Brain and Spine Imaging: High Value Care CME/MOC for Primary Care Providers

From the 2019 HVPAA National Conference

Dr. Maura McGuire (Johns Hopkins School of Medicine), Dr. Pamela Johnson (Johns Hopkins Department of Radiology)


Low back pain (LBP) is the 5th most common diagnosis reported in ambulatory care visits, and more than 90% of US adults experience LBP at some time. Evaluation, treatment, and disability costs of LBP exceed $100 billion in the US annually. More than 50% of advanced imaging ordered for low back pain is medically unnecessary.

Headaches are common and the majority are due to tension or chronic migraine, which do not require imaging and can be diagnosed clinically. The yield of positive studies in patients with isolated, non-traumatic headache is 0.4%. More than half of imaging is unnecessary, costs >$1 billion annually.


To improve ordering primary care physician appropriateness with targeted online modules.


A collaborative team of radiology faculty and residents and primary care physicians created e-learning modules for low back pain and headache. The modules were case-based with immediate feedback and included pre-test and post-tests (10 questions) with Level 1 assessment.

These were assigned to 168 Primary Care Providers in JHCP (Internal Medicine, Family Medicine, Med-Peds, with completion incentivized by CME credit & MOC points.

Outcomes measures included completion rates , knowledge & attitudes and imaging order volume.


  • Completion Rates: 92% (brain); 87% (low back pain)
  • Knowledge: Average score knowledge assessment: 87% (brain); 92% (low back pain)
  • Attitudes: Order imaging less frequently: 78% (brain); 80% (low back pain)

Imaging utilization before & after education, for providers who completed/passed modules (Pre-Intervention: August 1 to December 31, 2017; Post-Intervention: August 1 to December 31, 2018)

  • 13% reduction in brain imaging
    • 1745 total studies before vs. 1516 studies after
    • Brain MRI wo (465 pre vs 375 post; 17% reduction, P<0.05
    • Brain CT w/wo (66 pre vs 40 post; 39%, P<0.05
  • 13% reduction in back imaging (MRI LS spine w/wo; LS spine wo)
    • 848 pre/741 post; P>0.05
  • 3.6% reduction in visits for the study group comparing control and intervention periods.


Focused case-based e-learning modules can effectively impart information on high-value imaging for headache and low back pain. Provider knowledge (% correct) and attitudes ( I will order less often) improved after the e-learning, and most providers would recommend the modules to others. This e-learning was associated with reductions in orders for the targeted studies. More work is needed to validate preliminary findings, verify that appropriate ordering was not adversely affected and assess knowledge retention.


What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

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