Back Pain: Early Imaging Of Older Adults Results in More Costs, Not Better Outcomes

Jeffrey (Jerry) G. Jarvik MD MPH Professor, Radiology, Neurological Surgery and Health Services Adjunct Professor, Pharmacy and Orthopedics & Sports Medicine Director, Comparative Effectiveness, Cost and Outcomes Research Center University of Washington Seattle, WA  98104-2499MedicalResearch.com Interview with:
Jeffrey (Jerry) G. Jarvik MD MPH
Professor, Radiology, Neurological Surgery and Health Services
Adjunct Professor, Pharmacy and Orthopedics & Sports Medicine
Director, Comparative Effectiveness, Cost and Outcomes Research Center University of Washington Seattle, WA

Medical Research: What is the background for this study?

Dr. Jarvik: 
When I arrived at the Univ of WA over 20 years ago, my mentor, Rick Deyo, had just finished leading a project that was responsible for developing one of the first set of guidelines for the diagnosis and treatment of acute low back pain. These guidelines, published in a booklet by AHRQ (then called AHCPR), recommended that patients with acute low back pain not undergo imaging for 4-6 weeks unless a red flag was present. One of the exceptions was that patients older than 50 could get imaged immediately, the rationale being that older adults had a higher prevalence of potentially serious conditions such as cancer, infections, etc, that would justify the early imaging. As a practicing neuroradiologist, it was clear that a potential problem with this strategy is that the prevalence of age-related changes, which may or may not be related to back pain, also increases with age. So earlier imaging of older adults would almost certainly reveal findings, and these could easily start a series of unfortunate events leading to potentially poor outcomes and more healthcare resource use. Thus this policy of early imaging of older adults didn’t entirely make sense.

About 5 years ago, these guidelines hit home when I developed acute low back pain and since I was over 50 (barely) my doctor recommended that I get an imaging study. Being a knowledgeable patient and having a reasonable doctor, we mutually agreed not to get the study. I improved but that wasn’t the end of it. When we had the chance to apply for one of the CHOICE ARRA awards funded by AHRQ, we made answering this question of early imaging in older adults one of our primary goals.

Medical Research: What are the main findings?

Dr. Jarvik:

  1. Older adults with back pain who seek care and get imaging within 6 weeks of their doctors visit for back pain do not have better outcomes than similar older adults who do not get early imaging.
  2. While early imaging is not associated with better pain and function outcomes, it is associated with greater use of healthcare services, such as visits, injections, etc.
  3. The overall difference in resource utilization translates into a nearly $1,500 per patient additional cost for no measurable benefit. This is the opposite of “high value healthcare”- no benefit at great cost.

Medical Research: What should clinicians and patients take away from your report?

Dr. Jarvik: Our study suggests that older adults should not be treated differently than younger adults with respect to low back imaging guidelines. In the absence of “red flags” older adults should not undergo immediate spine imaging, but like younger adults, wait at least 6 weeks before being imaged. Early imaging doesn’t help improve outcomes for older adults experiencing back pain, but does lead to great health resource use.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Jarvik: While we now know that early imaging does not improve the pain or function of older adults with new primary care visits for back pain, we have some evidence from the same cohort of patients that early physical therapy may be beneficial. Work done by one of our junior faculty in Rehabilitation Medicine, Sean Rundell, PhD, suggests this sort of benefit. A rigorous trial investigating early physical therapy could well be informative.

However, the next challenge that we face on this topic is not so much a need for future research studies, but rather the challenge of communicating and disseminating these results so that they can become integrated into primary care. The routine use of imaging shortly after a patient presents with low back pain, regardless of their age, will hopefully become a thing of the past.

 Citation:

 

MedicalResearch.com Interview with: Jeffrey (Jerry) G. Jarvik MD MPH (2015). Back Pain: Early Imaging Of Older Adults Results in More Costs, Not Better Outcomes