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Original Investigation |

Worsening Trends in the Management and Treatment of Back Pain

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.
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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.

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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.

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