Insurance Study Evaluates ER Imaging For Low Back Pain Interview with:
Erin R. Schlemmer, MPH
Health Care Manager / Epidemiologist
Department of Clinical Epidemiology & Biostatistics
Blue Cross Blue Shield of Michigan

MedicalResearch: What is the background for this study?

Response: Low back pain (LBP) is a common reason for emergency department (ED) visits. Usually, uncomplicated acute LBP is a benign, self-limited condition that can be managed without the need for imaging studies. However, national data have shown that a substantial proportion of ED patients with LBP receive imaging studies, and that the use of advanced imaging has increased considerably for this population in recent years.

A number of groups (including specialty societies, a consortium of health plan medical directors, and an expert panel of emergency medicine physicians) have offered recommendations for the appropriate use of imaging for Low back pain. Within these guidelines, there are a number of “red flag” conditions that serve as indications for Low back pain imaging, and it is generally accepted that most patients do not require imaging to inform treatment of their Low back pain unless they have one or more red flags.

Our objective was to use claims data from a large commercial insurer to describe the imaging indications and imaging status of patients presenting to the ED with Low back pain, and to describe demographic and healthcare use characteristics associated with non-indicated imaging.

MedicalResearch: What are the main findings?

Response: We found that over half (51.9%) of all patients presenting to the ED with low back pain had no claims-based evidence of indications for imaging. Overall, 36.5% of patients received imaging, and 10.2% received advanced imaging (CT or MRI). Among patients with imaging indications, the most common indication was trauma (71.6%), followed by cancer (24.0%). Although nearly a third of non-indicated patients received imaging, this population had a lower prevalence of imaging compared to patients with imaging indications (30.1% vs. 43.5%), and were also less likely to have prior healthcare use (such as ED visits) in the past year. Among non-indicated patients who received imaging, 26.2% received advanced imaging (CT or MRI) and 4.3% had >1 type of imaging.

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

Response: Over half of patients presenting to the ED with Low back pain in our study did not have claims evidence of indications to receive imaging, suggestive of uncomplicated low back pain and potentially-avoidable ED visits. Further, according to our data, over 70% of patients with non-indicated imaging saw a PCP in the past year. Greater communication among PCPs, ED physicians, and patients may help prevent unnecessary imaging for LBP or reduce patient demand for imaging.

It is important to note that the generalizability of our findings is limited in that our study population was restricted to commercially insured residents of Michigan. While BCBSM covers about 40% of the commercially insured adults in Michigan and is representative of that population, results should not be generalized to those with public insurance or the uninsured. In addition, patients with commercial health insurance may be more likely to receive imaging because they have third party coverage.

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

Response: Administrative claims data can provide us with useful information about a patient’s medical history, but it is important to keep in mind that claims do not provide a complete medical record. Our ability to characterize indications for imaging is therefore limited. An important next step will be to conduct chart review studies to determine how closely claims data and patient medical records align regarding Low back pain diagnosis, imaging, and imaging indications. In addition, although relatively few patients in our study had observation/treatment room use, non-indicated imaging (particularly MRI) was very common for these patients. Further work could examine imaging in the observation unit to better understand its role in the treatment of low backpain.


Imaging During Low Back Pain Emergency Department Visits – A Claims-Based Descriptive Analysis


Last Updated on February 17, 2015 by Marie Benz MD FAAD