0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Worsening Trends in the Management and Treatment of Back Pain FREE

John N. Mafi, MD1; Ellen P. McCarthy, PhD, MPH1; Roger B. Davis, ScD1; Bruce E. Landon, MD, MBA, MSc1,2
[+] Author Affiliations
1Division of Primary Care and General Internal Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
2Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
JAMA Intern Med. 2013;173(17):1573-1581. doi:10.1001/jamainternmed.2013.8992.
Text Size: A A A
Published online

Importance  Back pain treatment is costly and frequently includes overuse of treatments that are unsupported by clinical guidelines. Few studies have evaluated recent national trends in guideline adherence of spine-related care.

Objective  To characterize the treatment of back pain from January 1, 1999, through December 26, 2010.

Design, Setting, and Patients  Using nationally representative data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, we studied outpatient visits with a chief symptom and/or primary diagnosis of back or neck pain, as well as those with secondary symptoms and diagnoses of back or neck pain. We excluded visits with concomitant “red flags,” including fever, neurologic symptoms, or cancer. Results were analyzed using logistic regression adjusted for patient and health care professional characteristics and weighted to reflect national estimates. We also present adjusted results stratified by symptom duration and whether the health care professional was the primary care physician (PCP).

Main Outcomes and Measures  We assessed imaging, narcotics, and referrals to physicians (guideline discordant indicators). In addition, we evaluated use of nonsteroidal anti-inflammatory drugs or acetaminophen and referrals to physical therapy (guideline concordant indicators).

Results  We identified 23 918 visits for spine problems, representing an estimated 440 million visits. Approximately 58% of patients were female. Mean age increased from 49 to 53 years (P < .001) during the study period. Nonsteroidal anti-inflammatory drug or acetaminophen use per visit decreased from 36.9% in 1999-2000 to 24.5% in 2009-2010 (unadjusted P < .001). In contrast, narcotic use increased from 19.3% to 29.1% (P < .001). Although physical therapy referrals remained unchanged at approximately 20%, physician referrals increased from 6.8% to 14.0% (P < .001). The number of radiographs remained stable at approximately 17%, whereas the number of computed tomograms or magnetic resonance images increased from 7.2% to 11.3% during the study period (P < .001). These trends were similar after stratifying by short-term vs long-term presentations, visits to PCPs vs non-PCPs, and adjustment for age, sex, race/ethnicity, PCP status, symptom duration, region, and metropolitan location.

Conclusions and Relevance  Despite numerous published clinical guidelines, management of back pain has relied increasingly on guideline discordant care. Improvements in the management of spine-related disease represent an area of potential cost savings for the health care system with the potential for improving the quality of care.

Figures in this Article

Spinal symptoms are among the most common reasons for visiting a physician and significantly contribute to health care expenditures. More than 10% of visits to primary care physicians (PCPs) relate to back or neck pain (hereafter referred to as back pain), representing the fifth most common reason for all physician visits and accounting for approximately $86 billion in health care spending annually.13 Indirect costs related to lost productivity amount to an additional $20 billion per year, which likely is an underestimate because the prevalence of chronic back pain may be increasing.35 Moreover, spending for these conditions has increased more rapidly than overall health expenditures from 1997 to 2005.6

Well-established guidelines for routine back pain stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy, but avoiding early imaging or other aggressive treatments, except in rare cases, such as acute neurologic compromise or other “red flags,” including a history of malignant neoplasms. In the absence of these features, routine back pain will usually improve with such conservative treatments within 3 months.79 Prior research among patients with back pain revealed significant increases in the use of computed tomography (CT) or magnetic resonance imaging (MRI), outpatient surgical procedures, and narcotic prescriptions, but many of these studies are more than a decade old, are limited to specific populations (eg, Medicare recipients), or study different measures, such as operations or hospitalizations.6,1015

In this context, we used nationally representative data on outpatient visits to physicians to evaluate trends in use of diagnostic imaging, physical therapy, referrals to other physicians, and use of medications during the 12-year period from January 1, 1999, through December 26, 2010. We hypothesized that with the additional guidelines released during this period,8,1621 use of recommended treatments would increase and use of nonrecommended treatments would decrease.

Data Sources

We used nationally representative data on visits to physicians available from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) for 1999-2010. These surveys are designed to be combined to represent outpatient care in the United States.22 The NAMCS comprises a probability sample of outpatient visits to nonfederal, office-based physician practices. Designed in parallel, the NHAMCS consists of outpatient visits to hospital-based ambulatory departments, including outpatient clinics, and visits to emergency departments. The NAMCS and NHAMCS share common design and survey variables and patient visit weights and when analyzed together reflect national estimates.23 Further documentation of survey methods are available at the National Center for Health Statistics (NCHS) website.24

Data Collection Procedures

Both the NAMCS and NHAMCS use a multistage probability sample design to obtain nationally representative samples of ambulatory patient visits in the United States.22 In the first stage of sampling, 112 primary sampling units were selected from among those used in the National Health Interview Survey. For the second stage, physician practices or hospitals were selected from within these primary sampling units. Finally, in the last stage, physicians or clinics sampled a subset of visits in their practices during a predefined period. This design enables calculation of national-level estimates and associated SEs using survey weights provided by the NCHS.24

Data are collected using a standardized form completed during each patient visit. Both the NAMCS and NHAMCS include data on the patient’s primary reason for visit (eg, chief symptom), 2 other nonprimary reasons for visit, up to 3 diagnoses derived from the International Classification of Diseases, Clinical Modification, Ninth Revision (ICD-9-CM), expected payer for the visit (eg, Medicare or commercial insurance), various patient demographic characteristics, and medications listed during the visit.

