Use of Imaging Studies for Low Back Pain

Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis

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Low back pain is a pervasive problem that affects three quarters of adults at some time in their lives (Chou et al., 2012). It ranks among the top ten reasons for patient visits to internists and is the most common and expensive reason for work disability in the U.S. Low back pain is second only to upper respiratory problems as a symptom-related reason for visits to a physician (Jarvik and Deyo, 2002). 

Each year in the United States low back pain is experienced by 25 to 50 percent of adults, making it one of the most common reasons for seeking health care services (Haldeman and Dagenais, 2008). Low back pain results in high indirect costs from disability, lost time from work, and decreased productivity while at work, and is the number one cause for activity limitations in younger adults (Chou, 2012). The costs associated with health care services for spine pain (primarily low back pain) in the U.S. increased from $45.9 billion in 1997 to $102.6 billion in 2004 (Martin et al., 2008).

American College of Physicians and the American Pain Society (Chou et al., 2007)
 
Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). 

Institute for Clinical Systems Improvement (2012)

Clinicians should not recommend imaging (including computed tomography [CT], magnetic resonance imaging [MRI] and x-ray) for patients with non-specific low back pain (Strong Recommendation, Moderate Quality Evidence).

* Low back pain assessment should include a subjective pain rating, functional status, patient history including notation of presence or absence of "red flags," psychosocial indicators, assessment of prior treatment and response, employment status, and clinician's objective assessment.
* Reduce or eliminate imaging for diagnosis of non-specific low back pain in patients 18 years and older.
* First-line treatment should emphasize patient education and a core treatment plan, that includes encouraging activity, use of heat, no imaging, cautious and responsible use of opioids, anti-inflammatory and analgesic over-the-counter medications and return to work assessment.
* Patients with acute or subacute low back pain should be advised to stay active and continue ordinary daily activity as tolerated.
* Use opioids cautiously and responsibly in the presence of acute or subacute low back pain.

Higher score indicates better quality

Chou, R., A. Qaseem, V. Snow, D. Casey, J.T. Cross Jr., P. Shekelle, D.K. Owens, and the Clinical Efficacy Assessment Subcommittee of the American College of Physicians and the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel. 2007. "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 147(7):478-491.

Chou R, et al. Radiologic Clinics of North America. Appropriate Use of Lumbar Imaging for Evaluation of Low Back Pain. 2012 Jul, Vol. 50, No. 4: 569-85.

Haldeman S, Dagenais S. A supermarket approach to the evidence informed management of chronic low back pain. Spine J 2008;8: 1-7.

Institute for Clinical Systems Improvement. 2012. "Health Care Guideline: Adult Low Back Pain" Bloomington: Institute for Clinical Systems Improvement.

Jarvik, J.G., and R.A. Deyo. 2002. "Diagnostic evaluation of low back pain with emphasis on imaging." Ann Intern Med 137:586-597.

Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA 2008;299: 656-64.

This measure applies to the first episode of low back pain during the measurement period.

Index episode start date: The date of the earliest visit during the measurement period with a diagnosis of low back pain. 

Eligible visit types:
- Outpatient visits  
- Emergency department visits 
- Osteopathic or chiropractic manipulative treatment 
- Physical therapy visits 
- Telehealth visits

The visit in the Initial Population needs to occur during the first 337 days of the measurement period (337 days allows 28 days for the numerator event). 

This visit must be the first visit for low back pain during the measurement period.

TBD

Patients 18-50 years of age with a diagnosis of Uncomplicated low back pain during a visit

Equals Initial Population

Exclude patients with a diagnosis of uncomplicated low back pain during the 180 days (6 months) prior to the index episode start date.

Exclude patients with neurologic impairment, spinal infection, or diagnosis of IV drug abuse any time during the 12 months prior to the index episode start date through 28 days after the index episode start date.

Exclude patients with trauma any time during the 90 days prior to the index episode start date through 28 days after the index episode start date.

Exclude patients with a diagnosis of HIV or cancer any time in the patient's history through 28 days after the index episode start date.

Exclude patients who had a major organ transplant any time in the patient's history through 28 days after the index episode start date.

Exclude patients who had prolonged use of corticosteriods (at least 90 consecutive days) any time in the 12 months prior to the index episode start date.

Exclude patients who were in hospice care during the measurement year.

Patients without an imaging study conducted on the index episode start date or in the 28 days following the index episode start date

Not Applicable

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For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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