Accepted Manuscript A Systematic Review of Diagnostic Imaging Utilization for Low Back Pain in the United States Simon Dagenais, DC, PhD, MSc Erin K. Galloway, BA Darren M. Roffey, PhD PII:

S1529-9430(13)01626-4

DOI:

10.1016/j.spinee.2013.10.031

Reference:

SPINEE 55625

To appear in:

The Spine Journal

Received Date: 8 June 2012 Revised Date:

23 August 2013

Accepted Date: 23 October 2013

Please cite this article as: Dagenais S, Galloway EK, Roffey DM, A Systematic Review of Diagnostic Imaging Utilization for Low Back Pain in the United States, The Spine Journal (2013), doi: 10.1016/ j.spinee.2013.10.031. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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A SYSTEMATIC REVIEW OF DIAGNOSTIC IMAGING UTILIZATION FOR LOW BACK PAIN IN THE UNITED STATES

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Simon Dagenais, DC, PhD, MSc 1; Erin K. Galloway, BA 1; Darren M. Roffey, PhD 1,2,3

Palladian Health, West Seneca, NY 14224, USA

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Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario

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K1Y 4E9, Canada

University of Ottawa Spine Program, The Ottawa Hospital, Ottawa, Ontario K1Y 4E9, Canada

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Please address correspondence and reprint requests to:

2732 Transit Road,

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Simon Dagenais, DC, PhD, MSc

West Seneca, NY, 14224, USA

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Phone: (716) 712-2700;

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Email: [email protected]

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ABSTRACT

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BACKGROUND CONTEXT: Various studies have previously reported on the rising

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utilization and costs of diagnostic imaging for low back pain (LBP) in the United States (US).

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However, it is unclear if the methods used in these studies allowed for meaningful comparisons,

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or if the reported utilization data can be used to develop evidence-based benchmarks.

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PURPOSE: The primary purpose of this study was to review previous estimates of the

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utilization of diagnostic imaging for LBP reported in the US.

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STUDY DESIGN/SETTING: Systematic review of published literature.

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METHODS: A search through May 2012 was conducted using keywords and free text terms

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related to health services and LBP in Medline and Health Policy Reference; results were

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screened for relevance independently, and full-text studies were assessed for eligibility. Only

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studies published in English since the year 2000 reporting on utilization of diagnostic imaging

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for LBP using claims data from the US were included. Reporting quality was assessed using a

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modified Downs and Black tool for observational studies. This study was funded by Palladian

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Health. Study authors were paid consultants and shareholders of Palladian Health when this

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study was conducted.

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RESULTS: The search strategy yielded 1102 citations, of which 7 met the criteria for eligibility.

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Studies reported utilization from commercial health plans (n=4) and Medicare (n=3), with

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sample sizes ranging from 13,760 to 740,467 members with LBP from specific states or across

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the US. The number of diagnostic codes used to identify nonspecific LBP ranged from 2 to 66;

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other heterogeneity was noted in the methods used across these studies. In commercial health

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plans, utilization of x-rays was 12.0% to 32.2% of patients with LBP, magnetic resonance

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imaging (MRI) was used in 16.0% to 21.0%, computed tomography (CT) was used in 1.4% to

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3.0%, and MRI and/or CT was used in 10.9% to 16.1%. Findings in Medicare populations were

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22.9% to 48.2% for x-rays, 11.6% for MRI, and 10.4% to 16.3% for MRI and/or CT.

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CONCLUSIONS: The reported utilization of diagnostic imaging for LBP varied across the

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studies reviewed; differences in methodology made meaningful comparisons difficult.

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Standardizing methods for performing and reporting analyses of claims data related to utilization

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could facilitate efforts by third-party payers, health care providers, and researchers to identify

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and address the perceived overuse of diagnostic imaging for LBP.

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Word count

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377

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Keywords

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Low back pain; diagnostic imaging; x-rays; magnetic resonance imaging; computed tomography;

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utilization; claims data

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INTRODUCTION

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Low back pain (LBP) is experienced by 25-50% of the adult population in the United States (US)

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each year, making it one of the most common reasons for seeking health care from a variety of

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clinicians, including primary care providers (PCPs), nonsurgical specialists, spine surgeons,

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allied health providers, as well as complementary and alternative medicine (CAM) providers (1-

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3). The costs associated with health care services for spine pain (primarily LBP) in the US rose

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from $45.9 billion in 1997 to $102.6 billion in 2004, an annualized growth rate of over 12% (4).

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Yet despite the increased resources allocated to health services for LBP, their value has been

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questioned due to rising chronicity, disability, and unexplained variations in care (4-8).

