Chronic back pain is among the most common patient complaints. Its prevalence and impact have spawned a rapidly expanding range of tests and treatments. Some of these have become widely used for indications that are not well validated, leading to uncertainty about efficacy and safety, increasing complication rates, and marketing abuses. Recent studies document a 629% increase in Medicare expenditures for epidural steroid injections; a 423% increase in expenditures for opioids for back pain; a 307% increase in the number of lumbar magnetic resonance images among Medicare beneficiaries; and a 220% increase in spinal fusion surgery rates. The limited studies available suggest that these increases have not been accompanied by population-level improvements in patient outcomes or disability rates. We suggest a need for a better understanding of the basic science of pain mechanisms, more rigorous and independent trials of many treatments, a stronger regulatory stance toward approval and post-marketing surveillance of new drugs and devices for chronic pain, and a chronic disease model for managing chronic back pain.

/pdf/overtreating-chronic-back-pain-time-to-back-off-6yvf7cj3d4.pdf

Overtreating Chronic Back Pain: Time to Back Off?

Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines.

While the United States leads the world in many measures of health care innovation, it has been suggested that it lags behind many developed nations in a variety of health outcomes. It has also been stated that the United States continues to outspend all other Organisation for Economic Co-operation and Development (OECD) countries by a wide margin. Spending on health goods and services per person in the United States, in 2007, increased to $7,290 - almost 2(1/2) times the average of all OECD countries. Rising health care costs in the United States have been estimated to increase to 19.1% of gross domestic product (GDP) or $4.4 trillion by 2018. The increases are illustrated in both public and private sectors. Higher health care costs in the United States are implied from the variations in the medical care from area to area around the country, with almost 50% of medical care being not evidence-based, and finally as much as 30% of spending reflecting medical care of uncertain or questionable value. Thus, comparative effectiveness research (CER) has been touted by supporters with high expectations to resolve most ill effects of health care in the United States and provide high quality, less expensive, universal health care. CER is defined as the generation and synthesis of evidence that compares the benefits and harms of alternate methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care. The efforts of CER in the United States date back to the late 1970's even though it was officially born with the Medicare Modernization Act (MMA) and has been rejuvenated with the American Recovery and Reinvestment Act (ARRA) of 2009 with an allocation of $1.1 billion. CER has been the basis for health care decision-making in many other countries. According to the International Network of Agencies for Health Technology Assessments (INAHTA), many industrialized countries have bodies that are charged with health technology assessments (HTAs) or comparative effectiveness studies. Of all the available agencies, the National Institute for Health and Clinical Excellence (NICE) of the United Kingdom is the most advanced, stable, and has provided significant evidence, though based on rigid and proscriptive economic and clinical formulas. While CER is making a rapid surge in the United States, supporters and opponents are expressing their views. Part I of this comprehensive review will describe facts, fallacies, and politics of CER with discussions to understand basic concepts of CER.

Facts, fallacies, and politics of comparative effectiveness research: Part I. Basic considerations.

Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis.

Objectives

The objectives were to evaluate general emergency department (ED) variation in head computed tomography (CT) use for pediatric head trauma, hospital factors associated with CT use, and recent secular trends in CT utilization for pediatric head trauma.



Methods

This was a cross-sectional study of a sample of general EDs in the Nationwide Emergency Department Sample (NEDS; 2006–2010). The authors included visits by patients <19 years of age with International Classification of Diseases, 9th Revision, Clinical Modification, diagnosis codes for head trauma and determined head CT use via Current Procedural Terminology (CPT), Fourth Edition, codes. Crude and risk-adjusted proportions of visits with CT for each hospital were calculated using multilevel mixed effects logistic regression. The association between hospital-level characteristics and head CT were evaluated by constructing multivariable negative binomial regression models.



Results

There were 324,435 pediatric head trauma visits to 848 EDs in the sample. Median patient age was 8 years (interquartile range [IQR] = 2 to 15 years) and 62% of visits were by males. A minority of patients (0.7%) were severely injured, and only 4.2% were admitted to the hospital. Most EDs (79%) were nonteaching institutions, and 84% were nontrauma centers. Risk-adjusted median CT use was 56.0% (IQR = 46.4% to 64.7%). In multivariate analysis, nontrauma centers were 9% (95% confidence interval [CI] = 4% to 15%) less likely to use head CT for pediatric head trauma patients and among discharged patients, EDs within nonteaching hospitals were 8% more likely to perform CT imaging (95% CI = 2% to 14%). There was no change in CT use from 2006 through 2010 (p = 0.31).



