Whenever advanced imaging for low-back pain gets knocked as the “poster child” for overutilization in U.S. healthcare—not an uncommon occurrence—the context of the charge tends to waft away, unconsidered. That’s problematic. To be sure, lumbar-spine MRI in particular has a dicey cost-benefit proposition all its own. The scan’s technical component alone can ring up a bill north of $3,000.
However, the initial outlay can end up looking like nickels and dimes when compared to the high price paid for too much follow-up care generated by the scan.
This angle of the story will get an airing at RSNA 2018 on Wednesday, Nov. 28, when Jeffrey Jarvik, MD, MPH, of the University of Washington in Seattle presents “MRI for Low-Back Pain” as part of a three-talk, 90-minute session on translating science into health policy and practice.
“Spine imaging is sort of like a gateway drug in that it opens the door to everything that happens downstream,” Jarvik told Radiology Business in a phone interview leading up to RSNA 2018. “It potentially leads to questionably needed interventions, which can raise the question of whether the spine imaging was necessary in the first place.”
Low value, high visibility
Jarvik, lead researcher in the eagerly anticipated (and nearly finished) Lumbar Imaging with Reporting of Epidemiology (LIRE) study, points out that upwards of 80 percent of Americans experience low-back pain at some point in their lives.
That’s a lot of sore backs, so any change in patterns of care for the complaint can yield major gains—or losses—at the level of population health.
What’s more, any interventions taken may end up being harmful, Jarvik says. He cites as an example a prescription painkiller addiction that, months or years later, traces to an initial scan of questionable necessity. “A cascade of unwanted effects can follow that scan with potentially enormous consequences in terms of both costs to society and disability to individuals," he said.
Add to this potentiality the research showing unimproved outcomes despite all-but-unabated imaging—a Health Affairs study published last year found a measly 4 percent decrease in “low-value” back imagining nearly three years after the launch of Choosing Wisely—and Jarvik’s recommendation moves beyond debate:
“More prudent use of spine imaging is critical,” he said. “And the easier we can make it to educate people about potential downsides of over-ordering lumbar spine imaging—the more radiologists can put into context what the findings actually mean—the better the chances for seeing more rational use of spine imaging.”
PAMA alone won’t solve
Doctors ordering any nonemergent advanced imaging will soon have no choice but to think twice. As of January 2020, they’ll need to show they consulted evidence-based guidelines via a clinical decision support (CDS) tool in order to avoid payment penalties under PAMA, the Protecting Access to Medicare Act. Payment adjustments will kick in a year later, and private payers are sure to follow suit once the die is cast.
Jarvik noted that it will take more than just a mandate to ensure a meaningful experience for providers and patients and, when imaging is involved, radiologists.
“Ultimately, involving patients and radiologists in the decision about whether to order diagnostic tests is going to be important to the advance of shared medical decision-making,” he said. “This is where medicine needs to go.”
Jarvik and colleagues’ LIRE study should help with the effort. The work demonstrates the power of relevant benchmark information when it’s automatically incorporated into routine radiology reports, he explains. A lumbar spine MRI report, for example, would show the age- and modality-matched prevalence of various findings in people who don’t have back pain.
“It’s sort of like pathology defining what constitutes a normal range in lab tests,” Jarvik said. “It’s one way to do on-the-fly education for patients as well as practitioners. The time is right, as patients now have access almost universally to their imaging study results.”
Two sides to the story
Of course, there are times when it would be inappropriate not to order lumbar-spine MRI. Examples include patients presenting symptoms of a spinal infection such as vertebral osteomyelitis and those who have radiculopathy (“pinched nerve”) persisting for six to eight weeks.
In the latter scenario, lumbar MRI “can be very useful in showing whether there’s focal nerve root compression that corresponds to the patient’s radicular symptoms,” Jarvik explained. “And if so, it may be reasonable to consider some sort of surgical intervention. So, for very targeted indications, lumbar MRI should be done and should prove useful.”
“The problem has been that we’ve used the exam for a host of other indications that are not as well defined,” he said. “Over time, that utilization has led to the overall perception that lumbar MRI is a low-value test. Like many technologies, MRI itself is neither good nor bad. It’s potentially both beneficial and dangerous. What’s good or bad is how we choose to use it.”
Jarvik will deliver his presentation as part of “Comparative Effectiveness Research: Translating Science into Health Policy and Practice” on Wednesday, Nov. 28, at 8:30 a.m. More information is available on the RSNA 2018 interactive program.