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One of the contributors to the growing costs of LBP is the increased use of medical technologies,

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particularly advanced diagnostic imaging such as magnetic resonance imaging (MRI) and

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computed tomography (CT), which now account for nearly 14% of Medicare part B (medical

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insurance) expenditures (7;9-12). Use of spinal MRI in Medicare increased by 83% from 1993 to

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1998, while lumbar MRI increased by 300% between 1994 and 2006 (7;10). Numerous factors

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have been offered to explain the rise of diagnostic imaging for LBP, including changing

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demographics, increased care seeking and patient expectations about LBP, increased physician

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ownership of imaging facilities, and reimbursement fee-for-service payment models (10;11;13-

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16). The supply of imaging equipment may also play a role, as the number of MRI scanners in

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the US increased from 7.6 to 26.6 per 1 million people between 2000 and 2005, and ongoing

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utilization is necessary to recoup initial and operating expenses (11;17).

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Researchers have observed large geographic variations in the utilization of diagnostic imaging

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for LBP across the US that seemingly cannot be attributed to clinical need alone, leading to

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concerns that these services are not always clinically necessary, compounded by the subsequent

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utilization of related health services (10;18-20). For example, MRI frequently detects anatomical

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irregularities that are not responsible for the symptoms of LBP observed, but which may

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nevertheless trigger a cascade of additional diagnostic testing or surgical procedures aimed at

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correcting anomalies on diagnostic imaging (17;20;21). Concerns have also been voiced about

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other harms associated with diagnostic imaging, including the ionizing radiation of spinal x-rays

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and CT that increase with repeated exposure (22).

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Reports of increased utilization, high costs, and potentially inappropriate use of diagnostic

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imaging for LBP have fueled interest in this topic by third-party payers, including commercial,

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employer-sponsored, and government-sponsored health plans, as well as health services

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researchers and health administrators eager to identify potential targets for cost containment,

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particularly when evidence-based clinical practice guidelines (CPGs) are available to guide

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appropriate utilization (13). For example, the proportion of patients with LBP receiving

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diagnostic imaging has been endorsed as a measure of health care quality by the National

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Committee for Quality Assurance (NCQA), is currently incorporated into the Healthcare

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Effectiveness Data and Information Set (HEDIS) measures reported by a majority of health

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plans, and will likely be included in quality measures for patient-centered medical homes

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(23;24).

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Efforts to develop programs targeting the potential overuse of health services often begin by

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analyzing claims data, which are readily available to third-party payers, administrators, and

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researchers, are directly relevant to the populations of interest, and offer relatively large sample

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sizes (25). Findings from such analyses can then be compared to various proposed benchmarks

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to determine if overuse is occurring, which can prompt administrative, reimbursement, or policy

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changes that can affect patients with LBP and spine care clinicians. However, it is unclear if

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meaningful benchmarks related to the utilization of diagnostic imaging for LBP can in fact be

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developed based on existing studies reporting on utilization of these health services.

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The primary objective of this study was therefore to conduct a systematic review to identify,

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appraise, summarize, and synthesize studies reporting on the utilization of diagnostic imaging for

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LBP in the US. Secondary objectives were to compare the methods used for such analyses, and

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describe factors that have been reported to influence utilization of diagnostic imaging for LBP.

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METHODS

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Information sources and search

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Medline was searched through May 2012 using the Medical Subject Headings (MeSH) and free

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text terms developed by the Cochrane Back Review Group to identify studies related to LBP,

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with additional terms related to utilization, claims, and third-party reimbursement (Appendix 1)

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(26). A broad search strategy was used to identify studies related to any health service for LBP;

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findings not related to diagnostic imaging will be reported in future studies. The Medline search

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strategy was modified for the Health Policy Reference Center (HPRC) database, using both

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subject headings and free-text to search abstracts of academic journals. Author files and

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references from relevant studies were also scanned to uncover additional studies.

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Eligibility criteria

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Studies were included if they reported on utilization of any diagnostic imaging for LBP in adults

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(aged 18 or older) in the US based on third-party payer records (e.g. claims). Studies were

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excluded if they were published prior to 2000, in languages other than English, relied on self-

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reported utilization (e.g. surveys), did not report primary data (e.g. reviews), did not report the

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International Classification of Diseases-Version 9 (ICD-9) diagnostic codes used in the analysis,

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or could not attribute utilization to LBP (e.g. use of lumbar spine MRI for any indication).

