Evidence-based guidelines for advanced diagnostic imaging: Prediction and assessment of costs and utilization among Washington State workers with low back pain

Background: While utilization of advanced diagnostic imaging has been increasing rapidly over the last decade, increased use of expensive technologies may contribute to higher costs without concomitant improvements in health outcomes. In order to address concerns of increasing health care costs, the Washington State Department of Labor and Industries (DLI) will institute a policy in 2010 that will require adherence to evidence-based guidelines for advanced diagnostic imaging use for workers' compensation patients. These guidelines apply to MRI for low back pain (LBP), a condition that accounts for up to a third of workers' compensation costs. Clinical practice guidelines for acute LBP maintain that routine imaging is not necessary during the first month of symptoms for non-medically emergent patients, yet many LPB patients still receive early MRI. Recent research suggests that early MRI is associated with increased treatment and expenditures (but not improved outcome). Washington State's new policy requiring evidence-based guidelines for advanced imaging aims to limit expenditures associated with early MRI use, given that such use is not associated with improved outcomes.

Methods: Decision-modeling methods were used to conduct a cost-minimization analysis of the 2010 policy change using available data from the DLI, national rates, and randomized controlled trials. Estimated expenditures under the guidelines were compared to expenditures in 2009. Analysis was conducted from the perspective of DLI and sensitivity analyses assessed the influence of various factors. Administrative data on expenditures from DLI will be collected prospectively for six months in 2010 and compared to modeled expenditures.

Results: Modeling suggests that limiting utilization of MRIs within the first six weeks of patients' symptoms was estimated to be cost-saving, decreasing expenditures on a relative basis by 44%. The expected rate of lumbar surgeries after implementing the early MRI guideline is estimated to decrease by 2%. Prospectively collected data from 2010 for comparison are forthcoming and will be compared to these estimates.

Conclusion: This study suggests that employment of evidence-based guidelines for advanced imaging management with utilization review, restricting early MRI use, would be cost-saving for the DLI. Its implementation may result in a reduction in health care expenditures among Washington workers' with LBP. These data will be compared to observed costs in the first six months of 2010.