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

Abstract

word count: 304 Manuscript word count: 3392 2 ABSTRACT Objectives: To (i) estimate the proportion of patients seeking care for low back pain (LBP) who are imaged, and (ii) explore trends in the proportion of patients who received diagnostic imaging over time. We also examined the effect of study-level factors on estimates of imaging proportion. Eligibility criteria for selecting studies: Observational designs and controlled trials that reported imaging for patients presenting to primary care or emergency care for LBP. We assessed study quality and calculated pooled proportions by care setting and imaging type, with strength of evidence assessed using the GRADE system. Results: 45 studies were included. They represented 19,451,749 consultations for low back pain that had resulted in 4,343,919 imaging requests/events over 21 years. Primary care: moderate quality evidence that simple imaging proportion was 16.3% (95%CI 12.6 to 21.1) and complex imaging was 9.2% (95%CI 6.2 to 13.5). For any imaging the pooled proportion was 24.8% (95%CI 19.3 to 31.1). Emergency care: moderate quality evidence that simple imaging proportion was 26.1% (95%CI 18.2 to 35.8) and high quality evidence that complex imaging proportion was 8.2% (95%CI 4.4 to 15.6). For any imaging the pooled proportion was 35.6 % (95%CI 29.8 to 41.8). Complex imaging increased from 7.4% (95%CI 5.7 to 9.6) forimaging requested in 1995, to 11.4% (95%CI 9.6 to 13.5) in 2015 (relative increase of 53.5%).Between-study variability in imaging proportions was only partially explained by study-level characteristics; there were insufficient data to comment on some pre-specified study-level factors.Summary/conclusion: One in 4 patients who presented to primary care with low back pain received imaging as did one in 3 who presented to the Emergency department. The rate of

Stratified primary care versus non-stratified care for musculoskeletal pain: findings from the STarT MSK feasibility and pilot cluster randomized controlled trial

“…At present, primary care decisionmaking for MSK pain is mostly based on ruling out serious pathology and using clinical reasoning without formal stratification tools to decide on treatment. Assessing the severity, impact and prognosis of individual patients can be difficult in short primary care consultations and patient access to other treatments is often variable [19][20][21][22]. Offering everyone consulting in primary care with MSK pain further treatments is both unnecessary and impractical [16,17].…”

Low back pain should be considered a health and research priority in Brazil: Lost productivity and healthcare costs between 2012 to 2016

“…We found more than 880,000 routine diagnostic imaging procedures were performed between 2012-2016 during inpatient and outpatient care, with a ratio of approximate 10 images per 1000 individuals affected by LBP in Brazil. Inappropriate use of routine diagnostic imaging for LBP is being widely discussed [14,[42][43][44][45]. Previous studies demonstrated frequent referral for diagnostic imaging, despite the absence of red flags, such as infection, progressive neurologic deficits, or underlying pathologies [44,46].…”

“…However, current recommendations rather discourage imaging as part of early management of LBP, because of harms such as unnecessary exposition to radiation, patient fear and sense of fragility, and use of additional procedures resulting in overmedicalization [14,44]. Nonetheless, a systematic review [45] found a 53% relative increase in diagnostic imaging use (e.g., CT-scans) for LBP in primary and emergency care, from 1995 to 2015, despite guidelines advice and campaigns otherwise [47]. Clinicians and decision-makers should be aware that unnecessary diagnostic imaging wastes scarce financial resources [45,48], and has little effect on clinical outcomes [47,48].…”

“…Nonetheless, a systematic review [45] found a 53% relative increase in diagnostic imaging use (e.g., CT-scans) for LBP in primary and emergency care, from 1995 to 2015, despite guidelines advice and campaigns otherwise [47]. Clinicians and decision-makers should be aware that unnecessary diagnostic imaging wastes scarce financial resources [45,48], and has little effect on clinical outcomes [47,48]. This finding warrants further research aiming to design specific strategies and interventions to reduce unnecessary diagnostic imaging in the Brazilian health system.…”

“…This finding warrants further research aiming to design specific strategies and interventions to reduce unnecessary diagnostic imaging in the Brazilian health system. We would recommend further studies to understand the clinical-decision reasoning and aspects that might explain the overuse of diagnostic imaging for LBP in Brazil [45,49], to improve evidence-based decision support [50].…”