Clinical StudyImpact of imaging guidelines on X-ray use among American provider network chiropractors: interrupted time series analysis

Background contextOveruse and misuse of spine X-ray imaging for nonspecific back and neck pain persists among chiropractors. Distribution of educational materials among physicians results in small-to-modest improvements in appropriate care, such as ordering spine X-ray studies, but little is known about its impact among North American chiropractors.PurposeTo evaluate the impact of web-based dissemination of a diagnostic imaging guideline on the use of spine X-ray images among chiropractors.Study design/settingQuasi-experimental design that used interrupted time series to evaluate the effect of guidelines dissemination on spine X-ray imaging claims by chiropractors enlisted in managed care network in the United States.Patient sampleConsecutive adult patients consulting for complaints of spine disorders.Outcome measuresA change in level (the mean number of spine X-ray imaging claims per month immediately after the introduction of the guidelines), change in trend (any differences between preintervention and postintervention slopes), estimation of monthly average intervention effect after the intervention.MethodsThe imaging guideline was disseminated online in April 2008. Administrative claims data were extracted between January 2006 and December 2010. Segmented regression analysis with autoregressive error was used to estimate the impact of guideline recommendations on the rate of spine X-ray studies. Sensitivity analysis considered the effect of two additional quality improvement strategies, a policy change and an education intervention.ResultsTime series analysis revealed a significant change in the level of spine X-ray study ordering weeks after introduction of the guidelines (−0.01; 95% confidence interval=−0.01, -0.002; p=.01), but no change in trend of the regression lines. The monthly mean rate of spine X-ray studies within 5 days of initial visit per new patient exams decreased by 10 per 1000, a 5.26% relative decrease after guideline dissemination. Controlling for two quality improvement strategies did not change the results.ConclusionsWeb-based guideline dissemination was associated with an immediate reduction in spine X-ray imaging claims. Sensitivity analysis suggests our results are robust. This passive strategy is likely cost-effective in a chiropractic network setting.