rehabilitation); Richard Timming, MD(HealthPartners Medical Group) (Physical Medicine and Rehabilitation); Andrew Vo, MD (Marshfield Clinic) (Physical Medicine and Rehabilitation); Chris Kramer, PT (Park Nicollet Health Services) (Physcial Therapy); Steve Peterson, PT (Orthopaedic Sports, Inc.) (Physical Therapy); Thomas Gilbert, MD (Center for Diagnostic Imaging) (Radiology); Janet Jorgenson-Rathke, PT (Institute for Clinical Systems Improvement) (Facilitator); Pam Pietruszewski, MA (Institute for Clinical Systems Improvement) (Facilitator)

Measure was not adapted from another source.

2003 Sep

2008 Nov

This is the current release of the measure.

This measure updates a previous version: Institute for Clinical Systems Improvement (ICSI). Adult low back pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2006 Sep. 65 p.

• Institute for Clinical Systems Improvement (ICSI). Adult low back pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2008 Nov. 66 p. [105 references]

This NQMC summary was completed by ECRI on May 4, 2004. This NQMC summary was updated by ECRI Institute on October 14, 2004, November 3, 2005, December 6, 2006, and again on February 19, 2009.

This NQMC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Measure) is based on the original measure, which is subject to the measure developer's copyright restrictions.

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