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How Fast and What Type of Imaging Elderly Low-Back Pain Patients Get Linked to Patient/Physician Traits Not Clinical Indications

Archives Study Underscores Need for Quality Metrics to Measure Overuse of Care

News Release
May 25, 2009

Alwyn Cassil (202) 264-3484 or

WASHINGTON, DC—Although rapid X-rays or other imaging for uncomplicated low-back pain are rarely indicated, almost 1 in 3 elderly Medicare patients received imaging services within a month of low-back pain diagnosis, according to a study by researchers at the Center for Studying Health System Change (HSC) in the May 25 Archives of Internal Medicine.

Well-established guidelines suggest that patients with low-back pain (LBP) do not require imaging until after a month of conservative therapy in the absence of specific clinical "red flags," such as cancer. Yet, 28.8 percent of elderly Medicare beneficiaries with LBP were imaged within 28 days of diagnosis, according to the study.

Unnecessary imaging exposes patients to potential harm from follow-up procedures and wastes health care resources. Among imaged patients, 88.2 percent had a plain X-ray, while 11.8 percent had a computed tomography (CT) or magnetic resonance imaging (MRI) scan as their initial study. Nearly a third of imaging studies were performed in the practice of the patient’s primary physician.

Most standardized performance measures focus on underused services, leaving unclear what areas exist for quality improvement in terms of reducing overuse of services. The researchers used LBP as a prism to examine how patient, physician and practice characteristics influence the likelihood of potential overuse of care.

White patients were more likely to receive rapid imaging and CT/MRI than minority patients. Medicaid patients received less rapid or advanced imaging than other patients. Similarly, patients treated in practices more reliant on Medicaid revenues received less rapid or advanced imaging, according to the study. Patients received higher levels of imaging if their primary care physician was exposed to satisfaction-based incentives or worked in large group practices.

"The findings indicate that how rapidly and what type of imaging low-back pain patients receive have more to do with patient, physician and practice characteristics than clinical indications. The results underscore the need for physician measurement and incentive programs to encompass both underuse and overuse metrics, as a signal to physicians that appropriate care sometimes means less care" said Hoangmai H. Pham, M.D., M.P.H., the study’s lead author and a senior health researcher at HSC, a nonpartisan policy research organization funded in part by the Robert Wood Johnson Foundation, which supported the study along with the National Institute on Aging.

"As the nation confronts the need to control rapidly rising health care costs, identifying ways to encourage physicians to focus on both overuse and underuse of care is a way to generate more value for patients," said Pham, who coauthored the article with Bruce E. Landon, M.D., M.B.A., an associate professor at Harvard Medical School; James D. Reschovsky, Ph.D., an HSC senior researcher; Beny Wu, M.S., of Social and Scientific Systems; and Deborah Schrag, M.D., M.P.H., of the Dana Farber Cancer Institute.

The study, "Rapidity and Modality of Imaging for Acute Low Back Pain in Elderly Patients," is based on an analysis of Medicare claims from 2000-2002 and 2004-2006 for 35,0039 fee for service Medicare beneficiaries who were treated by one of 4,567 primary care physicians responding to the 2000-2001 or 2004-2005 Community Tracking Study Physician Survey.

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The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation’s changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is funded principally by the Robert Wood Johnson Foundation and is affiliated with Mathematica Policy Research, Inc.



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The Center for Studying Health System Change Ceased operation on Dec. 31, 2013.