Study Sample

To identify visits for spine-related conditions, we selected outpatient visits (excluding emergency department visits) with a chief symptom and/or a primary diagnosis of back or neck pain, as well as those with secondary symptoms and diagnoses of back or neck pain but unrelated primary reasons for the visit (eg, hypertension). We used reason for visit codes from both the NAMCS and NHAMCS to identify visits with a chief or secondary symptom of back pain (eAppendix, eTable 1, and eTable 2 in the Supplement).

In the subset of visits with a chief symptom of back or neck pain (>50% of visits in our sample), the NAMCS and NHAMCS provide the duration or context of symptoms in 5 categories: (1) new onset (<3 months’ duration), (2) acute on chronic flare-up, (3) chronic routine, (4) routine or preventive care visit, and (5) preoperative or postoperative visit. This variable was missing 1.3% of the time. We defined acute visits by combining those with new-onset symptoms with those with acute on chronic flare-up. We then compared the acute group with those with chronic routine symptoms. Our results were not substantively different when the acute on chronic flare-up category was categorized as chronic.

We excluded visits with concomitant “red-flag” diagnoses or symptoms, including fever, weight loss, cachexia, neurologic symptoms, cancer, spinal fracture, myelopathy, or postlaminectomy syndrome, that might be indicative of something other than routine musculoskeletal back pain.2527 As a sensitivity analysis, we also excluded visits with a coexistent diagnosis with similar treatment options (eg, knee pain and spasm of muscle) and those with concomitant trauma, fracture, various abdominal, musculoskeletal, neurologic, pulmonary, and infectious diagnoses. When including these visits, however, the results were similar (eTable 3 in the Supplement), so we included these visits in our final analyses.

Main Outcomes Measures

We focused on 3 types of measures: (1) referrals for physical therapy or to other physicians; (2) use of imaging, including both CT or MRI and plain radiography (eTable 4 in the Supplement); and (3) use of medications, including NSAIDs (eg, cyclooxygenase-2 inhibitors) and acetaminophen (NSAIDs or acetaminophen both prescription and over the counter), narcotics, tramadol, benzodiazepines and muscle relaxants (eg, cyclobenzaprine hydrochloride), and agents to treat neuropathic pain (eg, gabapentin). We considered NSAIDs or acetaminophen use as guideline concordant and considered narcotic prescriptions as guideline discordant.21 Before 2003, the NAMCS and NHAMCS only collected data on up to 6 drugs; therefore, to maintain consistency over time, we limited analysis of all years to the first 6 drugs listed.

We considered referrals for physical therapy to be concordant with current guidelines, but referrals to other physicians, presumably for consideration of treatments such as injections or surgery, to be discordant with current guidelines. We also considered use of imaging studies for routine back pain to be discordant with clinical guidelines. Although the American College of Physicians guidelines were published in 2007, clinical guideline recommendations have remained generally consistent across specialties and around the world since the 1990s (eTable 8 and eTable 9 in the Supplement).28,29 Moreover, although some visits classified as guideline discordant might in fact be appropriate if additional clinical data (eg, neurologic examination) were available, our focus is less on the proportion of guideline adherent treatments and more on trends over time. We have no reason to suspect that the proportion of visits with indications for various procedures or treatments would have changed over time.

Finally, using logistic regression pooled across the entire study sample and including a control variable for year, we evaluated factors independently associated with ordering CT or MRI studies, narcotic medication use, and referring to another physician—the 3 outcomes we thought were most important.

Stratified Analyses

To evaluate the degree to which symptom duration affected our results, we analyzed the subset of visits with a chief symptom of back pain after stratifying by acute vs chronic presentations as defined above.

We also stratified our analyses of the full sample based on whether the health care professional identified himself or herself as the patient’s PCP. We also assessed interactions between visit year and symptom duration and visit year and PCP status. In addition, we stratified results by data from the NAMCS vs NHAMCS (eTable 10 in the Supplement). Finally, because comorbid conditions were not collected until 2005, we examined trends in the 14 comorbid conditions collected in 2005-2010 using χ2 tests.

Statistical Analysis

We assessed unadjusted trends using bivariable logistic or linear regression when appropriate and evaluated categorical variables using χ2 tests. For each outcome measure, we report proportions of use for each interval after pooling the survey data into six 2-year intervals as recommended by the NCHS (1999-2000, 2001-2002, 2003-2004, 2005-2006, 2007-2008, and 2009-2010). For adjusted and stratified analyses, we estimated logistic regression models for each outcome of interest, focusing on a linear trend for each 2-year interval and adjusting for age, sex, race/ethnicity, insurance status, whether the health care professional was the PCP, location in a metropolitan area, region, and the duration of symptoms when available (because physician specialty information was only available in the NAMCS, this variable was not included in our models; however, sensitivity analyses in the NAMCS subset revealed that the presence of specialty variables did not alter our results). Race/ethnicity was defined by the health care professionals completing the survey instruments. We divided race into 3 categories: white, black, and other, which includes persons of Asian, Native Hawaiian, Pacific Islander, American Indian, or multiple races. We then recategorized patients of any race who were identified as Hispanic to create a single 4-level race/ethnicity variable.

