Reducing Wasteful Healthcare Spending

Costly Imaging for Low Back Pain is Often Unnecessary

“87% of young people have back pain. The other 13% have no computer.” - Unknown

Most of us have experienced back pain at some point. ln fact, low back pain (LBP) is one of the most common conditions, with approximately 25% of U.S. adults experiencing LBP over a three-month period.1 The increase in individuals working remotely has likely exacerbated the situation due to poor ergonomic home set-ups.2

The pain can be quite debilitating, and patients are frequently eager to have an explanation that will explain their pain and help them begin to recover. As a result, LBP commonly drives individuals to seek treatment, which often leads to a physician ordering costly imaging studies, including x-rays, computed tomography (CT) scans, or magnetic resonance imaging (MRI) studies.

Abnormalities, mainly due to aging, are often found through these studies. Patients with LBP may be relieved when their physician shows or describes these abnormalities, believing that the source of their pain has been found. Treatment recommendations are made based on the findings, which may include surgery.

You may be surprised to know that despite how often they’re ordered, imaging studies for acute LBP are often cited on lists of common low-value care services - care that contributes to costs or causes additional harm without improving outcomes.

If these studies frequently find real abnormalities, why are they considered low-value services?

It turns out that findings from imaging studies of the spine are often incidental, and not actually associated with the true cause of low back pain. Studies have shown that anatomic abnormalities on imaging studies become increasingly common as we age (over half of 30-year-olds have abnormalities) and are just as common in asymptomatic individuals as in individuals with low back pain.3

In other words, despite the relief of receiving an explanation for a patient’s pain, the explanation may not be the correct one, and may lead to a less than optimal treatment path.

Acute back pain is commonly due to muscle strain, which is not identified with imaging. Furthermore, most individuals will improve from conservative treatment within a few weeks, rendering the studies unnecessary unless pain persists.

Imaging for low back pain can lead to other harm and costs, including:

  • Unnecessary radiation

  • Incidental findings that lead to additional tests

  • Patient perception that they have a signficant issue, leading to stress and unnecessary limitation of activity

  • Higher use of opioids for pain management4

  • Increased likelihood of being referred for unnecessary surgical procedures like spinal fusion to correct the “problem”

Like most forms of low-value care, use of spine imaging is clinically nuanced. Imaging may be necessary when pain does not improve after four to six weeks of conservative care, or sooner in patients who are found to have severe or progressive neurologic deficits, fever, trauma, or serious underlying medical conditions like cancer.


Magnitude of the Problem

The magnitude of the problem in the United States has been estimated at about 1.6 million avoidable imaging services annually for low back pain with an aggregate cost of about $500 million.5

Related costs for lower back imaging tests and potential surgical procedures, based on the 2020 Springbuk Book of Business, include


Actions Employers Can Take

Employer actions that can reduce both costs and harms of unnecessary low back imaging include:

  • Reduce the incidence of low back pain by providing guidance on proper lifting and ergonomic tips for those sitting at a desk

  • Institute narrowly targeted prior authorization plans for lower back imaging and other high cost and/or high volume tests that are often unnecessary

  • Encourage use of high-deductible health plans, which have been shown to decrease use of low value care more than necessary care

  • Increase patient cost sharing for lower back imaging and other services that are frequently unnecessary

  • Empower employees to ask how diagnostic testing will be used in determining treatment planning, and potential risks of tests

  • Request that onsite clinics distribute or review Choosing Wisely’s patient information on imaging for low back pain6

  • When establishing a contract with a health plan, look for plan(s) that incorporate low-value care performance in network design


Key Takeaways

Low back pain is a common condition that usually resolves within a few weeks. Much of the imaging related to LBP is unnecessary, costly, and has the potential to cause harm.

Employer actions can reduce wasteful spending due to unnecessary low back pain imaging. Low Value Care Insights cards, available in the Springbuk health data analytics platform, provide information related to occurrences and potential strategies to reduce low back pain imaging, other unnecessary imaging procedures, antibiotic misuse, and non-recommended screening exams.


References

  1. https://www.cdc.gov/acute-pain/low-back-pain/index.html#ftn2

  2. https://www.nytimes.com/2020/0...

  3. https://www.bmj.com/content/372/bmj.n291

  4. https://pubmed.ncbi.nlm.nih.gov/32989711/

  5. The Top Five Low-Value Services

  6. Choosing Wisely Patient Information - Imaging Tests for Lower-Back Pain


Meet the Author

Janet Young, M.D.

With more than 20 years of experience, Janet Young has provided clinical expertise and oversight to the development of healthcare analytics used in provider, payer, employer, and government sectors. Most recently, Young served as a lead clinical scientist at IBM Watson Health, guiding clinical content development related to new models, methods and analytics using claims, EMR, Health Risk Assessment, and socio-demographic data.