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Two common low-value services are related to acute low back pain. Choosing Wisely advises avoiding the use of imaging during the first 6 weeks of low back pain (per the American Academy of Family Physicians and other organizations). Similarly, Choosing Wisely advises avoiding opioids in the treatment of low back pain until other alternatives have been attempted (per the North American Spine Society). Together, overutilization of these two services (imaging and opioids for low back pain) costs more than $500 annually, not including downstream costs, and is a source of patient harm. In the state of Virginia, the Virginia Center for Health Innovation has identified the two back pain measures as priority for reducing as part of their 3-year intervention (Smarter Care Virginia): https://www.vahealthinnovation.org/scv/

As a participant in Smarter Care Virginia (SCV), Carilion receives data showing each Carilion Clinic clinician's performance on SCV measures, including the two back pain measures. For example, Carilion receives a database that lists the clinician's name, department, number of appropriate orders for each SCV measure made and the number of low-value orders for each SCV measure made. Carilion (and the other 7 participating health systems) are asked to use this information to generate quality improvement initiatives. We have designed a quality improvement initiative focused on family and community medicine clinicians and the two back pain measures.

First, we will use the most recent data provided by the SCV project (2020 and Q1-Q2 of 2021) to rank FCM practices and clinicians by utilization of low-value back pain services, their waste index, and impact score. We will identify from this ranking the top 5 to 10 performing practices and the bottom 5 to 10 performing practices. If there are any outlier clinicians who are bottom performing (ie: provide the most low-value services or have the highest impact score) but who do not fall among the bottom performing practices, we will consider including their practice among the bottom 5 to 10.

We will survey clinicians in top and bottom performing practices to learn more about their knowledge, perceptions, and practice workflow related to the two back pain measures. They will also be asked about their trust in data measures. No identifying information will be collected from clinicians in the survey.

From what we learn from survey data, we will design up to four brief education points to be communicated during regular practice quality improvement meetings with population health managers.

Prior to the delivery of quality improvement education about back pain measures, we will obtain an EMR report for the top and bottom performing practices showing utilization rate of both back pain measures. We will also conduct a chart review (Epic) to identify indication for provision of the back pain services that could not be detected in claims data or Epic data. This addresses a common concern of clinicians - that clinical nuance is not being detected and low value care is being over-assigned. The Epic reports and chart reviews will continue monthly for the first 3 months and then at months 6 and 12.

Inclusion Criteria:

Current primary care clinician in a top or bottom performing practice

Exclusion Criteria:

<90 days of tenure in current position

Primary care clinicians (physicians, PAs, NPs)

No individual data will be shared.