All analyses were performed using SAS-callable SUDAAN, version 10.0 (RTI International) to account for the complex survey sample design. As noted above, we followed the NCHS recommendations for combining the NAMCS and NHAMCS data sets.23 The Harvard Medical School Committee on Human Studies determined that this study was exempt from review.

We identified 23 918 visits related to back pain, representing an estimated 440 million visits during the 12-year period or a mean of 73 million visits biennially. The number of patient visits related to back pain increased during the period from 3350 visits in 1999-2000 (representing 61 million visits or 3.1% of all visits) to 4078 visits during 2009-2010 (representing 87 million visits or 3.5% of all visits). Table 1 summarizes trends in visit characteristics among patients presenting with back pain (eTable 5 in the Supplement provides year-by-year trends). Mean age increased from 49 to 53 years (P < .001), whereas the proportion of females remained stable at approximately 58%. A total of 17.0% of visits were from Medicare enrollees in 1999-2000 compared with 28.4% in 2009-2010 (P = .01). Among those with a chief symptom of back pain (51.8% of the sample), the proportion with acute or new-onset symptoms decreased from 63.7% in 1999-2000 to 58.6% in 2009-2010, whereas those with long-term symptoms increased from 29.7% to 37.1% during the same period (P < .001). Comorbidities did not significantly change with the exception of asthma, which increased from 3.6% in 2005-2006 to 6.5% in 2009-2010 (P < .001, eTable 6 in the Supplement).

Table Graphic Jump LocationTable 1.  Patient and Visit Characteristics Over Time
Unadjusted Trends in Use
Medications

Use of NSAIDs or acetaminophen decreased from 36.9% in 1999-2000 to 24.5% in 2009-2010 (P < .001, Table 2). In contrast, use of narcotics increased from 19.3% to 29.1% during the same period (P < .001 for trend). Use of muscle relaxants and benzodiazepines increased from 19.6% in 1999-2000 to 23.7% in 2009-2010 (P < .001), and use of neuropathic agents more than doubled, from 3.4% to 7.9%, during the same period (P < .001).

Referrals and Imaging

Referrals to physical therapy remained unchanged at approximately 20.0% across the study period, but referrals to other physicians increased from 6.8% in 1999-2000 to 14.0% in 2009-2010 (P < .001). There was no observed change in the use of plain radiographs (approximately 17.0% across the study period), but use of MRI or CT increased from 7.2% in 1999-2000 to 11.3% in 2009-2010 (P < .001).

Adjusted and Stratified Trends in Use

After adjustment, trends in use did not differ substantively from the unadjusted findings. The Figure shows adjusted proportions of referrals to physical therapy, referrals to physicians, and narcotic and NSAID or acetaminophen use over time.

Place holder to copy figure label and caption
Figure.
Adjusted Proportions of Referrals and Selected Drugs Over Time

Estimates adjusted for age, sex, race/ethnicity, region, insurance type, symptom duration and context, whether the health care professional was the primary care physician, and whether the visit was located in a metropolitan area.

Graphic Jump Location

Stratified analyses of visits with a chief symptom of back pain comparing visits with acute vs chronic pain revealed similar trends for the 2 groups during the study period (Table 3). Among patients with chronic symptoms, however, referrals to other physicians increased more rapidly when compared with those with acute symptoms (P = .01 for interaction with time), with referrals to physicians increasing from 3.0% to 13.4% for chronic symptoms and from 6.7% to 10.5% for those with acute symptoms during the study period (P < .001 and P = .07 for trend, respectively). Although changes in referrals to other physicians among patients with acute symptoms and CT or MRI use among patients with chronic symptoms did not achieve statistical significance, use of these indicators also increased over time for both groups.

Table Graphic Jump LocationTable 3.  Adjusted Proportions of Use Stratified by Chief Symptom of Acute vs Chronic Back Pain Over Timea

Comparing visits to PCPs and non-PCPs also revealed similar trends, albeit with a few exceptions (Table 4). Among non-PCPs, CT or MRI use increased somewhat more rapidly when compared with visits to PCPs, increasing from 4.9% to 6.6% among PCPs (P = .02) vs 9.5% to 14.3% for non-PCPs (P = .002) throughout the study period; however, interactions with time were nonsignificant. Finally, NSAID or acetaminophen use decreased by almost half among PCPs (P < .001 for trend) and remained flat among non-PCPs (P = .47 for trend), and this difference was statistically significant (P = .01).

