Feb 2014

Illinois Chiropractic Society Journal Article - February 2014

Alarming Data on the Treatment of Lower Back Pain over the Past Decade

From 1997 to 2005, spending for back pain has increased more rapidly than any other health expenditure. 10% of all primary care visits are related to back and neck pain, representing the 5th most common reason for a physician visit. With annual expenditures at $86 billion, the healthcare market is posed for providers who can provide cost effective care that is highly successful.
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As practicing chiropractic physicians, you know the value in the service that we provide to our patients, and we have the potential as a profession to be the highly successful provider who offers cost effective care that helps wrestle the growing cost of back pain down to a more manageable level. We have a deep knowledge of the mechanical causes of musculoskeletal pain, therefore allowing us not to be dependent upon advanced imaging techniques for diagnosing patients. As you will see in the article listed below, these advanced techniques are part of a growing trend that is increased the cost of care for back pain.

Worsening Trends in the Management and Treatment of Back Pain

In this recent article published by JAMA Internal Medicine, the authors used nationally representative data on outpatient visits to physicians to evaluate trends in use of diagnostic imaging, physical therapy, referrals to other physicians and the use of medications during the 12-year period from 1999 - 2010. They hypothesized that with additional guidelines released during that time, the use of recommended treatments would increase and the use of non-recommended treatments would decrease.

During that time period, the authors identified 440 million physician visits for spinal related problems. During the time frame of the study, the number of visits for back pain increased from 61 million in 1999-2000 to 87 million in 2009-2010. Those with Medicare increased from 17.0% in 1999-2000 to 28.4% in 2009-2010. Acute onset diagnosis of back pain actually decreased, however those with long term symptoms increased from 29.7% to 37.1%. The use of narcotics also increased from 19.3% to 29.1%, as well as muscle relaxants from 19.6% to 23.7% and neuropathic agents doubled in usage from 3.4% to 7.9% while the use of NSAIDS and acetaminophen actually decreased. Use of plain film was unchanged during the time frame of the study, however the use of advanced imaging, CT or MRI increased from 7.2% to 11.3%.

As you can see, there is a significant amount of data in this study. In the discussion, it is first noted that the decrease in NSAID and acetaminophen usage, the increase in narcotics, referrals to other physicians and the increase in CT/MRI usage are discordant with current guidelines in the management of back pain.

As the article states, “The 106% increase in referrals to other physicians is a previously unrecognized and important finding because such referrals likely contributed to the recent increase in costly, morbid, and often ineffective outpatient spine operations observed in other studies.
2-5 Recent meta-analysis and research6,7 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. Further, when comparing visits with the patient’s self-identified PCP vs those with another health care professional, we found that non PCPs were much more likely to order advanced imaging. Presumably, this group includes those who perform procedures such as spinal surgery. Thus, these referrals from PCPs are likely to result in substantial downstream use that is disconcordant with current guidelines.”

The authors also found a 50.6% decrease in NSAID usage accompanied by a 50.8% increase in narcotic prescriptions. This trend was noted in both acute and chronic cases of back pain and did not discriminate if the patient was seen by his/her PCP or non-PCP provider. As sited by the authors, a recent meta-analysis
8 revealed that narcotics provide little to no benefit in acute back pain, they have not proved efficacy in chronic back pain, and 43% of patients have concurrent substance abuse disorders, with aberrant medication taking disorders as high as 24% of cases of chronic back pain. Considering there has been a 300% increase in narcotics prescription sales since the 1990s and that overdose deaths in narcotics led to more deaths than cocaine and heroin combined is extremely alarming.9-11

The findings from the study also show an increase of 56.9% in the use of advanced diagnostic imaging. The authors note that there is likely a correlation between the number of advanced images taken and the number of spinal surgeries performed. As sited by the authors, one study revealed that early MRI for acute back pain was associated with an 8-fold increased risk of surgery.

Conclusion
When I first read this article, I was alarmed, however I think there is a significant amount of opportunity for chiropractic physicians. We understand that there is a natural history to back pain, we don’t order excessive imaging, and we can’t prescribe. What we do is restore mobility/mechanics, provide stability and hopefully instill confidence in our patients that they should play an active role in their health. As I mentioned, the data is alarming regarding the current trends in back pain care. By continuing to take excellent and compassionate care for your patients, continuing educating them regarding the safety and efficacy of your care, supporting the ICS and ACA with your membership, the chiropractic profession is posed to help lower the runaway cost and risky practices that associated with back pain today.


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