Guidelines Urge Evidence-Based Imaging For Low Back Pain

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American College of Physicians issues updated guidelines for back pain imaging. Systematic review concludes that routine imaging of lower back is a "low-value" intervention.

Routine back imaging is not associated with clinically meaningful benefits and exposes patients to unnecessary harms say a clinical guidelines committee of the American College of Physicians.

 An American College of Physicians panel says routine imaging for common low-back pain is a costly, potentially harmful and of little clinical value.Led by Dr. Roger Chou, of the Oregon Health & Science University, the Clinical Guidelines Committee of the American College of Physicians issued updated guidelines for diagnostic imaging for low back pain in the Feb. 1, issue of the Annals of Internal Medicine.

The ACP has found strong evidence that routine imaging for low back pain by using radiography or advanced imaging methods is not associated with a clinically meaningful effect on patient outcomes, the authors wrote. Unnecessary imaging exposes patients to preventable harms, may lead to additional unnecessary interventions, and results in unnecessary costs.

In developing the new guidelines, the ACP cited imaging usage for back pain between 1998 and 2005, as well as a systematic review by the ACP/APS in 2007 and a meta-analysis conducted following that review.

Total U.S. expenditures for back pain care were estimated at $90 billion in 1998 at a per patient cost of about $4,795. By 2005, the cost per patient had risen to $6,096. After adjusting for inflation that represented a 65% increase in costs, which the authors noted was a higher rate of increase than for overall health expenditures.

In a meta-analysis of six randomized trials involving 1,804 patients with acute or subacute low back pain, but with no clinical or historical features that suggested underlying disease showed no difference in outcomes among those who underwent imaging compared to those who had no imaging as part of their treatment.

Furthermore, the conclusions of the meta-analysis did not seem to be affected by whether x-rays or advanced imaging  (MRI or CT) was used.

“On the basis of the systematic review, routine imaging can be considered a low-value health care intervention,” the committee wrote. “Because it is more costly than usual care without routine imaging and offers no clear clinical advantages, it cannot be cost-effective.”

The meta-analysis also assessed the potential harms of imaging. One study estimated that on the basis of 2.2 million lumbar CT scans 1,200 additional future cases of cancer would result. Another study calculated that the average radiation exposure from lumbar x-rays was 75 times higher than that for chest x-rays. The researchers noted that this is of particular concern for young women due to the difficulty of shielding the ovaries. Of more concern to the committee was a randomized trial of patients with low back pain showing that those who had rapid MRI had spine surgery about twice as often as those who had radiography, although the difference did not reach statistical significance.

Chou and colleagues acknowledged multiple influences drive inappropriate use of low back imaging.

“Patient expectations and preferences about diagnostic testing, when communicated to physicians, can affect clinical decisions,” the committee wrote. “Patients expect a clear diagnosis for their low back pain. They want to know what is causing their symptoms and may equate a decision to not obtain imaging or provide a precise diagnosis with low-quality care or as a message that their pain is not legitimate or important.”

In addition, the committee listed financial performance incentives, greater availability of imaging resources, higher Medicare reimbursement for advanced imaging than for conventional x-rays, and higher rates of physician ownership or investment in imaging facilities, as drivers of inappropriate use. They cited statistics showing that the U.S. has almost twice as many MRI sites per capita as any other industrialized country.

To reduce unnecessary expense and risks of radiation exposure, the committee summarized its guidelines:

  • Diagnostic imaging studies should be performed only in selected, higher-risk patients who have severe or progressive neurologic deficits or are suspected of having a serious or specific underlying condition.
  • Advanced imaging with MRI or CT should be reserved for patients with a suspected serious underlying condition or neurologic deficits, or who are candidates for invasive interventions.
  • Decisions about repeated imaging should be based on development of new symptoms or changes in current symptoms.
  • Patient education strategies should be used to inform patients about current and effective standards of care.

“To be most effective, efforts to reduce use of imaging should be multifocal and address clinician behaviors, patient expectations, and financial incentives,” the committee concluded. “The mindset that more testing means better care must be abandoned in favor of a more evidence-based approach.”

By: Michael O'Leary, contributing editor Health Imaging Hub


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