Table Graphic Jump LocationTable 4.  Adjusted Proportions of Use by Identified PCP vs Non-PCP Over Timea
Correlates of Use

eTable 7 in the Supplement presents the results of multivariable logistic regression models estimating use of CT or MRI studies, referrals to physicians, and narcotic prescriptions with visits pooled for the entire period. Patients of black, Hispanic, and other race/ethnicity had lower odds ratios (ORs) for receiving narcotic medications (OR, 0.77; 95% CI, 0.65-0.92; OR, 0.60; 95% CI, 0.39-0.95; and OR, 0.51; 95% CI, 0.40-0.65; respectively), as did female patients (OR, 0.86; 95% CI, 0.77-0.96). Uninsured patients had a lower OR for being referred to other physicians (OR, 0.74; 95% CI, 0.57-0.97). A subanalysis of specialists revealed that neurologists and orthopedic surgeons had a higher OR for ordering CT and MRI (OR, 3.57; 95% CI, 2.60-4.90). Finally, health care professionals in the Southern and Western United States had greater ORs for prescribing narcotic medications (OR, 1.56; 95% CI, 1.21-2.02; and OR, 1.57; 95% CI, 1.22-2.03; respectively).

In this nationally representative study of treatment patterns for patients presenting to physicians with back pain during the last decade, we observed several notable findings. First, we observed a significant increase in the frequency of treatments that are considered discordant with current guidelines, including use of advanced imaging (ie, CT or MRI), referrals to other physicians (presumably for procedures or surgery), and use of narcotics. Second, we also observed a decrease in use of first-line medications, such as NSAIDs or acetaminophen, but no change in referrals to physical therapy. Third, although opiate prescriptions increased markedly during this period, we also observed lower odds of receiving narcotics among female, black, Hispanic, and other race/ethnicity patients, which may signify potential disparities in pain management that have also been noted previously.30

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.3134 Recent meta-analyses and research35,36 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.

We also found a 50.6% decrease in first-line NSAID or acetaminophen use accompanied by a 50.8% increase in narcotic prescriptions, including a near doubling among patients presenting with chronic back pain. These results are unexplained by a change in the frequency of short-term vs long-term presentations or the extent to which patients were seen by their PCP vs another physician because similar trends were observed for each of these groups in our stratified analyses. Although some of the decrease in NSAID use might have been due to the decrease in use of cyclooxygenase-2 inhibitors, the marked decrease in use of first-line therapies accompanied by the rapid increase in narcotic prescriptions raises significant concerns. A recent meta-analysis37 revealed that narcotics provide little to no benefit in acute back pain, they have no 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. Although we lack adequate data to make firm recommendations on narcotic medications, which may be indicated in certain circumstances, such increases in narcotic prescriptions may be contributing to a current crisis in public health: the rapid increase in narcotic overdose deaths parallels a reported 300% increase in the US sales of prescription narcotics since the 1990s. In 2008, overdoses in narcotic analgesics led to an estimated 14 800 deaths—more than cocaine and heroin combined.3840

Our findings also confirm an inappropriate increase in advanced diagnostic imaging that has been seen previously,1214,41 with use of CT or MRI increasing by 56.9% in our study sample. Six randomized controlled trials have found that imaging in the acute care setting provides neither clinical nor psychological benefit to patients with routine back pain,25 and multiple prospective studies42 have found the lack of serious disease in the absence of red-flag symptoms. In addition to being of low value, the overuse of diagnostic imaging leads to more exposure to ionizing radiation. In 2007, a projected 1200 additional future cancers were created by the 2.2 million lumbar CTs performed in the United States.43,44 Finally, the significant increase in spine operations seen during the last decade is almost certainly related to the overuse of imaging. One study45,46 revealed that early MRI for acute back pain was associated with an 8-fold increased risk of surgery, whereas another found that regions with more MRIs perform more operations, with 22% of the variability in spine surgery rates explained by rates of spine MRI use—more than twice the predictive power of patient characteristics.

Our study is subject to several limitations. Although we lacked complete data on the duration of symptoms, we present stratified results for short-term vs long-term presentations that showed similar trends. Moreover, these visits comprised more than half of our sample. In addition, because the NAMCS and NHAMCS are visit-level data sets, we lacked longitudinal data on treated patients. Consequently, we could not measure treatment patterns over time for individual patients. Because these visit-level data are collected in the same way each year, however, trends over time are likely to be reflective of changes in practice patterns and not changes in the patient population presenting for treatment. A lack of major changes in most of our own population characteristics also supports this assessment, and those factors that did change (eg, age and insurance status) were accounted for in our model. Furthermore, our analyses control for important potential confounders that might have changed over time, such as the proportion of visits for short-term vs long-term presentations and whether the visit was with a self-identified PCP. Finally, because comorbidity data were not collected until 2005, we could not use comorbidities in our adjusted analyses. However, our evaluation of trends in the 14 comorbid chronic conditions (including arthritis and depression) in our sample revealed significant increases only for asthma, which had very low prevalence rates that were unlikely to alter our results.

Despite numerous published national guidelines, management of routine back pain increasingly has relied on advanced diagnostic imaging, referrals to other physicians, and use of narcotics, with a concomitant decrease in NSAID or acetaminophen use and no change in physical therapy referrals. With health care costs soaring, improvements in the management of back pain represent an area of potential cost savings for the health care system while also improving the quality of care.

Accepted for Publication: May 13, 2013.

Corresponding Author: Bruce E. Landon, MD, MBA, MSc, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02215 (landon@hcp.med.harvard.edu).

Published Online: July 29, 2013. doi:10.1001/jamainternmed.2013.8992.

Author Contributions: Dr Mafi had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Mafi, McCarthy, Landon.

Acquisition of data: Mafi, McCarthy.

Analysis and interpretation of data: All authors.