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Screening

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Search results were screened by two reviewers to determine eligibility; if eligibility could not be

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determined from the search records, the full-text article was obtained. Reviewer consistency was

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examined and calibrated using the first 50 search records. Conflicts were resolved by discussion

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until consensus was achieved, or by using a third reviewer. Studies meeting eligibility criteria

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were assessed for reporting quality, and relevant data were abstracted.

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Quality assessment

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Since authors could not locate a validated tool to assess the reporting quality of utilization

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studies, one was developed by modifying the Downs and Black checklist for observational

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studies (Appendix 2) (27;28). Reporting quality was assessed by determining if the following

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items were present: 1. type of third-party payer, 2. type of health plan management, 3. date/year 6

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of data analyzed, 4. time interval for utilization, 5. general eligibility criteria, 6. LBP eligibility

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criteria, 7. total population size, 8. LBP population size, 9. current procedural terminology (CPT)

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codes used to identify health services, and 10. utilization reported separately for each type of

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health service. Quality was assessed independently by two reviewers, who discussed potential

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conflicts until consensus was reached.

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Data items and data collection process

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Data used to assess reporting quality were also abstracted into evidence tables by two reviewers

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independently and discussed until consensus was reached. Utilization data for each type of

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diagnostic imaging (e.g. x-rays, MRI, CT, MRI and/or CT) were abstracted using raw data (i.e.

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numerator and denominator) if available, or rates otherwise, for all claimants and various

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subgroups of interest (e.g. etiology of LBP, duration of LBP, severity of LBP, clinician specialty,

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current/previous utilization of other health services).

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Funding and potential conflicts of interest

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This study was funded by Palladian Health, a company that manages specialty health benefits

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such as chiropractic, physical therapy, physical fitness, and complementary and alternative

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medicine on behalf of health plans and insurers. Although Palladian Health does not currently

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manage the utilization of diagnostic imaging services related to low back pain (other than x-rays

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performed by chiropractors), it may offer such services in the future. Study authors are paid

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consultants (SD, DMR, EKG) and shareholders (SD) of Palladian Health.

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RESULTS

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Literature search

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The literature search returned 1102 citations, including 897 from MEDLINE and 205 from

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HPRC, of which 24 were duplicates, yielding 1078 unique citations. Upon screening the

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abstracts and search records, 1010 were deemed not relevant, and full-text articles were obtained

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for 68 studies, 62 of which were identified from Medline, and 6 from HPRC. Based on full-text

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articles, 61 studies were excluded, most commonly because they did not state the ICD-9

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diagnosis codes used to identify claims related to LBP (n=18), did not identify LBP as the

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indication for utilizing various health services (n=9), or were not related to diagnostic imaging

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(n=8) (Figure 1). Seven studies met the stated eligibility criteria (11;13;20;29-32).

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Study characteristics

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The seven included studies reported on utilization in commercial (n=4) and government-

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sponsored (i.e. Medicare) health plans (n=3) at the regional (n=2), state (n=2), or national (n=3)

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level, with population sample sizes ranging from 165,569 to over 8 million individuals (mean

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1,678,102; median 453,265) (Table 1). One study analyzed data from a staff-model health

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maintenance organization (HMO) for patients of all ages, including those who may have been

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enrolled in managed Medicare health plans (30). As utilization was reported for all ages and only

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21.2% of patients were older than 65, findings are presented along with other commercial health

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plans rather than Medicare. The number of years of data analyzed ranged from 1 to 8 (mean 3.9;

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median 3), while utilization was measured over a period that varied from 6 months to 36 months.

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While the stated eligibility criteria for each study differed, most focused on measuring utilization

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of diagnostic imaging for patients with nonspecific (i.e. mechanical) LBP, generally defined by

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excluding serious spinal pathology such as cancer, trauma, or infection. Four of the studies

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required that individuals be enrolled for a minimum amount of time – from 6 to 24 months –

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before and/or after the initial claim identifying LBP, termed the “index” visit. The number of

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individuals with LBP in the studies included varied from 13,760 to 740,467 (mean 152,706;

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median 34,408), representing 2.6% to 8.3% of all individuals in a health plan. Five studies

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reported on the utilization of x-rays for LBP, four studies on MRI for LBP, two studies on CT for

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LBP, and four studies reported on MRI and/or CT for LBP; findings are presented below by type

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of modality.

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Reporting quality

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The mean number of items reported in each study varied from 5 to 9 (mean 7; median 7) of the

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10 assessed (Table 2). The most commonly reported item was the date/year of data analyzed

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(n=7), followed by type of third-party payer (n=6), utilization for a given time interval (n=6),

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general eligibility criteria (n=6), and number of individuals with LBP (n=6). The least commonly

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reported items were total population size (n=3), and utilization reported separately for each type

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of health service (n=3).

