INTRODUCTION
METHODS
Study Design and Setting
Data Collection
Data Analysis
RESULTS
Primary care providers (n = 55) | High-guideline concordance (n = 22) | Low-guideline concordance (n = 33) |
---|---|---|
Provider type, no. (%) | ||
Physician | 19 (86) | 16 (49) |
Nurse practitioner | 3 (14) | 15 (45) |
Physician assistant | 0 (0) | 2 (6) |
Facility type, No. (%) | ||
VA medical center | 8 (36) | 11 (33) |
Community-based outpatient clinic | 14 (64) | 22 (64) |
Gender, No. (%) | ||
Female | 12 (55) | 20 (61) |
VA regional service networks* | 11 of 18 | 17 of 18 |
High-guideline-concordant PCPs | Low-guideline-concordant PCPs | |
---|---|---|
Environmental factors | ||
Radiology review | When I order MRIs, the head of radiology calls me to justify it. He wants to automatically cancel it because of the cost. It's frustrating having them canceled by people who have never laid eyes on the patient. To get MRIs approved, I have to show they've done physical therapy, used pain relief, used muscle relaxers. (NP*, CBOC†, #2058) | Before working in VA, I ordered MRI as nurse practitioner, the radiologist had to approve it. Here sometimes they don’t. Maybe if they got more involved in discussing the MRIs [with us] that would be helpful. (NP, CBOC, #3135) |
Patient travel burden management | In community clinics, some services are not readily available. You have to work around them, like X-rays and labs. You have to base your diagnosis mainly on clinical [exam] on the first visit. (MD‡, CBOC, #2003) | We had pushback [from radiology] because they felt [LS-MRI and X-ray] shouldn’t be ordered together. We helped them recognize we have patients driving five hours for an X-ray. As Veterans have complained enough, they’ve recognized it won’t hurt to do two services at once. (NP, CBOC, #4030) |
Time constraints | We are limited in our time as primary care providers. Finding time to educate patients, for some providers that opportunity is lost because we feel overwhelmed. I try to take time and my patients appreciate that. It makes me feel better at the job I’m doing. Sometimes you have to say, “We’re not able to address other issues.” (MD, CBOC, #6071) | We’re pressed for time, it’s a six-minute walk-in visit, pinched nerve, pain going down leg, I need to know what’s going on and may not have time to elaborate, sometimes it’s easier to order the test. (MD, VAMC§, #3032) |
Specialty care requirements | I worked for Department of Defense and we rarely ordered MRIs. It was usually ordered by the anesthesiologist or physiatrist. Here [at VA], it’s completely flipped on its head and it’s done by primary care doctors. (MD, VAMC, #6045) | I inherited patients on narcotics, so when I talk to them about physical therapy, chiropractic treatment, and epidural injections, a lot of them haven't had that. When I'm referring to pain management for epidural injection, you have to order MRI. I ordered a lot because I was getting people off pain meds and treatment they needed. (MD, CBOC, #3089) |
Patient factors | ||
Pressures provider | There is a mindset that every back injury requires an MRI for diagnostic purposes. Patients sometimes pressure providers to request an MRI. (MD*, CBOC, #6192) | [A patient says,] “Look at what they’re getting on the outside. People are getting their backs cured. Why can’t you give me an MRI?” (MD, VAMC, #2039) |
Value of imaging | Let's say a patient did not get physical therapy but says, "I know my body. My son had it and physical therapy did not help. I'm not doing physical therapy because I don't see how they can treat somebody when they don't know what the problem is. I want an MRI.” (MD, CBOC, #6055) | A lot of them are not satisfied with a spine X-ray because they want to know is there something that’s hidden that would be revealed with an MRI. (NP, CBOC, #3022) |
Provider factors | ||
Guideline (un)familiarity | We don’t want to stop imaging completely, but we try to image appropriately. I run our lecture series here, and we go over the evidence and then we see what we can do to help patients [with] the tools that we have at VA. (MD, VAMC, #6103) | No, I don’t [rely on guidelines], but when my utilization review nurse says, “You haven’t met this protocol or exhausted other means,” then I’ll stop. I need to be refreshed on the protocol. When you get used to practicing a certain way, you’re like, “do I need it, do I don’t? I’m going to try it and if it goes through, fine. If it doesn’t, then somebody will stop me.” (NP, VAMC, #3047) |
Guideline (dis)agreement | I like clinical practice guidelines. It would be good to educate our patients. I think 80 percent of people in their lifetime will have low-back pain and it will resolve within a certain amount of time. (NP, CBOC, #2058) | There’s no criteria for military services and back pain. Our Veterans are unique when it comes to low-back pain. Whether they’re 20 or over 80, even though it may look like no big deal, it could always be something. (NP, CBOC, #4030) |
Acquiescing to patients | A guy wanted an MRI now. I said, “What have you done to get better?” He had done nothing. I said, “If you’re an NFL quarterback who sustained a big hit, they might do an acute MRI right now. For the rest of us, that’s not the guideline.” I share evidence-based stuff with them. Generally, guys are agreeable. (MD, CBOC, #6158) | From the patient’s perspective, they are paranoid there’s something missing until we do the MRI. We tell them there is nothing that can be surgically corrected. They want that final step. I don’t know if you listen to the patients or you listen to the guidelines, but if you’re trying to help the patient, that’s who we have to follow, not the guidelines. (MD, CBOC, #3113) |
Value of imaging | If there are no red-flags, no reason to think that I need to send this patient on for some intervention, I’m not ordering an MRI. I’m only ordering if there are some red-flag symptoms and I’m going to send them to a neurosurgeon. I look at MRI as a preliminary workup for some invasive procedure. An orthopedic surgeon once told me, “Why draw a map if you’re not ready to take the trip?” (MD, VAMC, #2077) | If there’s been trauma involved, even though there’s no red-flags, I think it’s worthwhile. Sometimes their complaints are vague, or you’re not sure if it’s something else, so there’s value in that. (NP, CBOC, #3015) |