Mismanagement of technology: back pain treatment edition

Speaking of our anathema to rational management of health care technology, we’re doing a terrible job of it with back pain treatment. John Mafi and colleagues bring the, ahem, pain.

In this nationally representative study of treatment patterns for patients presenting to physicians with back pain during the last decade, we observed several notable findings. First, we observed a significant increase in the frequency of treatments that are considered discordant with current guidelines, including use of advanced imaging (ie, CT or MRI), referrals to other physicians (presumably for procedures or surgery), and use of narcotics. Second, we also observed a decrease in use of first-line medications, such as NSAIDs or acetaminophen, but no change in referrals to physical therapy. […]

Recent meta-analyses and research of lumbar fusion surgery have not revealed improvement in patient outcomes and demonstrate that these procedures lead to significant adverse consequences, including 5.6% with life-threatening complications and 0.4% mortality. Further, when comparing visits with the patient’s self-identified PCP vs those with another health care professional, we found that non-PCPs were much more likely to order advanced imaging. Presumably, this group includes those who perform procedures such as spinal surgery. Thus, these referrals from PCPs are likely to result in substantial downstream use that is disconcordant with current guidelines.

We also found a 50.6% decrease in first-line NSAID or acetaminophen use accompanied by a 50.8% increase in narcotic prescriptions, including a near doubling among patients presenting with chronic back pain. […] A recent meta-analysis revealed that narcotics provide little to no benefit in acute back pain, they have no proved efficacy in chronic back pain, and 43% of patients have concurrent substance abuse disorders, with aberrant medication-taking disorders as high as 24% of cases of chronic back pain. […]

Our findings also confirm an inappropriate increase in advanced diagnostic imaging that has been seen previously, with use of CT or MRI increasing by 56.9% in our study sample. Six randomized controlled trials have found that imaging in the acute care setting provides neither clinical nor psychological benefit to patients with routine back pain, and multiple prospective studies have found the lack of serious disease in the absence of red-flag symptoms. In addition to being of low value, the overuse of diagnostic imaging leads to more exposure to ionizing radiation. In 2007, a projected 1200 additional future cancers were created by the 2.2 million lumbar CTs performed in the United States. Finally, the significant increase in spine operations seen during the last decade is almost certainly related to the overuse of imaging. One study revealed that early MRI for acute back pain was associated with an 8-fold increased risk of surgery, whereas another found that regions with more MRIs perform more operations, with 22% of the variability in spine surgery rates explained by rates of spine MRI use—more than twice the predictive power of patient characteristics. [Numbered indices to references omitted.]


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