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Reducing Low-Value Imaging for Low Back Pain: Systematic Review With Meta-analysis.

OBJECTIVE
To examine the effectiveness of implementing interventions to improve guideline-recommended imaging referrals in low back pain.


DESIGN
Systematic review with meta-analysis.


LITERATURE SEARCH
We searched MEDLINE, EMBASE, CINAHL, Web of Science Core Collection and CENTRAL from inception until June 14, 2021, Google Scholar, and reference lists of relevant systematic reviews published in the last 10 years. We conducted forward and backwards citation tracking.


STUDY SELECTION CRITERIA
Randomised controlled/clinical trials in adults with low back pain to improve imaging referrals.


DATA SYNTHESIS
Bias was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool. Data were synthesised using narrative synthesis and random effects meta-analysis (Hartung-Knapp-Sidik-Jonkman method). We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.


RESULTS
Of 2719 identified records, eight trials were included, with six studies eligible for meta-analysis (participants: N=170460). All trials incorporated clinician education; four included audit/feedback components. Comparators were no-intervention control and passive dissemination of guidelines. Five trials were rated as low risk of bias and two as having some concerns. There was low-certainty evidence of no effect of implementing interventions to improve guideline-recommended imaging referrals (odds ratio [95% CI]: 0.87 [0.72, 1.05], I2=0%; studies: n=6). The main finding was robust to sensitivity analyses.


CONCLUSION
We found low-certainty evidence that interventions to reduce imaging referral or use in low back pain had no effect. Education interventions are unlikely to be effective. Organisational and policy level interventions are more likely to be effective. J Orthop Sports Phys Ther, Epub 5 Feb 2022. doi:10.2519/jospt.2022.10731.