An Evidence-Based Approach to Treating Low Back Pain

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An Evidence-Based Approach to Treating Low Back Pain

Chapter 1: Impact of COVID-19 on the Utilization of Early Magnetic Resonance Imaging in the Assessment of Acute Uncomplicated Low Back Pain and the Subsequent Impact to Healthcare Services and Patient Outcomes

CHAPTER 1 |

1.1 Background and Need

INTRODUCTION

The United States spends more on healthcare than any other country; in 2021 the Organization for Economic Co-Operations and Development (OECD) published that the U.S. spent over $12,000 per capita on healthcare, which was 17.8% of gross domestic product and is twice as much as the average OECD country.1 Despite this level of spending, the U.S. ranks worst in measures of healthcare access and quality as compared to the comparable countries of Australia, Canada, and the UK. The U.S. had a 2016 Healthcare Access and Quality (HAQ) Index score of 88.7 compared to a comparable country average of 93.7. The HAQ Index is measured on a scale of 0 (worst) to 100 (best) based on risk-standardized mortality rates from 32 causes that should not normally result in death in the presence of quality healthcare — also called amenable mortality.2

2 © Kim Radcliffe 2024 All rights reserved

A significant contributor to high healthcare costs is waste, which accounts for 25%–30% of total healthcare spending at an estimated annual amount of $750 billion.3,4 Of that $750 billion, $100–$200 billion is specifically attributed to overuse or the delivery of unnecessary services that have little or no proven clinical benefit or impact on clinician decisions. Moreover, unnecessary care not only contributes to excessive costs, it also has been shown to cause patient harm.5,3 In examining the specific tests and procedures that are overused and can cause patient harm, advanced imaging is particularly concerning, with studies showing that 26% of these imaging procedures are unnecessary or inappropriate.3

One area of care where advanced imaging, such as magnetic resonance imaging (MRI), is frequently misused is in the assessment of acute noncomplicated low back pain (LBP), despite evidence and guidelines providing specific guidance against MRIs for acute uncomplicated LBP in the first three to six months.6,3,7 These recommendations are based on clinical evidence that most patients improve within

the first month with conservative treatment, even with symptoms of radiculopathy or disc herniation.8 There is evidence that less than 10% of LBP is due to spinal pathology9 and that degenerative disc disease is a normal aging process that is seen in up to 97% of asymptomatic patients.10 Moreover, multiple studies have shown that not only does the use of MRIs in assessing acute LBP not improve clinical decision-making, but it can also result in a cascade of additional unnecessary medical services, including spinal surgery, with worse patient outcomes — including increased length of disability and work absence.6,11,7,12 For work-related acute LBP, a study by Webster et al.8 concluded that eMRIs resulted in a fivefold increase in total medical costs, an eightfold increase in risk for surgery, and worse disability. Chou et al.,13 reported that surgery rates in the U.S. are two to five times higher than in other developed countries with no evidence showing improved outcomes, which further confirms the underlying problem of unnecessary care leading to higher healthcare spending yet worse health outcomes.

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$100–$200 billion is specifically attributed to overuse or the delivery of unnecessary services that have little or no proven clinical benefit or impact on clinician decisions.

1.2 Problem Statement

Uncomplicated acute LBP is generalized low back pain of six weeks or less duration with or without radiating pain in the lower extremities. An MRI within the first six weeks of symptoms is thus defined as an early MRI (eMRI). The Agency for Healthcare Policy and Research (AHCPR) published guidelines in 1994 advising against the use of any lumbar imaging, including eMRIs, in the first six weeks unless there was a presence of any of the following red flags: recent significant trauma, unexplained weight loss, unexplained fever, immunosuppression, history of cancer, intravenous drug use, prolonged use of corticosteroids, osteoporosis, age older than 70 years, or focal neurologic deficits with progressive or disabling symptoms. Current guidelines by the American Academy of Family Physicians, the Board of Internal Medicine, and the American Association of Neurological Surgeons also recommend against the use of MRIs within the first six weeks of symptoms.

Research findings highly suggest that eliminating unnecessary eMRIs in the assessment of acute LBP would help reduce the cascade of unnecessary care and both reduce costs associated with LBP while maintaining quality of care and even improving patient outcomes. However, despite these findings, the use of advanced imaging continues to increase. Chou et al.13 reported data showing a fourfold increase of lumbar MRIs between 1994 and 2005 for Medicare B beneficiaries, and a threefold increase between 1997 and 2006 for large healthcare organizations; this was associated with similar rates of increased risk for surgery and other interventional procedures such as epidural injections. Downie et al.,14 found a 53% relative increase in complex imaging from

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Research findings highly suggest that eliminating unnecessary eMRIs in the assessment of acute LBP would help reduce the cascade of unnecessary care and both reduce costs associated with LBP while maintaining quality of care and even improving patient outcomes.

