Effect of Clinical Decision Support-Generated Report Cards Versus Real-Time Alerts on Primary Care Provider Guideline Adherence for Low Back Pain Outpatient Lumbar Spine MRI Orders.

OBJECTIVE. The purpose of this study is to determine whether the type of feedback on evidence-based guideline adherence influences adult primary care provider (PCP) lumbar spine (LS) MRI orders for low back pain (LBP). MATERIALS AND METHODS. Four types of guideline adherence feedback were tested on eight tertiary health care system outpatient PCP practices: no feedback during baseline (March 1, 2012October 4, 2012), randomization by practice to either clinical decision support (CDS)generated report cards comparing providers to peers only or real-time CDS alerts at order entry during intervention 1 (February 6, 2013December 31, 2013), and both feedback types for all practices during intervention 2 (January 14, 2014June 20, 2014, and September 4, 2014January 21, 2015). International Classification of Disease codes identified LBP visits (excluding Medicare fee-for-service). The primary outcome of the likelihood of LS MRI order being made on the day of or 130 days after the outpatient LBP visit was adjusted by feedback type (none, report cards only, real-time alerts only, or both); patient age, sex, race, and insurance status; and provider sex and experience. RESULTS. Half of PCPs (54/108) remained for all three periods, conducting 9394 of 107,938 (8.7%) outpatient LBP visits. The proportion of LBP visits increased over the course of the study (p = 0.0001). In multilevel hierarchic regression, report cards resulted in a lower likelihood of LS MRI orders made the day of and 130 days after the visit versus baseline: 38% (p = 0.009) and 37% (p = 0.006) for report cards alone, and 27% (p = 0.020) and 27% (p = 0.016) with alerts, respectively. Real-time alerts alone did not affect MRI orders made the day of (p = 0.585) or 130 days after (p = 0.650) the visit. No patient or provider variables were associated with LS MRI orders being generated on the day of or 130 days after the LBP visit. CONCLUSION. CDS-generated evidence-based report cards can substantially reduce outpatient PCP LS MRI orders on the day of and 130 days after the LBP visit. Real-time CDS alerts do not.