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Care for back pain often out of sync with medical guidelines

An increasing number of patients with uncomplicated lower back pain get unnecessary tests, specialist referrals and opioid prescriptions, a study says.

By Kevin B. O’Reilly — Posted Aug. 14, 2013

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Use of imaging, narcotic painkillers and referrals to other physicians has skyrocketed in treatment of patients with acute back pain, despite clinical practice guidelines urging doctors to take a conservative approach to such cases. This trend in back-pain care is getting worse with time, said a study of nearly 24,000 spine-related visits between 1999 and 2010.

Researchers found that patients presenting with uncomplicated acute back pain received a computed tomography or magnetic resonance imaging scan 6.7% of the time during 1999 and 2000. By the 2009-2010 period, 10.6% of such patients had CTs or MRIs.

That growth came despite the 2007 publication of joint guidelines from the American College of Physicians and the American Pain Society that urged physicians to skip imaging for back-pain patients who do not show severe or progressive neurological deficits.

For the study, published online July 29 in JAMA Internal Medicine, researchers excluded from their analysis visits with “red flag” diagnoses or symptoms such as fever, weight loss, neurological symptoms or cancer.

Guidelines also urge physicians to consider acetaminophen or nonsteroidal inflammatory drugs as their first-line options in treating patients with acute back pain. Yet the study found that opioid prescribing rose 44% between 1999 and 2010, with more than one in four back-pain patients getting narcotic prescriptions.

Meanwhile, the rate of referrals for physical therapy — which evidence shows can help — was flat during the study period. But referrals to specialists rose from 6.8% to 14%.

“The 106% increase in referrals to other physicians is a previously unrecognized and important finding, because such referrals likely contributed to the recent increase in costly, morbid and often ineffective outpatient spine operations observed in other studies,” said the study (link).

Why guidelines get ignored

Patient demand for quick answers, physician time constraints and medical liability fears are just a few of the factors that could explain why doctors are often failing to follow the evidence on treatment of low back pain, said Donald E. Casey Jr., MD, MPH, vice president for network integration at the New York University Langone Medical Center. Dr. Casey helped write the American College of Physicians’ guidance on back pain and wrote a July 29 JAMA Internal Medicine commentary on the topic (link).

He added that practice guidelines should be integrated into point-of-care clinical checklists and shared decision-making tools to help doctors and other health care team members deliver evidence-based care.

“Guidelines tell you what to do or what not to do, but they don’t necessarily tell you how to do it, or how to do it effectively,” Dr. Casey said. “This is where the rubber meets the road for the average practicing physician who’s trying to get through his or her day. There are many patient care issues for which there are good clinical practice guidelines and trying to keep track of all of them at once without better systems is very challenging.”

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