Hospital report card: MGH shows appropriate use of imaging for low back pain

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Standards for the appropriate use of medical imaging on patients complaining of low back pain in the emergency department (ED) are being followed successfully, at least at one high ranking institution, according to a study published online in the Journal of the American College of Radiology (JACR).

As medical expenditures continue to swell in size around the world, an increased emphasis on imaging efficiency is targeting excessive and unnecessary scans as a means of driving down costs and reducing waste in the medical industry. Researchers have estimated that as much as $300 million could be saved by following guidelines for the appropriate use of imaging set forth by the American College of Radiology (ACR) in cases of low back pain alone.

“Americans spend more than $50 billion each year on the diagnosis and treatment of low back pain, which is the most common job-related disability in the United States,” wrote lead author Sishir Rao, MD, and his colleagues at Massachusetts General Hospital in Boston. “Moreover, individuals with back pain incur 60 percent higher per capita health care costs than those without back pain.”

To assess how well the ACR recommendations were being followed in their hospital, the researchers performed a retrospective analysis on ED records of 100 random patients who presented with low back pain between January and April 2013. Patient demographics, symptoms, treatments, use of imaging, imaging study indications and outcomes were evaluated and compared with the ACR guidelines for appropriate imaging use.

Their results showed that a majority of the patients studied (54 percent) were not imaged, and that the decision to forgo imaging screening was appropriate 96 percent of the time. Of the 46 patients who underwent imaging procedures, 96 percent were determined to have received appropriate ED or outpatient imaging services.

Previous research, including a 2010 study published in JACR and a 2013 study published in the European Journal of Radiology, have reported rates of inappropriate imaging somewhere between 7 and 26 percent. But according to Rao, the Massachusetts General researchers’ rate of 4 percent does not come as a surprise. “Our hospital efforts to promote imaging decision support were based on the strength of the ACR [imaging guidelines],” wrote Rao et al. “We believe a radiologist-driven decision-support system based on the ACR [appropriateness criteria] can have hospital-wide patient-quality and system-efficiency benefits.”

While the appropriateness of imaging for low back pain and guidelines governing its use continue to be assessed in our nation’s hospitals, the fact remains that most patients presenting with low back pain in EDs can be spared exorbitant costs and unnecessary exposure to harmful radiation by forgoing excessive scans and following physicians’ orders for conservative treatment.

“Imaging of uncomplicated [low back pain] patients is associated with increased costs without additional clinical benefit, and may even be harmful for patients, owing to incidental findings, needless diagnostic radiation, and unnecessary surgical interventions,” Rao and his colleagues wrote. “[Our] findings suggest that, in our patient group, with predominately uncomplicated acute or acute on chronic back pain, rest, physical therapy, and pain medication can lead to resolution of symptoms without unnecessary imaging or procedures.”