Physicians are drifting away from evidence-based care for back pain patients and are treating them with growing rates of referrals to surgeons and other doctors and orders for "inappropriate" CT or MRI images, a study shows.
Doctors were less likely to follow established evidence-based guidelines for treating back or neck pain and prescribe anti-inflammatory drugs. Instead, they were more likely to prescribe narcotics and order expensive, inappropriate imaging tests, despite no evidence of benefit.
Usually, and absent other red flags like neurological problems or fever indicating more serious issues, back pain resolves within three months, and neither imaging, narcotics or surgery, which carry serious risks, are likely to hasten relief.
That's according to a study of 23,918 patients who sought care for spinal problems between 1999 and 2010 by researchers at Beth Israel Deaconess Medical Center in Boston.
"We were hoping that practices would get a little better, but what we found was that everything just got worse," says John Mafi, MD, the study's lead author and a fellow in Beth Israel's division of general medicine and primary care.
"It's hard to change behavior of patients and it's hard to change behavior of physicians. We live in a society or culture that expects a quick, effective, and immediate solution. We do have good technologies for treatment for many conditions, but unfortunately, back pain is just not one of them."
Mafi adds that within the first three months of pain onset, "surgery, MRI or CT scanners and specialty visits don't tend to improve outcomes for patients with back pain, which is just one of those frustrating things we don't have a quick fix for."
The study, published in JAMA Internal Medicine, found that over the 12-year period, recommendations that patients with back pain use non-steroidal anti-inflammatory drugs or acetaminophen decreased from 36.9% in 1999-2000 to 24.5% while narcotic use went from 19.3% to 29.1%.
Physician referrals, including referrals to surgeons or other physicians for procedures, increased from 6.8% to 14%. And the number of "inappropriate" CT or MRI images among patients with back pain increased from 7.2% to 11.3%.
Back pain care represents an enormous segment of the healthcare industry, with an estimated $86 million spent annually on back or neck pain issues. It's the fifth biggest reason people see a physician, and accounts for more than 10% of all appointments with primary care doctors, the researchers wrote.
Mafi blames three factors for the movement away from evidence-based care for back pain patients.
1. Patient expectations
Increasingly, patients expect that if their doctor is really listening to them, they will order the MRI and have lots of tests, with lots of referrals to other physicians, Mafi says. So physicians basically oblige their patients, even if they know it's not likely to help.
2. Ease of ordering imaging tests
"Doctors are increasingly pressed for time, and it's just easier to order the MRI, or make a referral to a back specialist then to give a nice, satisfying explanation" why the patient will have the same outcome by waiting for a few months.
Also, Mafi says, doctors think that ordering the imaging test "will provide the patient some psychological benefit."
3. Financial incentives
MRI machines are costly, as are back surgeries, and when the doctors own the imaging equipment, they're more likely to order an imaging test, Mafi says. "I don't think there's anything intentional, but there's an unconscious bias. And we know that regions that have more MRI machines also have more surgeries. They go hand-in-hand," he says.
In an invited commentary in the same issue of JAMA Internal Medicine, Donald Casey, MD, of New York University Langone Medical Center, suggested that doctors use consistent "checklist-based algorithms" that track patient-reported outcomes to improve how they care for these patients.
Second, Casey recommended that patients have higher out-of-pocket insurance co-payments for imaging associated with back pain.
And third, "perhaps the biggest challenge," he wrote, is all the groups, "that promote self-proclaimed intellectual property-based ownership of interventions (including complementary and alternative therapies)…" but which lack "formal and rigorous quality of evidence evaluations…" need to agree on an "objective, common framework or evaluating the value of individual and combination modalities for back pain.
"It is only by achieving greater concordance on the evaluation of the efficacy of back pain interventions that we can achieve greater concordance on our practices."