June 5, 2012 — As part of its "Promoting Good Stewardship in Clinical Practice," the National Physicians Alliance recommended against imaging for low back pain within the first 6 weeks of onset unless red flags are present. Now, a new literature and financial analysis supports and explains that recommendation.
In one sense, the analysis by Shubha V. Srinivas, MD, MPH, from the Department of Medicine, University of Connecticut Health Center, Farmington, and colleagues covers well-traveled ground from the 30-year history of clinical guidelines indicating that most cases of lumbar back pain resolve themselves with minimal clinical intervention.
However, the findings of the analysis, published online June 4 in the Archives of Internal Medicine, as part of the "Less is More" series, also help maintain momentum for Choosing Wisely, a multi–medical society initiative designed to encourage physicians and their patients to make smart choices about the use of expensive medical technologies that do not deliver improved clinical outcomes in every situation.
The recommendation to avoid early imaging for low back pain was included in the National Physicians Alliance’s list of " 'Top 5' Health Care Activities for Which Less Is More" which was published in the August 8, 2011, issue of the Archives of Internal Medicine.
In the current literature review, Dr. Srinivas and colleagues report that imaging for lower back pain is extremely common. A 2011 study ( Spine J. 2011;11:622-632) indicated that 42% of patients with back pain undergo imaging (mainly plain radiography) within a year of the onset of pain. Of that total, 6 of 10 patients had imaging on the same day as their diagnosis. Eight of 10 underwent imaging within a month.
Dr. Srinivas and colleagues also note that another review concluded that lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes ( Lancet. 2009;373:463-472).
Furthermore, Dr. Srinivas and colleagues estimated that nearly $300 million could be saved annually by restricting imaging during the first 6 weeks of lumbar back pain to specific severe indications, including severe or progressive neurological deficits or when serious underlying conditions, such as osteomyelitis, are suspected.
They surmised that the only benefit of authorizing early low back imaging would be to cater to the patient's demands and emotional need for clinical action. With that issue at hand, they cited an article titled, "Getting to 'No': Strategies Primary Care Physicians Use to Deny Patient Requests" as an example of how to deny imaging to patients with lower back pain without inciting rebellion ( Arch Intern Med. 2010;170:381-388).
Daniel Wolfson, MHSA, executive vice president of the American Board of Internal Medicine Foundation, Philadelphia, Pennsylvania, picked up on this theme in an invited commentary.
"Srinivas et al recognize the problem of translating guidelines and comparative effectiveness research into practice, but they do not offer solutions," he wrote.
So, Wolfson has offered for consideration the efforts of the American Board of Internal Medicine Foundation, along with 9 medical specialist societies and Consumer Reports, to bring their lists of scientifically questionable medical practices to the attention of the general public.
Choosing Wisely features "Five Things Physicians and Patient Should Question," lists, which are geared to educating each society's physician members and their patients about the clinical appropriateness and costs of popular medical tests and therapies. The lists were announced simultaneously April 4.
"Choosing Wisely will test whether this type of campaign will spur translation of clinical recommendations into practice," Wolfson said.
Consistent with Dr. Srinivas's article, lists supported by the American Academy of Family Physicians and the American College of Physicians both advise against imaging of low back pain within the first 6 weeks unless red-flag conditions are suspected.
The authors and commentator have disclosed no relevant financial relationships.
Arch Intern Med. Published online June 4, 2012. Article full text, Commentary full text
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