• 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.]

    @afrakt

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    • What’s the point of having MRI and CT Scan machines if you don’t use them? I believe the marginal cost of each additional scan is the additional cost of the electricity to run the scan. The technician is there all day, whether the machine is used or not.

      You can certainly blame providers for bad diagnoses and non-efficacious treatments, but don’t blame the advanced imaging tools.

      • In the US, there’s a whole world of contracting that you must consider, including payments between hospitals and private radiology practices, payments between practices and individual clinicians, payments between payors and hospitals, payments between payors and practices, etc. Depending on the device and maintenance agreement, there is likely also a payment to a manufacturer and/or maintenance provider. These agreements often include components that are paid per scan.

        Unnecessary back pain scans also increase the likelihood of unnecessary surgical procedures, which is the primary reason the guidelines recommend against initial imaging without particular symptoms like a foot drop. Plus, there’s the whole radiation/cancer thing.

        So, no, the marginal cost isn’t just the additional electricity.

        • “There’s a whole world of contracting that you must consider… ”

          Please consider the fixed cost of an MRI before the whole world of contracting steps in:

          The top end cost of a new MRI machine is around 1.2 million. Say it has an amortization period of ten years, thus the cost is 328 dollars a day. If you staff it twelve hours a day with a technician, that’s another 500 dollars a day, give or take. The office space to house it, another 300 dollars a day. All together, an MRI machine runs about 1100 a day or 7700 per week in fixed costs. Say you do ten scans a day on weekdays and five on Saturday, or 55 scans a week. The average fixed cost of a scan is twenty dollars. The typical charge for a scan is 400 to four thousand dollars.

          I say that is a whole lot of contracting costs added in. To repeat my point, it is wrong to blame the imaging tools for bad diagnoses, bad treatments, and out of control charges.

      • “What’s the point of having MRI and CT Scan machines if you don’t use them? I believe the marginal cost of each additional scan is the additional cost of the electricity to run the scan. The technician is there all day, whether the machine is used or not.”

        Actually, this, in a sense, illustrates why we can in fact blame the imaging tools. As you said, they are expensive, and if not used, you are stuck with the fixed costs anyway. So, doctors who own advanced imaging equipment tend to use it more, and in fact, they try to use it as much as possible, because from a business standpoint, they have to. Doctors who have to refer the patient to the hospital are going to use it less. Advanced imaging is an example of supply-sensitive healthcare.

        http://www.dartmouthatlas.org/downloads/reports/supply_sensitive.pdf

        That would be great if imaging had similar levels of costs and benefits as vaccinations. It does not. Imaging can produce a lot of inconclusive results and physicians can follow up for further tests or surgeries that turn out to be unnecessary. The study cited alludes to this.

        • You are mistaken, MRI’s are not expensive to deliver. In my illustration I showed that an MRI scan averages twenty dollars in fixed costs. This is similar to the fixed cost of an office visit to a family practice. You are welcome to refute that.

          Inconclusive results are as important to proper diagnosis as a conclusive result, since one avenue for diagnosis can then be definitively ruled out.

          Bad diagnosis and treatment are wholly the fault of the practitioner and his willing accomplice, the patient. The diagnostic equipment is not to blame for bad diagnosis, bad treatment and high costs.

    • Back Sense by Dr. Ronald D. Siegel. Best book I have read on the subject and the idea from the book that sticks in my head is the fact that if you take an MRI of “normal” backs you will find all kinds of issues that you find in “irregular” scans that people get treated for.

    • I suspect that the issue with narcotics is related to the palliative care movement. I am strongly on the side of palliative care, which strongly pushed for making pain management easier. I think some of the palliative care folks underestimated how addictive narcotics are. For instance, here is a perspective that opioids are safe and can be self-administered by a pump:

      http://www.caringinfo.org/files/public/brochures/narcotics_safety.pdf

      The link below provides a physician’s perspective and argues that physicians should adopt a more parsimonious approach.

      http://www.kevinmd.com/blog/2010/04/pain-management-depends-heavily-narcotics.html

      My personal perspective: my mom has chronic back pain (somewhat intermittent) which surgery and PT failed to completely resolve. She lives in Singapore, which is very strict with prescription of opioids. Her physician has her on Lyrica, a non-narcotic medication that treats nerve pain (which is what she has). She was always very worried about getting addicted, and she was reluctant to take sufficient doses, but it appears that Lyrica does have some abuse potential but not as much as opiates.

      At the same time, we want to relieve severe pain, and fear of addiction may lead to the underuse of pain medications, which is also not good. I would also argue that restrictions on prescribing opiates in nursing homes should be relaxed. Many NF residents have severe pain or are at risk of developing it.

    • I have chronic back pain and have for years; I was a daily long distance runner, having accumulated well over 40,000 miles. Dumb me. Years ago I had an MRI as part of an evaluation to determine what, if anything, to do about the pain. Valium was a nice addition to the MRI, but otherwise it was a waste of time and resources. I chose not to have surgery, but I did spend time with a physical therapist. I make a distinction between people like me whose work isn’t significantly affect by chronic back pain and people like my neighbor whose work is significantly affected by chronic back pain. He chose surgery. I can understand why, even if he is informed that the surgery may not improve his condition and, indeed, may make it worse. I quit running, believing that the ability to run for exercise wasn’t worth the risk of surgery. It’s people like me who choose surgery that I don’t understand.

    • While I am not about to defend overdiagnosis and overtreatment of back pain, I note that some of the findings are what you would expect if the system worked well. Patients who are referred to specialists for their back pain probably should be more likely to get imaging than those who are not. If there was a rational basis for the referral, it was due to a concern that conservative therapy may be inadequate, or the diagnosis might be wrong. This would make imaging appear reasonable.

      Of course, a large element in imaging use is that the same people who profit from the treatment also profit from the imaging. They did not discuss it here, but I believe other studies have shown that the bulk of the imaging boom occurred in self-referral situations. The doc sends a patient to an imaging center in which the doc has an investment.

    • The big question in my mind is why do insurance companies pay for this stuff.

      • BTW to me this shows that since people are not so reasonable, diligent and nice especially spending other people’s money we need much higher deductibles. If all people had $50,000/year deductibles how many back surgeries would there be and how many people would get images done for back pain.

        People are not nice enough to care much about over spending insurance company or government money.