Physicians have gotten worse at following clinical guidelines on routine back pain, JAMA study shows

Over the last decade, physicians have gotten worse at following "well-established' guidelines for treating routine back pain, which has potentially contributed to soaring U.S. health costs and led to unnecessary surgeries, according to a study published in JAMA Internal Medicine.

Comparing data from 2000 to 2010, researchers found that over that time physicians prescribed more narcotics, made more referrals to other physicians and used more imaging procedures such as CT and MRI for patient visits involving routine back pain, according to the study. Researchers considered those actions to be "discordant" with current clinical guidelines.

In contrast to much of the physician behavior observed in the study, well-established guidelines for routine back pain stress conservative management, including use of nonsteroidalanti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy, but avoiding early imaging or other aggressive treatments, except in rare cases, the authors write.

However, in analyzing data associated with nearly 24,000 visits for spine problems, researchers found that NSAID or acetaminophen use per visit decreased from 37% in 2000 to 25% 2010. In contrast, narcotic use increased from 19% to 29% per visit over that time frame.

Physical therapy referrals remained unchanged at about 20%, but referrals to physicians increased from 7% to 14%. The number of CTs and MRIs increased from 7% to 11% during the study period, according to the study.

The excessive spending caused by this failure to follow guidelines is potentially significant, simply because back pain is such a common condition. More than 10% of visits to primary care physicians (PCPs) relate to back or neck pain, representing the fifth-most-common reason for all physician visits and accounting for approximately $86 billion in healthcare spending annually, the study says.

"With healthcare costs soaring, improvements in the management of back pain represent an area of potential cost savings for the healthcare system while also improving the quality of care," the researchers note.

About half of the physicians involved in the study were PCPs, and the authors noted two significant contrasts between PCPs and other specialists that were observed in the study. First, the use of CT and MRI increased more rapidly among non-PCPs over the study's timeframe. Second, NSAID or acetaminophen use decreased by almost half among PCPs, but remained flat among non-PCPs.

John Mafi, MD, of Harvard Medical School was the study's lead author. Researchers obtained data for the study from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey.

In an accompanying editorial, Donald Casey Jr., MD, of the NYU Langone Medical Center, offers several potential explanation for why physicians are following clinical guidelines for routine back-pain treatment less frequently. Those explanations include reduced time for PCPs to evaluate back-pain patients, patient demand for quick answers and a resolution of symptoms, fear by physicians of malpractice liability for "missing something" and "price insensitivity" for healthcare services by both physicians and patients.

"The first step in addressing a problem is to admit that you have it, and in that regard the article by Mafi et al forces us to admit that development of clinical guidelines alone will not solve our problem in managing back pain," Casey says.

Casey offers three possible solutions to the problem:

• Better standardization of care through the use of consistent algorithm-based checklists by well-trained, multidisciplinary clinical teams.

• More appropriate economic incentives for patients and physicians, such as higher patient copays for expensive imaging procedures.

• Bringing together all key stakeholders - physicians, government, payers, employers and consumer groups - to agree on "an objective, common framework" for evaluating the value of various back-pain treatment options.

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