Description:The percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis


Denominator:

Product line
Commercial, Medicaid (report each product line separately).
Ages
18 years as of January 1 of the measurement year to 50 years as of December 31 of the measurement year.
Continuous enrollment
180 days (6 months) prior to the IESD through 28 days after the IESD.
Allowable gap
No gaps in enrollment during the continuous enrollment period.
Anchor date
IESD.
Benefit
Medical.
Event/ diagnosis
Outpatient or ED visit with a primary diagnosis of low back pain. Follow the steps below to identify the eligible population.

Step 1

Identify all members in the specified age range who had any of the following during the Intake Period:
Outpatient visit (Outpatient Value Set), with a principal diagnosis of low back pain (Low Back Pain Value Set).
Observation visit (Observation Value Set), with a principal diagnosis of low back pain (Low Back Pain Value Set).
ED visit (ED Value Set), with a principal diagnosis of low back pain (Low Back Pain Value Set). Do not include ED visits that result in an inpatient admission.
Osteopathic manipulative treatment (Osteopathic Manipulative Treatment Value Set), with a principal diagnosis of low back pain (Low Back Pain Value Set).

Step 2

Determine the IESD. For each member identified in step 1, determine the earliest episode of low back pain. If the member had more than one encounter, include only the first encounter.

Step 3

Test for Negative Diagnosis History. Exclude members with a diagnosis of low back pain (Low Back Pain Value Set) during the 180 days (6 months) prior to the IESD.

Step 4:
Required exclusions

Exclude any member who had a diagnosis for which imaging is clinically appropriate. Any of the following meet criteria:
Cancer. Cancer any time during the member’s history through 28 days after the IESD. Any of the following meet criteria:
Malignant Neoplasms Value Set.
Other Neoplasms Value Set.
History of Malignant Neoplasm Value Set.
Recent trauma. Trauma (Trauma Value Set) any time during the 12 months (1 year) prior to the IESD through 28 days after the IESD.
Intravenous drug abuse. IV drug abuse (IV Drug Abuse Value Set) any time during the 12 months (1 year) prior to the IESD through 28 days after the IESD.
Neurologic impairment. Neurologic impairment (Neurologic Impairment Value Set) any time during the 12 months (1 year) prior to the IESD through 28 days after the IESD.

Step 5

Calculate continuous enrollment. Members must be continuously enrolled for 180 days
(6 months) prior to the IESD through 28 days after the IESD.


Numerator: 

An imaging study (Imaging Study Value Set) with a diagnosis of low back pain (Low Back Pain Value Set) on the IESD or in the 28 days following the IESD.