Blog | Wednesday, July 31, 2013

QD: News Every Day--Back pain guidelines not influencing how doctors manage care

In stark contrast to guidelines for managing routine back pain, doctors are increasing their use of diagnostic imaging, referrals and narcotics, while nonsteroidal anti-inflammatory drug or acetaminophen use has declined and physical therapy referrals remain constant, a study found.

Researchers used nationally representative data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey from January 1999 through December 2010 to identify nearly 24,000 visits for spine problems. Results appeared online at JAMA Internal Medicine.

NSAID 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%. The number of radiographs remained at about 17%, but the number of computed tomograms or magnetic resonance images increased from 7.2% to 11.3%.

Physical therapy referrals remained unchanged at about 20%, but physician referrals increased from 6.8% to 14%, and this increase "likely contributed to the recent increase in costly, morbid, and often ineffective outpatient spine operations observed in other studies. Recent meta-analyses and research of lumbar fusion surgery have not revealed improvement in patient outcomes and demonstrate that these procedures lead to significant adverse consequences, including 5.6% with life-threatening complications and 0.4% mortality."

In an editorialDonald E. Casey Jr., MD, MPH, MBA, FACP, wrote, "Whereas these guidelines promote use of nonopioid analgesics, avoidance of imaging tests, use of physical therapy-based exercises, and primary care for this population, the results of this analysis demonstrate recent significant decreases for these recommendations. 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."