Overutilization in the ED: One in three visits for lower back pain includes imaging

One in three new visits to the emergency department for lower back pain includes an imaging exam, according to a new study published in the American Journal of Roentgenology.

While the researchers did find a “modest decline” in 2016, the overall figures are still too high, they wrote. This overutilization comes despite industry guidance to only image cases that include “red flags” such as suspected fracture, malignancy or infection.

“Reducing low back pain imaging in the ED specifically is one of the targets of the national Choosing Wisely campaign, a U.S. initiative to reduce unnecessary costs and radiation for patients by encouraging evidence-based dialogue between patients and ordering providers,” Jina Pakpoor, with the Hospital of the University of Pennsylvania, and colleagues wrote.

The researchers analyzed more than 134,000 ED visits over five years for patients with low back pain who were part of a national commercial claims and encounters database. Imaging—including x-ray, CT and MRI—was performed in 33.7% of those visits. Utilization fell from 34.4% in 2011, to 31.9% in 2016. A majority of patients received a radiography exam (30.9%), while 2.7% underwent CT and 0.8% received MRI.

According to the authors, the slight dip in imaging may be due to an increased use of clinical decision support tools and physicians' fears of litigation, which can prompt some to order imaging exams to back up their clinical diagnosis.

Pakpoor and co-authors also found that imaging utilization was different according to geographical region. For example, patients in the southern U.S. underwent 10% more exams than those in the west. While the primary causes of this variation are unknown, the researchers suggested insurance status, rural versus urban setting and physician availability in the ED as potential explanations.

“The use of imaging in new ED visits for low back pain has declined in recent years but continues to occur at a relatively high rate in the United States,” Pakpoor et al. wrote. “Additional research is needed to understand the underlying reasons for persistent use of potentially unwarranted imaging in the emergency setting."