1995 to 2015 based on a systematic review and meta-analysis of 27 included studies. With the continued increased overuse of MRIs there has been limited data for a substantive comparative analysis on the benefits of avoiding early MRI, particularly at a population level. This study provides an opportunity to add to the body of evidence examining the impact of avoiding early MRIs for acute LBP on patient outcomes and healthcare costs. Data gathered

from this study can be used to help inform clinical decisionmaking for providers, patient education, and reimbursement decisions to support the population health initiative to deliver value-based care and improve U.S. healthcare quality and costs.15

By the Numbers: Cascade of Unnecessary Care

$750 billion in excess annual healthcare spending in the U.S. annually. $200 billion in excessive spending is due to overuse or unnecessary care.

of advanced imaging (MRIs) are not needed; 26%

however, complex imaging increased 53% from 1995 to 2015

For work-related LBP, eMRIs resulted in:

5x increase in total medical costs

8x increase in risk for surgery

Worse disability

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1.3 Research Questions and Research Hypotheses:

Was there an impact on eMRI rates in the assessment of acute LBP during and post-COVID-19, and did it impact the utilization of other healthcare services and patient outcomes?

COVID-19 provided a natural experimental condition where elective procedures such as MRIs were reported to have significantly decreased. It is estimated that nonemergent medical care decreased by up to 60% in spring 2020.16 This change in overall medical utilization reported during COVID, provides an opportunity to perform a pre-post quantitative retrospective observational cross-sectional study comparing the utilization of eMRIs in the assessment of acute non-complicated LBP and the subsequent impact on healthcare services and patient outcomes before and after COVID-19. The hypothesis of this study is that COVID-19 had a national impact on elective procedures such as eMRI. Based on research findings, a reduction in eMRIs, which were being done against evidence-based guidelines, should result in reduced unnecessary healthcare services, particularly surgery, and result in improved patient outcomes.

The comparative years for the study will be 18 months from June 2018 to December 2019 for pre-COVID period, 18 months from June 2020 to December 2021 for COVID period, and June 2021 to December 2020 for post COVID. We are excluding the period of January 2020 through May 2020 as this was early in the pandemic where much about COVID-19 was unknown and the impacts to

healthcare utilization were more sporadic. It was not until March 2020 when the Centers for Medicare and Medicaid Services (CMS) made recommendations to stop elective and non-essential surgeries and procedures.17 We are also using the same months of the year for pre and post periods to control for seasonal effects to healthcare utilization (e.g., increased use of elective surgeries and procedures at the end of a calendar year when deductibles have been met).

MarketScan Commercial Insurance database (MarketScan) — a non-research-oriented administrative healthcare records database — will be the primary dataset used to perform a comparative study of healthcare utilization and patient outcomes. This study will first examine the rate of MRIs to verify the hypothesis that COVID-19 impacted the incidence of MRIs for acute LBP. This study will then examine differences in healthcare service utilization and patient clinical outcomes between the periods. Based on research findings, healthcare services expected to be impacted by a change in eMRI rates and that will be studied include surgical and steroid epidural injection rates. Patient outcomes will be assessed based on healthcare service proxies to include physician office visits, opioid use, hospital days, and rehab days.

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1.4 Population

The population group for this study will include patients aged 18–55 with diagnosis codes associated with LBP: ICD10 codes M54.50 for LBP unspecified, M54.51 for vertebrogenic LBP, and M54.59 for other LBP.18 The first medical visit associated with the diagnosis must be no longer than six months, and the first MRI must have occurred within the first six weeks of the initial medical visit. Patients with red flags that indicate support for an eMRI per AHCPR guidelines are excluded.

Connect With Me

Kim Radcliffe

904-705-9551

kim.radcliffe@vgmhomelink.com linkedin.com/in/kim-radcliffe-pt/

Kim Radcliffe is a clinical operation and workers’ compensation expert with more than 20 years of experience in clinical settings and commercial operations. She ensures that care coordination teams leverage evidence and valuebased care to improve patient healthcare delivery.

Radcliffe earned her MHA from the University of North Florida and is currently completing her DHA through the Medical University of South Carolina.