Drafting of the manuscript: Mafi.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Administrative, technical, and material support: McCarthy, Landon.

Study supervision: Landon.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by National Research Service Award training grant T32HP12706 from the US Health Services and Research Administration (Dr Mafi), the Ryoichi Sasakawa Fellowship Fund (Dr Mafi), and the Harvard Catalyst National Institutes of Health Award UL1 RR 025758 (Dr Davis).

Disclaimer: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Additional Contributions: Edward Marcantonio, MD, SM, Christina Wee, MD, MPH, John Orav, PhD, and John Ayanian, MD, MPP, provided methodologic and conceptual advice.

Correction: This article was corrected for an error in the text on January 14, 2014.

Hart  LG, Deyo  RA, Cherkin  DC.  Physician office visits for low back pain: frequency, clinical evaluation, and treatment patterns from a U.S. national survey. Spine (Phila Pa 1976). 1995;20(1):11-19.
PubMed   |  Link to Article
Deyo  RA, Mirza  SK, Martin  BI.  Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine (Phila Pa 1976). 2006;31(23):2724-2727.
PubMed   |  Link to Article
Martin  BI, Turner  JA, Mirza  SK, Lee  MJ, Comstock  BA, Deyo  RA.  Trends in health care expenditures, utilization, and health status among US adults with spine problems, 1997-2006. Spine (Phila Pa 1976). 2009;34(19):2077-2084.
PubMed   |  Link to Article
Stewart  WF, Ricci  JA, Chee  E, Morganstein  D, Lipton  R.  Lost productive time and cost due to common pain conditions in the US workforce. JAMA. 2003;290(18):2443-2454.
PubMed   |  Link to Article
Freburger  JK, Holmes  GM, Agans  RP,  et al.  The rising prevalence of chronic low back pain. Arch Intern Med. 2009;169(3):251-258.
PubMed   |  Link to Article
Martin  BI, Deyo  RA, Mirza  SK,  et al.  Expenditures and health status among adults with back and neck problems. JAMA. 2008;299(6):656-664.
PubMed   |  Link to Article
Pengel  LHM, Herbert  RD, Maher  CG, Refshauge  KM.  Acute low back pain: systematic review of its prognosis. BMJ. 2003;327(7410):323.
PubMed   |  Link to Article
Chou  R, Qaseem  A, Snow  V,  et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel.  Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491.
PubMed   |  Link to Article
Williams  CM, Maher  CG, Hancock  MJ,  et al.  Low back pain and best practice care: a survey of general practice physicians. Arch Intern Med. 2010;170(3):271-277.
PubMed   |  Link to Article
Gray  DT, Deyo  RA, Kreuter  W,  et al.  Population-based trends in volumes and rates of ambulatory lumbar spine surgery. Spine (Phila Pa 1976). 2006;31(17):1957-1964.
PubMed   |  Link to Article
Feuerstein  M, Marcus  SC, Huang  GD.  National trends in nonoperative care for nonspecific back pain. Spine J. 2004;4(1):56-63.
PubMed   |  Link to Article
Weiner  DK, Kim  Y-S, Bonino  P, Wang  T.  Low back pain in older adults: are we utilizing healthcare resources wisely? Pain Med. 2006;7(2):143-150.
PubMed   |  Link to Article
Deyo  RA, Mirza  SK, Turner  JA, Martin  BI.  Overtreating chronic back pain: time to back off? J Am Board Fam Med. 2009;22(1):62-68.
PubMed   |  Link to Article
Mitchell  JMJ.  Utilization trends for advanced imaging procedures: evidence from individuals with private insurance coverage in California. Med Care. 2008;46(5):460-466.
PubMed   |  Link to Article
Jackson  JL, Browning  R.  Impact of national low back pain guidelines on clinical practice. South Med J. 2005;98(2):139-143.
PubMed   |  Link to Article
van Tulder  M, Becker  A, Bekkering  T,  et al; COST B13 Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care.  Chapter 3, European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15(suppl 2):S169-S191.
PubMed   |  Link to Article
Airaksinen  O, Brox  JI, Cedraschi  C,  et al; COST B13 Working Group on Guidelines for Chronic Low Back Pain.  Chapter 4, European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15 (suppl 2):S192-S300.
PubMed   |  Link to Article
Goertz M, Thorson D, Bonsell J, et al. Adult Acute and Subacute Low Back Pain. 15th ed. Bloomington, MN: Institute for Clinical Systems Improvement; November 2012.
Davis  PC, Wippold  FJ  II, Brunberg  JA,  et al.  ACR Appropriateness Criteria on low back pain. J Am Coll Radiol. 2009;6(6):401-407.
PubMed   |  Link to Article
Albright  J, Allman  R, Bonfiglio  RP,  et al.  Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for low back pain. Phys Ther. 2001;81:1641-1674.
Chou  R, Huffman  LH; American Pain Society; American College of Physicians.  Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147(7):505-514.
PubMed   |  Link to Article
McCaig  LF, McLemore  T.  Plan and operation of the National Hospital Ambulatory Medical Survey, series 1: programs and collection procedures. Vital Health Stat 1. 1994;(34):1-78.
PubMed