Conclusions

There is significant variability among general EDs in CT use for pediatric head trauma, indicating the need for strategies to reduce variation and improve ED imaging practices for this population.


Resumen
Objetivos

Evaluar en un servicio de urgencias (SU) la variacion en el uso de la tomografia computarizada (TC) craneal para el traumatismo craneoencefalico pediatrico, los factores hospitalarios asociados con el uso de la TC y las recientes tendencias en la utilizacion de la TC para el traumatismo craneoencefalico pediatrico.



Metodologia

Estudio transversal de una muestra de SU generales de la Nationwide Emergency Department Sample (NEDS; 2006–2010). Se incluyeron visitas de pacientes menores de 19 anos de edad con el diagnostico codificado de traumatismo craneoencefalico segun la Clasificacion Internacional de Enfermedades, 9° Revision, Modificacion Clinica y se determino el uso de la TC craneal segun los codigos de la Current Procedural Terminology (CPT), Fourth Edition. Las proporciones crudas y ajustadas de las visitas con TC para cada hospital se calcularon usando regresion logistica. La asociacion entre las caracteristicas del nivel de hospital y la TC craneal se evaluaron por modelos de regresion binomiales negativos multivariables.



Resultados

Hubo en la muestra 324.435 visitas por traumatismos craneoencefalicos pediatricos en 848 SU. La edad mediana de los pacientes fue de 8 anos (rango intercuartil [RIC] 2 a 15 anos) y un 62% fueron varones. Una minoria de los pacientes (0,7%) tuvo una lesion grave y solo un 4,2% fueron ingresados en el hospital. La mayoria de los SU (79%) fueron centros no universitarios y un 84% fueron centros no traumatologicos. La mediana de riesgo ajustado del uso de la TC fue de un 56,0% (RIC 46,4% a 64,7%). En el analisis multivariable, los centros no traumatologicos tuvieron un 9% (IC 95% = 4% a 15%) menos de probabilidad de usar la TC craneal para los pacientes con traumatismo craneoencefalico pediatrico y, entre los pacientes dados de alta, los SU de hospitales no universitarios tuvieron un 8% mas de probabilidad de realizar una TC (IC 95%= 2% a 14%). No hubo cambio en el uso de la TC desde 2006 hasta 2010 (p = 0,31).



Conclusiones

Hay una variabilidad significativa entre los SU generales en el uso de la TC para el traumatismo craneoencefalico pediatrico, lo cual indica la necesidad de estrategias para reducir la variacion y mejorar las practicas de imagen en el SU para esta poblacion.

https://www.onlinelibrary.wiley.com/doi/pdf/10.1111/acem.12458

Variation in emergency department head computed tomography use for pediatric head trauma

OBJECTIVE To compare primary care providers' (PCPs') use of lumbar spine magnetic resonance imaging (MRI) studies and surgical referrals for patients with low back pain (LBP) before and after dissemination of the 1994 Agency for Healthcare Policy and Research (AHCPR) LBP guidelines. DESIGN Retrospective cohort study. PATIENTS AND METHODS Computerized audits identified patients with LBP evaluated by PCPs in 1994 or 1996 at a university-affiliated Veterans Affairs medical center who had an MRI order and/or a surgical referral. Research assistants recorded patients' demographic characteristics, LBP-related symptoms, and whether the PCP ordered an MRI and/or a surgery consult. For patients referred to surgery without an MRI, subsequent MRI orders by surgeons were recorded. We compared patient characteristics and utilization patterns for 1994 and 1996 and identified independent predictors of MRI orders. RESULTS PCPs saw 279 and 261 patients with LBP in 1994 and 1996, respectively. An almost identical number of MRIs were ordered in 1994 (99 by PCPs and 42 by surgeons) and 1996 (105 by PCPs and 32 by surgeons). Nearly 50% of patients meeting AHCPR guidelines underwent an MRI in 1994 or 1996. PCPs more frequently ordered a surgery consult in 1994 than in 1996. Providers were less likely to order an MRI for patients with a previous MRI and more likely to order an MRI for those seen in an urgent visit clinic. Neither year nor meeting AHCPR guidelines predicted MRI ordering. CONCLUSIONS Orders for MRI did not decrease after education on the guidelines. Limiting MRI orders to only "appropriate" patients would not have changed the observed results.

Can guidelines impact the ordering of magnetic resonance imaging studies by primary care providers for low back pain

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Can guidelines impact the ordering of magnetic resonance imaging studies by primary care providers for low back pain