MONDAY, Jan. 31 (HealthDay News) -- X-rays, CT scans and MRIs
may be routinely ordered for people with low back pain, but often
these tests are unnecessary, suggests new guidance from the
American College of Physicians.
What's more, these imaging tests have the potential to cause
harm by exposing people to unnecessary radiation and by uncovering
abnormalities -- such as a bulging disc -- that may not be causing
However, once such abnormalities are uncovered, they may be
treated, potentially with an unneeded surgery, experts say.
And then there's the matter of expense.
"Health-care costs are increasing unsustainably, and a crucial concern for everyone is how do we maintain or improve the quality of care without increasing costs? One way is for physicians to stop ordering tests that may not be beneficial," said Dr. Amir Qaseem, one of the authors of the back pain guidelines, and director of clinical policy in the medical education division of the American College of Physicians (ACP) in Philadelphia.
The new guidelines on diagnostic imaging for people with low
back pain are published in the Feb. 1 issue of the
Annals of Internal Medicine.
Almost everyone will experience back pain at some point in their
lives, according to the U.S. National Institute for Neurological
Disorders and Stroke. The costs of treating low back pain are
staggering: the ACP guidelines estimate that about $90 billion is
spent each year in the United States on low back pain. In 1997, the
average cost of treating one patient with back or neck problems
averaged $4,795, according to the ACP. By 2005, that amount had
climbed to $6,096.
Imaging tests make up a significant portion of those costs. The
bill doesn't only include the test, but follow-up that might occur
afterward such as additional tests, referrals and additional
treatments that sometimes include surgery.
Despite this increase in spending, the ACP cite data from six
different studies that found that people with spine problems who
got radiological tests had similar or worse scores on quality of
life and physical functioning assessments a year later, compared to
patients who went without the scans.
One of the reasons that the increased spending may not be
improving outcomes is that most people with back pain will get
better on their own -- no matter what tests or interventions are
done, the ACP experts said. In fact, they say, most people with
acute back pain will begin to feel better within a month.
Overall, the results of X-rays, CT scans and the like rarely
affect treatment plans, says the ACP, and if an abnormality
is found on an imaging test, it can be difficult to know if
that's the cause of the symptoms or if it was always there.
For example, in one study of people over 60 who did
not have any back pain, the ACP reports that 90 percent had
either spinal disc degeneration or a bulging disc in their back,
and another 21 percent had narrowing in their spinal canal.
"Essentially, using routine imaging is not benefiting patients and it may even be harmful, because it can lead to further unnecessary additional tests, perhaps invasive procedures and increased radiation," said Qaseem.
So, what drives doctors to order these tests? Qaseem said there
are a number of reasons. One is that physicians may feel that a
patient expects a diagnostic test. Another is "defensive medicine,"
when a doctor orders a test to be sure he or she hasn't somehow
missed an unusual condition. The wider availability of scanning
technology may play a role, as may certain financial incentives, he
Dr. Anders Cohen, chief of neurosurgery and spine surgery at The
Brooklyn Hospital Center in New York City, agreed that patient
expectations and a concern about malpractice are significant
contributors to the overuse of imaging for back pain.
"Back pain is one of the more poorly understood aspects of medicine, and diagnosing and treating low back pain can be a tricky diagnosis, even for people who do it full-time. But there does need to be some curtailing in the use of imaging, because diagnostic costs are getting out of control," said Cohen.
However, both experts said that doctors can usually tell from a
physical exam and someone's description of their pain whether or
not an imaging test is really necessary.
Both Cohen and Qaseem said that a better dialogue between
patient and physician could go a long way in reducing the use of
unnecessary imaging tests.
"Shared decision-making is really important. Most patients don't want to get tests that aren't beneficial, so it's important to talk. Patients need to ask questions like, 'If I do get this test, what are the benefits or harms?'" said Qaseem.
"We have a bountiful access to technology, but we don't necessarily need all that stuff every time. The majority of back pain will get better without surgery. We need to empower patients, and let patients be a part of the process," said Cohen.
Read more about back pain from the
U.S. National Institute of Neurological Disorders and
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