National Center for Health Statistics. Using ultimate cluster models. 2004:1–5. http://www.cdc.gov/nchs/ahcd/ahcd_questionnaires.htm. Accessed February 8, 2013.
National Center for Health Statistics. Ambulatory Health Care Data. http://www.cdc.gov/nchs/ahcd/ahcd_questionnaires.htm. Accessed February 25, 2013.
Chou  R, Qaseem  A, Owens  DK, Shekelle  P; Clinical Guidelines Committee of the American College of Physicians.  Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154(3):181-189.
PubMed   |  Link to Article
National Committee for Quality Assurance. Technical Specifications. Washington, DC: National Committee for Quality Assurance; 2010. HEDIS 2011: Healthcare Effectiveness Data and Information Set; vol 2.
Kale  MS, Bishop  TF, Federman  AD, Keyhani  S.  Trends in the overuse of ambulatory health care services in the United States. JAMA Intern Med. 2013;173(2):142-148.
PubMed   |  Link to Article
Koes  BW, van Tulder  MW, Ostelo  R, Kim Burton  A, Waddell  G.  Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine (Phila Pa 1976). 2001;26(22):2504-2514.
PubMed   |  Link to Article
Koes  BW, van Tulder  M, Lin  C-WC, Macedo  LG, McAuley  J, Maher  C.  An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010;19(12):2075-2094.
PubMed   |  Link to Article
Dominick  KL, Bosworth  HB, Dudley  TK, Waters  SJ, Campbell  LC, Keefe  FJ.  Patterns of opioid analgesic prescription among patients with osteoarthritis. J Pain Palliat Care Pharmacother. 2004;18(1):31-46.
PubMed   |  Link to Article
Weinstein  JN, Lurie  JD, Olson  PR, Bronner  KK, Fisher  ES.  United States’ trends and regional variations in lumbar spine surgery: 1992-2003. Spine (Phila Pa 1976). 2006;31(23):2707-2714.
PubMed
Schafer  J, O’Connor  D, Feinglass  S, Salive  M.  Medicare Evidence Development and Coverage Advisory Committee Meeting on lumbar fusion surgery for treatment of chronic back pain from degenerative disc disease. Spine (Phila Pa 1976). 2007;32(22):2403-2404.
PubMed   |  Link to Article
Mirza  SK, Deyo  RA.  Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine (Phila Pa 1976). 2007;32(7):816-823.
PubMed   |  Link to Article
Gray  DT, Deyo  RA, Kreuter  W,  et al.  Population-based trends in volumes and rates of ambulatory lumbar spine surgery. Spine (Phila Pa 1976). 2006;31(17):1957–1963.
PubMed   |  Link to Article
Gibson  JNA, Waddell  G.  Surgery for degenerative lumbar spondylosis: updated Cochrane Review. Spine (Phila Pa 1976). 2005;30(20):2312-2320.
PubMed   |  Link to Article
Deyo  RA, Mirza  SK, Martin  BI, Kreuter  W, Goodman  DC, Jarvik  JG.  Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010;303(13):1259-1265.
PubMed   |  Link to Article
Martell  BA, O’Connor  PG, Kerns  RD,  et al.  Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med. 2007;146(2):116-127.
PubMed   |  Link to Article
Luo  X, Pietrobon  R, Hey  L. Patterns and trends in opioid use among individuals with back pain in the United States. Spine (Phila Pa 1976). 2004;29(8):884–890.
PubMed   |  Link to Article
CDC-Prescription Painkiller Overdoses Policy Impact Brief-Home and Recreational Safety-Injury Center. NCHS. http://www.cdc.gov/homeandrecreationalsafety/rxbrief/. Accessed February 24, 2013.
Dunn  KM, Saunders  KW, Rutter  CM,  et al.  Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152(2):85-92.
PubMed   |  Link to Article
Pham  HH, Landon  BE, Reschovsky  JD, Wu  B, Schrag  D.  Rapidity and modality of imaging for acute low back pain in elderly patients. Arch Intern Med. 2009;169(10):972-981.
PubMed   |  Link to Article
Deyo  RA, Diehl  AK.  Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. J Gen Intern Med. 1988;3(3):230-238.
PubMed   |  Link to Article
Chou  R, Deyo  RA, Jarvik  JG.  Appropriate use of lumbar imaging for evaluation of low back pain. Radiol Clin North Am. 2012;50(4):569-585.
PubMed   |  Link to Article
Berrington de González  A, Mahesh  M, Kim  K-P,  et al.  Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med. 2009;169(22):2071-2077.
PubMed   |  Link to Article
Webster  BS, Cifuentes  M.  Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010;52(9):900-907.
PubMed   |  Link to Article
Lurie  JD, Birkmeyer  NJ, Weinstein  JN.  Rates of advanced spinal imaging and spine surgery. Spine (Phila Pa 1976). 2003;28(6):616-620.
PubMed

Figures

Place holder to copy figure label and caption
Figure.
Adjusted Proportions of Referrals and Selected Drugs Over Time

Estimates adjusted for age, sex, race/ethnicity, region, insurance type, symptom duration and context, whether the health care professional was the primary care physician, and whether the visit was located in a metropolitan area.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1.  Patient and Visit Characteristics Over Time
Table Graphic Jump LocationTable 3.  Adjusted Proportions of Use Stratified by Chief Symptom of Acute vs Chronic Back Pain Over Timea
Table Graphic Jump LocationTable 4.  Adjusted Proportions of Use by Identified PCP vs Non-PCP Over Timea

