Imaging utilization for low back pain on the rise

Imaging utilization for low back pain by primary care providers has increased in recent years, according to new findings published in the Journal of the American College of Radiology.

The study’s authors noted that the American Association of Family Physicians, North American Spine Society and American College of Radiology (ACR) all recommend limiting imaging for low back pain to instances where there are “progressive symptoms or red flag symptoms concerning for emergent problems.”

“These recommendations are based on evidence demonstrating that the majority of patients are unlikely to have a serious underlying cause, there may be a high rate of incidental findings on imaging, and the likelihood is high that acute low back pain will improve without intervention,” wrote Jina Pakpoor, MD, Johns Hopkins Hospital in Baltimore, Maryland, and colleagues. “Moreover, multiple randomized controlled trials have shown that imaging for new nontraumatic low back pain does not improve patient outcomes (pain, function, psychological benefits, and quality of life), yet represents high financial cost, resource utilization, and radiation exposure.”

To track utilization, Pakpoor et al. studied data from more than 627,000 patients who presented to a primary care providers for an initial evaluation for low back pain from 2011 to 2016. Only patients between the ages of 18 and 65 were included in the analysis.

Overall, imaging orders increased from 14% of patient encounters in 2011 to 16% in 2016. X-rays made up 96% of all ordered imaging examinations, followed by MRI scans (3%) and CT scans (2%). The team also noted that the likelihood of imaging exams being ordered was the highest in the South (18.5% of patient encounters) and lowest in the Northeast (6.2%). The Midwest (13.9%) and West (13.6%) landed in the middle of that range.

“Substantial national geographic variation in imaging has also been demonstrated in the literature for other indications (eg, prebiopsy prostate MRI, imaging for Crohn’s disease, and CT imaging),” the authors wrote. “Differing access to health care facilities, availability of imaging technology, and patient socioeconomic factors have all been shown to contribute to discrepancies in imaging rates, and further understanding of how to best reduce geographic variation is needed.”

Pakpoor and colleagues noted that there are numerous reasons why it can be hard to limit image utilization in these instances, even when numerous societies are recommending that healthcare providers change. Physicians want to make their patients feel satisfied, for instance, and many patients want to have the examination done to make sure nothing is seriously wrong. It’s also just generally challenging to change the “medical culture,” the authors observed.

“Possible solutions to this problem include reimbursement denials if appropriate use criteria are not employed, consistent with a mandate by CMS that will be enacted in 2021,” the authors wrote. “Other work has shown that providing physicians with periodic feedback in the form of report cards highlighting guideline adherence over a period of time is effective in reducing imaging and more effective than real-time clinical decision support tools. Another tool is theory-informed interventions in the form of educational workshops provided to ordering physicians."