Management of back pain appears to be variable across the country, despite numerous published clinical guidelines, according to a report published yesterday by JAMA Internal Medicine.
Spinal symptoms are among the most common reasons patients visit a healthcare provider and more than 10% of visits to primary care physicians relate to back and neck pain. Published guidelines for treating back pain promote the use of nonopioid analgesics, avoidance of imaging tests, use of physical therapy–based exercises, and primary care for this population. However, back pain treatment is costly and frequently includes overuse of treatments that are unsupported by clinical guidelines and few studies have evaluated recent national trends in guideline adherence of spine-related care.
A team of Boston-based researchers used nationally representative data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to examine the treatment of back pain from January 1999 through December 2010. Among 23,918 visits for spine problems, the researchers assessed imaging, the use of narcotic medications and referrals to physicians, as well as the use of nonsteroidal anti-inflammatory medications or acetaminophen and referrals to physical therapy. Approximately 58% of the patients were female, and the average age of patients increased from 49 to 53 years during the study period.
The results suggest that nonsteroidal anti-inflammatory drug or acetaminophen use per visit decreased from 36.9% in 1999-2000 to 24.5% in 2009-2010, while narcotic use increased from 19.3% to 29.1%. Referrals to physical therapy remained unchanged at about 20%, but physician referrals increased from 6.8% percent to 14%. The number of radiographs remained at about 17% but the number of computed tomograms or magnetic resonance images increased from 7.2% percent to 11.3% during the study period.
As a leader in evidence-based medicine, Hayes is pleased to see these data come to light, especially as the cost of outpatient interventions for back pain is estimated at $86 billion per year. However, the data raise two important questions: why does this discordance exist and how can we improve the management of routine back pain while managing costs? The discordance is driven in part by 1) greater availability of imaging centers; 2) reduced time of primary care providers for detailed evaluation of back pain; 3) lack of effective shared-decision making tools; 5) patient demand for a quick panacea; and 6) clinicians’ fear of liability that forces them to order more extensive diagnostic workups; and 7) a lack of patient and provider knowledge or sensitivity about the cost of more sophisticated modalities.
As far as balancing cost and care, an accompanying editorial offers some interesting solutions. The first suggests the standardization of the plethora of the existing guidelines to include algorithms, patient check lists and a national registry that could track outcomes and promote successful self management. The second is the implementation of financial incentives, such as higher co-payments for more expensive modalities. And the third is to get all the stakeholders to the table to implement an objective, common framework for evaluating the value of individual and combination modalities for back pain.