References

Hart  LG, Deyo  RA, Cherkin  DC.  Physician office visits for low back pain: frequency, clinical evaluation, and treatment patterns from a U.S. national survey. Spine (Phila Pa 1976). 1995;20(1):11-19.
PubMed   |  Link to Article
Deyo  RA, Mirza  SK, Martin  BI.  Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine (Phila Pa 1976). 2006;31(23):2724-2727.
PubMed   |  Link to Article
Martin  BI, Turner  JA, Mirza  SK, Lee  MJ, Comstock  BA, Deyo  RA.  Trends in health care expenditures, utilization, and health status among US adults with spine problems, 1997-2006. Spine (Phila Pa 1976). 2009;34(19):2077-2084.
PubMed   |  Link to Article
Stewart  WF, Ricci  JA, Chee  E, Morganstein  D, Lipton  R.  Lost productive time and cost due to common pain conditions in the US workforce. JAMA. 2003;290(18):2443-2454.
PubMed   |  Link to Article
Freburger  JK, Holmes  GM, Agans  RP,  et al.  The rising prevalence of chronic low back pain. Arch Intern Med. 2009;169(3):251-258.
PubMed   |  Link to Article
Martin  BI, Deyo  RA, Mirza  SK,  et al.  Expenditures and health status among adults with back and neck problems. JAMA. 2008;299(6):656-664.
PubMed   |  Link to Article
Pengel  LHM, Herbert  RD, Maher  CG, Refshauge  KM.  Acute low back pain: systematic review of its prognosis. BMJ. 2003;327(7410):323.
PubMed   |  Link to Article
Chou  R, Qaseem  A, Snow  V,  et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel.  Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491.
PubMed   |  Link to Article
Williams  CM, Maher  CG, Hancock  MJ,  et al.  Low back pain and best practice care: a survey of general practice physicians. Arch Intern Med. 2010;170(3):271-277.
PubMed   |  Link to Article
Gray  DT, Deyo  RA, Kreuter  W,  et al.  Population-based trends in volumes and rates of ambulatory lumbar spine surgery. Spine (Phila Pa 1976). 2006;31(17):1957-1964.
PubMed   |  Link to Article
Feuerstein  M, Marcus  SC, Huang  GD.  National trends in nonoperative care for nonspecific back pain. Spine J. 2004;4(1):56-63.
PubMed   |  Link to Article
Weiner  DK, Kim  Y-S, Bonino  P, Wang  T.  Low back pain in older adults: are we utilizing healthcare resources wisely? Pain Med. 2006;7(2):143-150.
PubMed   |  Link to Article
Deyo  RA, Mirza  SK, Turner  JA, Martin  BI.  Overtreating chronic back pain: time to back off? J Am Board Fam Med. 2009;22(1):62-68.
PubMed   |  Link to Article
Mitchell  JMJ.  Utilization trends for advanced imaging procedures: evidence from individuals with private insurance coverage in California. Med Care. 2008;46(5):460-466.
PubMed   |  Link to Article
Jackson  JL, Browning  R.  Impact of national low back pain guidelines on clinical practice. South Med J. 2005;98(2):139-143.
PubMed   |  Link to Article
van Tulder  M, Becker  A, Bekkering  T,  et al; COST B13 Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care.  Chapter 3, European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15(suppl 2):S169-S191.
PubMed   |  Link to Article
Airaksinen  O, Brox  JI, Cedraschi  C,  et al; COST B13 Working Group on Guidelines for Chronic Low Back Pain.  Chapter 4, European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15 (suppl 2):S192-S300.
PubMed   |  Link to Article
Goertz M, Thorson D, Bonsell J, et al. Adult Acute and Subacute Low Back Pain. 15th ed. Bloomington, MN: Institute for Clinical Systems Improvement; November 2012.
Davis  PC, Wippold  FJ  II, Brunberg  JA,  et al.  ACR Appropriateness Criteria on low back pain. J Am Coll Radiol. 2009;6(6):401-407.
PubMed   |  Link to Article
Albright  J, Allman  R, Bonfiglio  RP,  et al.  Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for low back pain. Phys Ther. 2001;81:1641-1674.
Chou  R, Huffman  LH; American Pain Society; American College of Physicians.  Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147(7):505-514.
PubMed   |  Link to Article
McCaig  LF, McLemore  T.  Plan and operation of the National Hospital Ambulatory Medical Survey, series 1: programs and collection procedures. Vital Health Stat 1. 1994;(34):1-78.
PubMed
National Center for Health Statistics. Using ultimate cluster models. 2004:1–5. http://www.cdc.gov/nchs/ahcd/ahcd_questionnaires.htm. Accessed February 8, 2013.
National Center for Health Statistics. Ambulatory Health Care Data. http://www.cdc.gov/nchs/ahcd/ahcd_questionnaires.htm. Accessed February 25, 2013.
Chou  R, Qaseem  A, Owens  DK, Shekelle  P; Clinical Guidelines Committee of the American College of Physicians.  Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154(3):181-189.
PubMed   |  Link to Article
National Committee for Quality Assurance. Technical Specifications. Washington, DC: National Committee for Quality Assurance; 2010. HEDIS 2011: Healthcare Effectiveness Data and Information Set; vol 2.
