Research at Beth Israel Deaconess Medical Center published in the July 29 issue of JAMA Internal Medicine,
suggests patient care could be enhanced and the health care system
could see significant cost savings if health care professionals followed
published clinical guidelines to manage and treat back pain."Back pain treatment is costly and frequently includes overuse of
treatments that are not supported by clinical guidelines, and that don't
impact outcomes," says lead author John N. Mafi, MD, a fellow in the
Division of General Medicine and Primary Care at BIDMC. "Improvements in
the management of spine-related disease represent an area of potential
for improving the quality of care and for potential cost savings for the
health care system." Americans spend approximately $86 billion annually on back or neck
pain-related health issues. It is ranked as the fifth most common reason
for doctor visits, which accounts for more than 10 percent of all
appointments made with primary care physicians. Lost productivity adds approximately another $20 billion per year. It is
predicted that expenditures will continue to grow along with the rise
of chronic back pain. Published guidelines for routine back pain advise use of non-steroidal
anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy.
Prior research shows that within three months of these treatments back
pain usually resolves. The guidelines, which have remained consistent since the 1990s, suggest
the need for imaging or advanced treatments is typically unnecessary, as
most cases of routine back pain improve with these conservative
measures. Other discordant recommendations would include prescription of
a narcotic or referral to a specialist, presumably for the
consideration of a procedure. However, if acute neurological compromise or other warning signs such as
past history of malignancy are connected with the back pain, further
steps can be taken to investigate. The researchers identified 23,918 visits for spine problems,
representing 73 million visits annually using nationally representative
data from the National Ambulatory Medicare Care and National Hospital
Ambulatory Care surveys between 1999-2010. They studied the changes in
utilization of diagnostic imaging, physical therapy or referral to other
physicians, and the use of medication when treating patients who
complained of back pain or were diagnosed with back pain. "We observed a significant rise in the frequency of treatments that are
considered discordant with current guidelines including the use of
advanced imaging, such as CT or MRI, referrals to other physicians
(presumably for procedures or surgery), and the use of narcotics," says
Mafi. "We also have observed a decline in the use of first-line
medications such as NSAIDs or acetaminophen, but no change in referrals
to physical therapy." "Although opiate prescriptions increased markedly over this time period,
we also observed lower odds of receiving narcotics among female, Black,
Hispanic, and other race/ethnicity patients, which may signify the
potential disparities in pain management that have also been noted
previously." Unnecessary treatment is not only expensive, but also can come with
complications. A meta-analysis concluded that narcotics offer minimal
benefit to relieve acute back pain and have no proven efficacy in
treating chronic back pain. The data also revealed that 43 percent of
the patients had concurrent substance abuse disorders. Researchers
believe that the increase in narcotic prescriptions is connected with
the rise of narcotic overdose deaths, which is creating a public health
crisis. The steady increase of doctors' request for advanced diagnostic imaging has become a concern as well. Overuse of imaging may not result in immediate problems but exposure to
ionizing radiation can lead to further health complications such as
cancer, Mafi notes, adding a study that linked regions with higher MRI
use found an increase in back surgeries, which can be a very costly
process and require recovery time. "Increased use of advanced imaging represents an area of particular
concern" says senior author Bruce Landon, MD. "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." "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," says
Mafi. Source: JAMA Internal Medicine
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