Early imaging for back pain in older adults not associated with better outcomes

SAN FRANCISCO — Early imaging of older adults who visit their primary care physician for new back pain may not lead to better treatment and may be a waste of resources, according to recently presented study results.

Most back pain treatment protocols call for early imaging of adults because of concerns about red flag conditions and serious underlying systemic diseases, but these may be unnecessary, according to Richard A. Deyo, MD, MPH.

At the International Society for the Study of the Lumbar Spine Annual Meeting, he said incidental findings unrelated to back pain in older adults are common and this, therefore, raises the question of whether early imaging for back pain in older adults can lead to unnecessary interventions and treatment. Study enrollment excluded patients already known to have conditions such as cancer, fractures or neurologic deficits.

Richard A. Deyo

“Among older adults going to a primary care physician for new back pain, early imaging was not associated with better outcomes in terms of disability, pain, or quality of life, but was associated with greater resource utilization,” Deyo said.

The prospective cohort study Deyo presented analyzed 3,000 patients visiting their primary care physician (PCP) for new back pain. Patients were excluded if they had visited their PCP within the previous 6 months for back pain. Researchers conducted the study at three institutions in California, Detroit and Boston.

The two patient cohorts consisted of virtually identical groups of patients based on baseline age, gender, education, comorbidity, diagnosis, Roland-Morris Disability score and back and leg pain scores.

For the primary outcomes for the study, Deyo and colleagues used the Roland-Morris Disability scale and relative value units (RVUs) as a measure of health care utilization.

The results showed older patients who underwent early imaging had no statistically significant differences in disability, back and leg pain and EuroQol-5D outcomes vs. patients who did not undergo early imaging.

“We were primarily interested in the Roland-Morris Disability scale as our primary outcome. But we also looked at resource or relative value units as a measure of health care utilization. Relative value units are ... used to quantify the work associated with a medical service based on the time and the skill required, the practice expenses to provide the service and malpractice costs. We use this in the United States for insurance reimbursement purposes,” Deyo said.

The investigators based RVUs on procedure codes they were able to extract from electronic medical records. The RVUs were used as a measure of intensity in services provided for back pain treatment.

“The only important difference was a much higher utilization in resources in patients that had the early imaging tests. It is a highly significant difference of 22 RVUs, which amounts to a difference of $1,300,” he said.

Earlier imaging tended to lead to more unnecessary interventions, such as physical therapy and injections, according to Deyo. Furthermore, early imaging did not lead to a greater rate of undetected malignancies being found in older patients. – by Robert Linnehan

References:
Jarvik JG, et al. Paper #24. Presented at: International Society for the Study of the Lumbar Spine Annual Meeting; June 8-12, 2015; San Francisco.
Jarvik JG, et al. JAMA. 2015;doi:10.1001/jama.2015.1871.

For more information:
Richard A. Deyo, MD, MPH, can be reached at the Departments of Family Medicine and Internal Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239; email: deyor@ohsu.edu.

Disclosure: Deyo reports no relevant financial disclosures.