Kale  MS, Bishop  TF, Federman  AD, Keyhani  S.  Trends in the overuse of ambulatory health care services in the United States. JAMA Intern Med. 2013;173(2):142-148.
PubMed   |  Link to Article
Koes  BW, van Tulder  MW, Ostelo  R, Kim Burton  A, Waddell  G.  Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine (Phila Pa 1976). 2001;26(22):2504-2514.
PubMed   |  Link to Article
Koes  BW, van Tulder  M, Lin  C-WC, Macedo  LG, McAuley  J, Maher  C.  An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010;19(12):2075-2094.
PubMed   |  Link to Article
Dominick  KL, Bosworth  HB, Dudley  TK, Waters  SJ, Campbell  LC, Keefe  FJ.  Patterns of opioid analgesic prescription among patients with osteoarthritis. J Pain Palliat Care Pharmacother. 2004;18(1):31-46.
PubMed   |  Link to Article
Weinstein  JN, Lurie  JD, Olson  PR, Bronner  KK, Fisher  ES.  United States’ trends and regional variations in lumbar spine surgery: 1992-2003. Spine (Phila Pa 1976). 2006;31(23):2707-2714.
PubMed
Schafer  J, O’Connor  D, Feinglass  S, Salive  M.  Medicare Evidence Development and Coverage Advisory Committee Meeting on lumbar fusion surgery for treatment of chronic back pain from degenerative disc disease. Spine (Phila Pa 1976). 2007;32(22):2403-2404.
PubMed   |  Link to Article
Mirza  SK, Deyo  RA.  Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine (Phila Pa 1976). 2007;32(7):816-823.
PubMed   |  Link to Article
Gray  DT, Deyo  RA, Kreuter  W,  et al.  Population-based trends in volumes and rates of ambulatory lumbar spine surgery. Spine (Phila Pa 1976). 2006;31(17):1957–1963.
PubMed   |  Link to Article
Gibson  JNA, Waddell  G.  Surgery for degenerative lumbar spondylosis: updated Cochrane Review. Spine (Phila Pa 1976). 2005;30(20):2312-2320.
PubMed   |  Link to Article
Deyo  RA, Mirza  SK, Martin  BI, Kreuter  W, Goodman  DC, Jarvik  JG.  Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010;303(13):1259-1265.
PubMed   |  Link to Article
Martell  BA, O’Connor  PG, Kerns  RD,  et al.  Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med. 2007;146(2):116-127.
PubMed   |  Link to Article
Luo  X, Pietrobon  R, Hey  L. Patterns and trends in opioid use among individuals with back pain in the United States. Spine (Phila Pa 1976). 2004;29(8):884–890.
PubMed   |  Link to Article
CDC-Prescription Painkiller Overdoses Policy Impact Brief-Home and Recreational Safety-Injury Center. NCHS. http://www.cdc.gov/homeandrecreationalsafety/rxbrief/. Accessed February 24, 2013.
Dunn  KM, Saunders  KW, Rutter  CM,  et al.  Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152(2):85-92.
PubMed   |  Link to Article
Pham  HH, Landon  BE, Reschovsky  JD, Wu  B, Schrag  D.  Rapidity and modality of imaging for acute low back pain in elderly patients. Arch Intern Med. 2009;169(10):972-981.
PubMed   |  Link to Article
Deyo  RA, Diehl  AK.  Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. J Gen Intern Med. 1988;3(3):230-238.
PubMed   |  Link to Article
Chou  R, Deyo  RA, Jarvik  JG.  Appropriate use of lumbar imaging for evaluation of low back pain. Radiol Clin North Am. 2012;50(4):569-585.
PubMed   |  Link to Article
Berrington de González  A, Mahesh  M, Kim  K-P,  et al.  Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med. 2009;169(22):2071-2077.
PubMed   |  Link to Article
Webster  BS, Cifuentes  M.  Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010;52(9):900-907.
PubMed   |  Link to Article
Lurie  JD, Birkmeyer  NJ, Weinstein  JN.  Rates of advanced spinal imaging and spine surgery. Spine (Phila Pa 1976). 2003;28(6):616-620.
PubMed

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Supplement.

eAppendix

eTable 1. Cohort Design

eTable 2. Proportions of Diagnostic Codes Over Time

eTable 3. Unadjusted Proportions of Use Over Time Without Competing Diagnoses (eg, Pain in Limb, Spasm of Muscle)

eTable 4. Unadjusted Percentages of CT/MRI Use Excluding 2001-2004

eTable 5. Patient Visit Characteristics Over Time

eTable 6. Unadjusted Proportions of Comorbid Conditions Over Time

eTable 7. Adjusted Odds Ratios for Factors Associated with Ordering CT/MRI, Referrals to Physicians, and Narcotic Prescriptions (Significant Factors in Bold)

eTable 8. Quality of Evidence Behind 3 Broad Clinical Guidelines for the Management of Routine Neck and Back Pain

eTable 9. Quality of Evidence Behind 3 Specific Guideline Recommendations for the Management of Routine Neck and Back Pain

eTable 10. Unadjusted Use Over Time (Percentage of Visits) by Practice Setting

eReferences

Supplemental Content

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 19

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
JAMAevidence.com