Do chiropractors adhere to guidelines for back radiographs?: A study of chiropractic teaching clinics in Canada

back_pain.jpg   From the October 15, 2007 issue of Spine [subscription required]:

Ammendolia CD, Cote PD, Hogg-Johnson SP, Bombardier CM. Do chiropractors adhere to guidelines for back radiographs?: A study of chiropractic teaching clinics in CanadaSpine 2007; 32(22):2509-2514.

Key Points
* There is high adherence to radiography guidelines for a new episode of low back pain among chiropractic teaching clinics.
* There is low radiography use rate for this patient population in this setting.
* There is a high red flag rate among patients with low back pain attending chiropractic teaching clinics

Study Design: Clinical cohort.
Objectives: To measure the adherence to 3 radiography guidelines for low back pain in chiropractic teaching clinics.
Summary of Background Data: Evidence-based guidelines for low back pain suggest that plain radiography should be restricted to patients with suspected serious disease. Among primary healthcare providers who can request radiographs, chiropractors are thought to have utilization rates that exceed what is recommended by practice guidelines. It is uncertain whether this gap between evidence and practice begins in undergraduate training.
Methods: We screened 1241 consecutive patients with a new episode of low back pain who presented to any of the 6 out-patient teaching clinics of the Canadian Memorial Chiropractic College between January 2004 and September 2004. We collected information about red flags and radiography recommendations from patients and chiropractic trainees using self-administered questionnaires. Radiography recommendations were compared with criteria used in 3 radiography guidelines. Adherence was measured as the proportion of patients without red flags who were not recommended for radiography.
Results: Of the 503 eligible patients, 448 (89.1%) agreed to participate in the study. Radiography was recommended for 12.3% of patients. According to the selected radiography guidelines, the proportion of patients with red flags ranged from 45.3% to 70.5%. The proportion of patients without red flags who were not recommended for radiography ranged from 89.4% (95% confidence interval, 85.5%-93.2%) to 94.7% (95% confidence interval, 90.9%-98.5%) for the selected guidelines.
Conclusions: The results suggest a strong adherence to radiography guidelines for patients with a new episode of low back pain who presented to chiropractic teaching clinics. Although a high proportion of patients had red flags, radiography utilization was lower than rates reported in previous studies suggesting that adherence to guidelines may help prevent unnecessary radiography.

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