Radiographs may raise cost of treating back pain
Canadian researchers have taken aim at yet another commonly accepted practice in diagnosing low back pain and found it lacking. Recent guidelines calling for increased use of lumbar radiographs for the early diagnosis of back pain may sharply increase utilization and the cost of care, say researchers who suggest deviating from the guidelines for a more conservative course of treatment.
Application of the recent back pain guidelines from the Agency for Health Care Policy and Research (AHCPR), an arm of the federal Department of Health and Human Services in Washington, DC, may increase utilization of lumbar radiographs by as much as 238%, according to a study by Maria E. Suarez-Almazor, MD, Msc, a public health researcher at the University of Alberta in Edmonton. The increased use of the lumbar radiographs may improve prompt diagnosis of potentially severe cases, she and her fellow researchers say, but there is no evidence yet that the early diagnosis has any impact on the ultimate prognosis of the patient.1
Suarez-Almazor reached those conclusions after conducting a retrospective study to see how applying the AHCPR guidelines to past patients would have affected their care. AHCPR released guidelines in 1994 that call for a largely conservative approach to diagnosing and treating back pain, but the guidelines also recommend lumbar radiographs for diagnosing back pain that may be related to certain serious conditions.2 (For a summary of the lumbar radiograph recommendations, see related story, p. 105.)
The study involved 963 patients with new episodes of low back pain. Thirteen percent underwent lumbar spine radiographs at the initial visit, and 4% had radiographs of the pelvis. Most patients undergoing pelvic radiographs also had lumbar radiographs, so a total of 14% had radiographs of some type.
Of the lumbar radiographs, 35% were normal. The most common abnormalities were related to degenerative changes, present in 50%. Three percent showed a fracture, and there was one diagnosis of possible metastatic disease.
If the AHCPR criteria had been applied, utilization of lumbar radiographs would have climbed from 13% to 44% of all patients with a new episode of low back pain. While acknowledging that lumbar radiographs are very good at detecting spinal tumor or fracture, Suarez-Almazor says the guidelines encourage broad utilization that will turn up mostly negative reports.
On the positive side, Suarez-Almazor says the AHCPR guidelines may decrease the use of oblique view lumbar radiographs, which cost more and expose the patient to much more radiation than other lumbar radiographs. Fifty-four percent of those undergoing lumbar radiographs in the study had oblique views. The AHCPR guidelines discourage oblique views unless indicated after anteroposterior and lateral views.
"In our view, further evaluation and modification of the guidelines are required," Suarez-Almazor concludes. "The age criterion, for instance, substantially increased utilization and had low specificity, and we recommend that it not be used to screen patients in the absence of other red flags. As an alternative, a delay of two or three weeks before ordering radiographs while offering conservative treatment could be appropriate for those patients without other red flags unless the diagnosis of malignant disease, infection, or fracture is clinically likely."
Reference
1. Suarez-Almado ME, Belseck E, Russell AS, et al. Use of lumbar radiographs for the early diagnosis of low back pain. JAMA 1997; 277:1,782-1,786.
2. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults: Clinical Practice Guideline Number 14. Rockville, MD: U.S. Dept. Of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1994. AHCP publication 95-0642.
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