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JAMA Study Targets ‘Low Value’ Back Imaging

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An article published online Monday in JAMA Internal Medicine takes blunt aim at what it calls overuse of advanced imaging, overprescription of narcotics, and overreferrals for surgery in the diagnosis and treatment of back pain.

The authors, all affiliated with Beth Israel Deaconess Medical Center in Boston, wrote:

In 2007, a projected 1,200 additional future cancers were created by the 2.2 million lumbar CTs performed in the United States.

The authors label most such advanced imaging “low value.” The article notes that “numerous published national guidelines” recommend against advanced imaging for back pain unless such “red flags” as fever, neurologic symptoms, or cancer are present.

“Increased use of advanced imaging represents an area of particular concern,” said senior author Bruce Landon, MD, who practices internal medicine at Beth Israel and is a professor of medicine there and a professor of health care policy at Harvard Medical School. “Early in the course of back pain, such imaging is almost always wasteful. Moreover, there are almost always some abnormalities, which increases the likelihood that a patient will undergo expensive spine surgery that might not improve their outcomes over the longer term.”

Dr. Landon was quoted in a Beth Israel news release.

For routine back or neck pain, those “numerous published national guidelines” recommend physical therapy and either nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen. Research has shown that with those treatments, the pain usually subsides within three months.

For the new study, the researchers examined 23,918 physician visits for back or neck pain from 1999 through 2010, using data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. The researchers found that over that period:

  • Use of X-rays remained steady at about 17 percent.
  • Use of CT or MRI increased from 7.2 percent to 11.3 percent.
  • Use of NSAIDs or acetaminophen per visit decreased from 36.9 percent to 24.5 percent.
  • Use of prescribed narcotics increased from 19.3 percent to 29.1 percent.
  • Referrals for physical therapy remained steady at about 20 percent.
  • Referrals to other physicians, presumably for possible surgery, increased from 6.8 percent to 14.0 percent.

Here’s the study’s conclusion, which will get maximum attention because it contains the magic phrase “cost savings”:

“Despite numerous published national guidelines, management of routine back pain increasingly has relied on advanced diagnostic imaging, referrals to other physicians, and use of narcotics, with a concomitant decrease in NSAIDs or acetaminophen use and no change in physical therapy referrals. With healthcare cost soaring, improvements in the management of back pain represent an area of potential cost savings for the healthcare system while also improving the quality of care.”

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