When dealing with lower back pain, patience may be the best prescription

August, 2008 April 1, 2009 — Lower back pain is a problem that affects a rapidly increasing number of Americans. Yet, in spite of medical evidence indicating that most back pain resolves itself within six weeks of diagnosis, a recent study conducted by HealthCore,1 WellPoint’s outcomes research subsidiary, found that more than 35,000 people had unnecessary imaging tests and almost 1,000 underwent inappropriate back surgery within the six weeks following their diagnosis.

Back pain: A pervasive and costly problem

According to study findings reported recently in the Journal of the American Medical Association (JAMA), the number of people suffering from back pain is increasing, as are the costs for treating it. In 2005, 15 percent of U.S. adults reported back problems — up from 12 percent in 1997. The same study found that treating back and neck pain can also be a pain in the wallet — Americans spent $85.9 billion on doctor’s visits, x-rays, MRI scans, and medications in an attempt to gain relief from back and neck pain, up 65 percent from the $52.1 billion spent in 1997.2

Back pain is a condition experienced by 9 out of 10 Americans at some point in their life. Lumbar injuries result in approximately 149 million lost work days per year, and the annual productivity losses resulting from those lost work days are estimated to be $28 billion. Back pain is also estimated to make up one-fourth to one-third of total workers’ compensation costs.3

From 1997 to 2005, spine-related medical expenses increased 65 percent — more rapidly than overall health expenditures; however, there’s no evidence to suggest that the outcome for many individuals with back pain has improved as a result of all this spending.2

Patience is often the best prescription

When dealing with back pain, immediate action may be warranted for patients with what physicians refer to as “red flag” conditions, e.g., cancer, trauma, fractures or progressive neurologic problems. However, for most patients, patience is the best policy. Why? According to the National Committee on Quality Assurance (NCQA) 2007 Back Recognition Program, most episodes of back pain resolve themselves within six weeks.

Despite these guidelines, more than 35,000 people without “red flag conditions” had potentially unnecessary imaging tests and almost 1,000 underwent potentially inappropriate back surgery less than six weeks after diagnosis, according to a study of six WellPoint-affiliated plans over a 12-month period, conducted by HealthCore, WellPoint’s outcomes research subsidiary.

“As Americans, we spend roughly as much on back problems as we do for cancer or diabetes with very little change in overall result,” said Dr. Sam Nussbaum, WellPoint chief medical officer. “In some cases, invasive measures are necessary, but in most, they are not. Most people will get better without having the risk, pain and expense of surgery.”

Despite the NCQA findings, HealthCore’s study showed that $23.6 million was spent on back surgery and diagnostic imaging during the first six weeks after members reported an episode of back pain.

The risks — and the costs — of moving too quickly

“It’s been well documented that 30 percent of health care spending goes toward redundant or inappropriate care,1” said Dr. Joseph Singer, vice president of medical affairs for HealthCore. “Our health care system should use evidence-based decision-making processes, such as the NCQA guidelines, to deliver clinical services that improve the quality of life and productivity of Americans.”

HealthCore’s analysis determined that a number of patients with back pain without “red flag conditions” received potentially inappropriate MRIs, X-rays, CT scans, and, in some cases, potentially unnecessary surgeries. While the number of surgeries was small in comparison to the overall number of individuals with back pain, these surgeries greatly increased the cost of caring for patients with back pain.

“We also have concerns for our members’ safety in exposing them to unnecessary radiation,” Nussbaum said. “A lumbar spine CT, for example, exposes a person to as much radiation as he or she would expect to receive from 65 X-rays. When these procedures are unnecessary, they should be avoided.”

The findings of the HealthCore study were entirely consistent with the findings of previous studies which indicated that most patients with back pain improved after six weeks.5, 6 Other key findings from the HealthCore study include:

•About half (52 percent) of patients with low back pain were treated by their doctor for six weeks or less

• Among those low-risk members treated for six weeks or less, 7 percent received an MRI, at an average cost of about $600 per procedure

• About $1.8 million could have been saved by the healthcare system if half of these members who received MRIs during the first six weeks after reporting back pain did not receive one

• About $1.3 million could have been saved by the healthcare system if 75 percent of those who received a second, and likely unnecessary, MRI avoided it

• Although less than 1,000 low-risk back pain patients (or 1 percent) had back surgery within the first six weeks of diagnosis, total healthcare costs over this same time period exceeded $18 million for these patients alone

• As the number of specialists a member saw increased, so, too, did overall treatment costs and the number of procedures orde
red

 “This is an area that lends itself to greater scrutiny, clinical study, and evidence-based medicine,” Nussbaum said.

Source: Iowa Chiropractic Society, www.iowadcs.org

About the study

The study is based on an analysis of clinical measures as established by the National Committee for Quality Association Back Pain Recognition Program. The study included 172,377 individuals with low back pain, in six WellPoint health plans, diagnosed with lower back pain from Jan. 1, 2005 through Dec. 31, 2005.

Three major categories of members were excluded from the study:

• Membership Duration: Members were excluded if they were not with a WellPoint health plan for at least six months before and 18 months after their initial back pain diagnosis.

• Age: Members were also excluded if they were younger than 18 or older than 64 on Jan. 1, 2005.

• Medical Condition: Members with certain “red flag” conditions, such as cancer, trauma and those with numbness, lack of sensation, loss of reflexes, and symptoms associated with nerve risk damage, were also excluded.

Those studied had a median age of 45 years and lived in California, Ohio, Missouri, Kentucky, Indiana and Georgia.

About the WellPoint Institute of Health Care Knowledge

The WellPoint Institute of Health Care Knowledge is a Web-based publishing clearinghouse for health-related research conducted by WellPoint and its subsidiary companies. The Institute regularly releases educational information in the form of reports, white papers and research summaries, with the goal of enhancing health care quality and value by providing facts and information to support informed health care decision-making. For more information, visit WellPoint Institute of Health Care Knowledge at www.wellpoint.com/institute.

2 Martin, Brook, Deyo, Richard, Mirza, Sohail. Expenditures and Health Status Among Adults with Back and Neck Problems. JAMA 2008: 299(6): 656-664.

3 Maetzel A, Li L. The economic burden of low back pain; a review of studies published between 1996 and 2001. Best Pract. Res Clin Rheumatol 2002; 16:23-30.

4 Skinner JS, Fisher ES. Regional disparities in Medicare expenditures: an opportunity for reform. National Tax Journal. 1997;50:413-25.

5 Cherkin DC, Deyo RA, Street JH, Barlow W. Predicting poor outcomes for back pain seen in primary care using patients’ own criteria. Spin 1996;21:2900-7.

6 Croft PR, Macfarlane GJ, Papageorgious AC, Thomas E, Silman AJ. Outcome of low back pain in general practice: a prospective study. BMJ 1998;316:1356-7