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References

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2. How does the quality of the U.S. health system compare to other countries? - Peterson-KFF Health System Tracker. (2022, September 23). Peterson-KFF Health System Tracker. https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/

3. Lyu, H., Xu, T., Brotman, D., Mayer-Blackwell, B., Cooper, M., Daniel, M., . . . Makary, M. A. (2017). Overtreatment in the United States. PloS one, 12(9), e0181970-e0181970. https://doi.org/10.1371/journal.pone.0181970

4. Shrank, W. H., Rogstad, T. L., & Parekh, N. (2019). Waste in the US Health Care System: Estimated Costs and Potential for Savings. JAMA: the journal of the American Medical Association, 322(15), 1501-1509. https://doi.org/10.1001/jama.2019.13978

5. Chalmers, K., Smith, P., Garber, J., Gopinath, V., Brownlee, S., Schwartz, A. L., . . . Saini, V. (2021). Assessment of Overuse of Medical Tests and Treatments at US Hospitals Using Medicare Claims. JAMA network open, 4(4), e218075-e218075. https://doi.org/10.1001/jamanetworkopen.2021.8075

6. Chou, R. D., Fu, R. P., Carrino, J. A. M. D., & Deyo, R. A. P. (2009). Imaging strategies for low-back pain: systematic review and meta-analysis. The Lancet (British edition), 373(9662), 463-472. https://doi.org/10.1016/S0140-6736(09)60172-0

7. Shraim, B. A., Shraim, M. A., Ibrahim, A. R., Elgamal, M. E., Al-Omari, B., & Shraim, M. (2021). The association between early MRI and length of disability in acute lower back pain: a systematic review and narrative synthesis. BMC musculoskeletal disorders, 22(1), 1-983. https://doi.org/10.1186/s12891-021-04863-9

8. Webster, & Cifuentes, M. (2010). Relationship of Early Magnetic Resonance Imaging for Work-Related Acute Low Back Pain With Disability and Medical Utilization Outcomes. Journal of Occupational and Environmental Medicine, 52(9), 900–907. https://doi.org/10.1097/JOM.0b013e3181ef7e53

9. Hall, Aubrey-Bassler, K., Thorne, B., & Maher, C. G. (2021). Do not routinely offer imaging for uncomplicated low back pain. BMJ (Online), 372, n291–n291. https://doi.org/10.1136/bmj.n291

10. Brinjikji, W., Diehn, F. E., Jarvik, J. G., Carr, C. M., Kallmes, D. F., Murad, M. H., & Luetmer, P. H. (2015). MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis. AJNR. American journal of neuroradiology, 36(12), 2394–2399. https://doi.org/10.3174/ajnr.A4498

11. Ganguli, I., Ying, W., Shakley, T., Colbert, J. A., Mulligan, K. L., & Friedberg, M. W. (2023). Cascade Services and Spending Following Low-Value Imaging for Uncomplicated Low Back Pain among Commercially Insured Adults. Journal of general internal medicine: JGIM, 38(4), 1102-1105. https://doi.org/10.1007/s11606022-07829-2

12. Wang D., Mueller K., Lea R., (2019) Do Treatment Guidelines Influence Early MRI and Decompression Surgery for Low Back Pain? August 2019. WC – 19-14

13. Chou, Deyo, R. A., & Jarvik, J. G. (2012). Appropriate Use of Lumbar Imaging for Evaluation of Low Back Pain. The Radiologic Clinics of North America, 50(4), 569–585. https://doi.org/10.1016/j.rcl.2012.04.005

14. Downie, Hancock, M., Jenkins, H., Buchbinder, R., Harris, I., Underwood, M., Goergen, S., & Maher, C. G. (2020). How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years. British Journal of Sports Medicine, 54(11), 642–651. https://doi.org/10.1136/bjsports-2018-100087

15. Zangerle, Harris, D. A., Rimmasch, H., & Randazzo, G. (2016). From Volume- to Value-Based Care: Leading Population Health Initiatives. Nurse Leader, 14(5), 318–322. https://doi.org/10.1016/j.mnl.2016.06.003

16. Roth, & Lazris, A. (2021). Benefits of Avoiding Unnecessary Medical Care During the COVID-19 Pandemic. American Family Physician, 103(10), 584–585.

17. CMS releases recommendations on Adult Elective Surgeries, Non-Essential Medical, Surgical, and Dental Procedures during COVID-19 response | CMS. (2020, March 18). https://www.cms.gov/newsroom/press-releases/cms-releases-recommendations-adult-elective-surgeries-non-essential-medical-surgical-and-dental

18. M54.5 - Low back pain - ICD List 2023. (n.d.). ICD List. https://icdlist.com/icd-10/M54.5

SOC aicpa.org/socFormerly SAS 70Reports A CPAServiceOrgan zat onControlReport s SER VICE ORGANIZATIONS C-100323-001-000-WC www.vgmhomelink.com 1111 Van Miller Way | Waterloo IA 50701 800-482-1993 | homelinkreferrals@vgm.com

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