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1.  Physicians' Initial Management of Acute Low Back Pain Versus Evidence-Based Guidelines 
Journal of General Internal Medicine  2005;20(12):1132-1135.
Background
Little information is available on physician characteristics and patient presentations that may influence compliance with evidence-based guidelines for acute low back pain.
Objective
To assess whether physicians' management decisions are consistent with the Agency for Health Research Quality's guideline and whether responses varied with the presentation of sciatica or by physician characteristics.
Design
Cross-sectional study using a mailed survey.
Participants
Participants were randomly selected from internal medicine, family practice, general practice, emergency medicine, and occupational medicine specialties.
Measurements
A questionnaire asked for recommendations for 2 case scenarios, representing patients without and with sciatica, respectively.
Results
Seven hundred and twenty surveys were completed (response rate=25%). In cases 1 (without sciatica) and 2 (with sciatica), 26.9% and 4.3% of physicians fully complied with the guideline, respectively. For each year in practice, the odds of guideline noncompliance increased 1.03 times (95% confidence interval [CI]=1.01 to 1.05) for case 1. With occupational medicine as the referent specialty, general practice had the greatest odds of noncompliance (3.60, 95% CI=1.75 to 7.40) in case 1, followed by internal medicine and emergency medicine. Results for case 2 reflected the influence of sciatica with internal medicine having substantially higher odds (vs case 1) and the greatest odds of noncompliance of any specialty (6.93, 95% CI=1.47 to 32.78), followed by family practice and emergency medicine.
Conclusions
A majority of primary care physicians continue to be noncompliant with evidence-based back pain guidelines. Sciatica dramatically influenced clinical decision-making, increasing the extent of noncompliance, particularly for internal medicine and family practice. Physicians' misunderstanding of sciatica's natural history and belief that more intensive initial management is indicated may be factors underlying the observed influence of sciatica.
doi:10.1111/j.1525-1497.2005.0230.x
PMCID: PMC1490268  PMID: 16423103
back pain; guidelines; practice variation; clinical vignette; decision making
2.  The Cascade of Medical Services and Associated Longitudinal Costs Due to Nonadherent Magnetic Resonance Imaging for Low Back Pain 
Spine  2014;39(17):1433-1440.
Supplemental Digital Content is Available in the Text.
Magnetic resonance imaging (MRI) without clear indications led to a cascade of subsequent diagnostic and invasive services, which occurred within 6 months after imaging. Early MRI was significantly associated with a large and sustained escalation in medical costs, even after grouping by severity and controlling for pain and demographic covariates.
Study Design.
Retrospective cohort study.
Objective.
To compare type, timing, and longitudinal medical costs incurred after adherent versus nonadherent magnetic resonance imaging (MRI) for work-related low back pain.
Summary of Background Data.
Guidelines advise against MRI for acute uncomplicated low back pain, but is an option for persistent radicular pain after a trial of conservative care. Yet, MRI has become frequent and often nonadherent. Few studies have documented the nature and impact of medical services (including type and timing) initiated by nonadherent MRI.
Methods.
A longitudinal, workers' compensation administrative data source was accessed to select low back pain claims filed between January 1, 2006 and December 31, 2006. Cases were grouped by MRI timing (early, timely, no MRI) and subgrouped by severity (“less severe,” “more severe”) (final cohort = 3022). Health care utilization for each subgroup was evaluated at 3, 6, 9, and 12 months post-MRI. Multivariate logistic regression models examined risk of receiving subsequent diagnostic studies and/or treatments, adjusting for pain indicators and demographic covariates.
Results.
The adjusted relative risks for MRI group cases to receive electromyography, nerve conduction testing, advanced imaging, injections, and surgery within 6 months post-MRI risks in the range from 6.5 (95% CI: 2.20–19.09) to 54.9 (95% CI: 22.12–136.21) times the rate for the referent group (no MRI less severe). The timely and early MRI less severe subgroups had similar adjusted relative risks to receive most services. The early MRI more severe subgroup cases had generally higher adjusted relative risks than timely MRI more severe subgroup cases. Medical costs for both early MRI subgroups were highest and increased the most over time.
Conclusion.
The impact of nonadherent MRI includes a wide variety of expensive and potentially unnecessary services, and occurs relatively soon post-MRI. Study results provide evidence to promote provider and patient conversations to help patients choose care that is based on evidence, free from harm, less costly, and truly necessary.
Level of Evidence: N/A
doi:10.1097/BRS.0000000000000408
PMCID: PMC4105318  PMID: 24831502
low back pain; radiculopathy; nonspecific back pain; evidence-based guidelines; MRI; workers' compensation; costs
3.  Iatrogenic Consequences of Early Magnetic Resonance Imaging in Acute, Work-Related, Disabling Low Back Pain 
Spine  2013;38(22):1939-1946.
Supplemental Digital Content is Available in the Text.
Results suggest that early magnetic resonance imaging (MRI) has a strong iatrogenic effect leading to prolonged disability and increased medical costs, regardless of whether a patient has acute radiculopathy. The findings support evidence-based guidelines to avoid MRI for acute back pain during the first month except for “red flag” indications.
Study Design.
Retrospective cohort study.
Objective.
To determine the effect of early (receipt ≤30 d postonset) magnetic resonance imaging (MRI) on disability and medical cost outcomes in patients with acute, disabling, work-related low back pain (LBP) with and without radiculopathy.
Summary of Background Data.
Evidence-based guidelines suggest that, except for “red flags,” MRI is indicated to evaluate patients with persistent radicular pain, after 1 month of conservative management, who are candidates for surgery or epidural steroid injections. Prior research has suggested an independent iatrogenic effect of nonindicated early MRI, but it had limited clinical information and/or patient populations.
Methods.
A nationally representative sample of workers with acute, disabling, occupational LBP was randomly selected, oversampling those with radiculopathy diagnoses (N = 1000). Clinical information from medical reports was used to exclude cases for which early MRI might have been indicated, or MRI occurred more than 30 days postonset (final cohort = 555). Clinical information was also used to categorize cases into “nonspecific LBP” and “radiculopathy” groups and further divided into “early-MRI” and “no-MRI” subgroups. The Cox proportional hazards model examined the association of early MRI with duration of the first episode of disability. Multivariate linear regression models examined the association with medical costs. All models adjusted for demographic and medical severity measures.
Results.
In our sample, 37% of the nonspecific LBP and 79.9% of the radiculopathy cases received early MRI. The early-MRI groups had similar outcomes regardless of radiculopathy status: much lower rates of going off disability and, on average, $12,948 to $13,816 higher medical costs than the no-MRI groups. Even in a subgroup with relatively minimal disability impact (≤30 d of total lost time post-MRI), medical costs were, on average, $7643 to $8584 higher in the early-MRI groups.
Conclusion.
Early MRI without indication has a strong iatrogenic effect in acute LBP, regardless of radiculopathy status. Providers and patients should be made aware that when early MRI is not indicated, it provides no benefits, and worse outcomes are likely.
Level of Evidence: 3
doi:10.1097/BRS.0b013e3182a42eb6
PMCID: PMC4235393  PMID: 23883826
low back pain; radiculopathy; nonspecific back pain; evidence-based guidelines; MRI; iatrogenic; workers compensation; disability; costs

Results 1-3 (3)