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Diagnostic codes

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A total of 76 unique ICD-9 diagnosis codes were used by the studies included to identify health

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care utilization related to LBP (Table 3). The number of codes used in each study varied from 2

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to 69, and the most common were 724.2 lumbago and 724.5 unspecified backache, both used in

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all 7 included studies. Three studies cited a list of 66 ICD-9 diagnosis codes developed by

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Cherkin et al. to identify claims for health services related to mechanical LBP (e.g. herniated

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disc, degenerative changes, spinal stenosis, instability, closed fractures, nonspecific backache,

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failed spine surgery, and other diagnoses) that excluded serious spinal pathology (e.g.

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malignancy, infection) (33). One study cited a list of ICD-9 diagnosis codes related to LBP that

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were developed by the NCQA for use in HEDIS measures (13;34).

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Utilization of spinal x-rays

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Three of the five studies measuring utilization of x-rays reported the CPT codes used to identify

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relevant claims; one included only lumbar x-rays, two also included full-spine and sacral x-rays,

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while one also included cervical spine x-rays (11;13;32). In commercial health plans, utilization

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of x-rays was 12.0% over 24 months, 30.9% over 12 months, and 32.2% over 12-36 months

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among those with mechanical LBP. Utilization of x-rays appeared to increase with the number of

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episodes of LBP, from 6.3% for those with only 1 episode of LBP (i.e. 30-day period with claim

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for utilization of health services related to LBP) to 30.9% for those with 6 or more episodes of

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LBP (30). Similarly, utilization increased with duration of LBP, with higher rates reported for

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those with (44.0%) than without (29.9%) chronic LBP (i.e. more than 3 months) (32). Use of x-

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rays also varied by etiology of LBP, being highest among those with no neurologic findings

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(32.8%) and lowest among those with other types of LBP (16.8%), and slightly lower among

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those with nonspecific LBP (27.4%) (31;32). Use of x-rays was similar for those with (31.4%) or

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without (29.0%) claims for opioid analgesics, and higher among those with (76.1%) than without

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(31.3%) claims for spinal surgery (31;32). The mean time interval between the index claim for

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LBP and subsequent utilization of x-rays was 34.7 days (32).

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In Medicare populations, utilization of x-rays was 22.9% over 36 months for acute

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uncomplicated LBP and 48.2% over 12 months for nonspecific LBP (11;13). For those who

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received only x-rays, utilization was slightly lower among those with (19.2%) than without

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(23.5%) dual Medicare-Medicaid eligibility, but did not differ for those above (23.3%) or below

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(22.5%) median income; utilization was notably higher among patients of clinicians whose

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compensation was partially related to patient satisfaction incentives (46.9%) (13).

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Utilization of spinal MRI

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Two of the four studies measuring utilization of MRI for LBP reported the CPT codes used to

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identify relevant claims; one included only lumbar MRI, while the other also included cervical

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and thoracic MRI, with or without contrast (20;32). In commercial health plans, utilization of

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MRI was 16.0% over 12 months, 18.0% over 12-36 months, and 21.0% over 19 months among

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those with mechanical LBP (29;31;32). Utilization of MRI was lower for those with nonspecific

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LBP (8.5%), and higher for those with (33.3%) than without (14.9%) chronic LBP (32). Use of

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MRI was higher among those with (75.7%) than without (16.8%) claims for spinal surgery (32).

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The mean time interval between the index claim for LBP and subsequent utilization of MRI was

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63.6 days (32). In Medicare, utilization of MRI was 11.6% over 6 months in those with

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nonspecific LBP, higher among patients who consulted with an orthopedist (20.1%) than with a

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PCP (10.5%), and higher among those clinicians with (11.4%) than without (20.6%) ownership

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in a MRI facility (20).

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Utilization of spinal CT

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Only one of the two studies measuring utilization of CT for LBP reported the CPT codes used to

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identify relevant claims, which included lumbar CT with or without contrast (31;32). In

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commercial health plans, utilization of CT was 3.0% over 12 months and 1.4% over 12-36

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months for those with mechanical LBP (31;32). Utilization of CT was lower for those with

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nonspecific LBP (0.4%), and higher for those with (3.5%) chronic LBP than non-chronic LBP

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(1.0%) (32). Use of CT was much higher among those with (14.0%) than without (1.2%) claims

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for spinal surgery (32). The mean time interval between the index claim for LBP and subsequent

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utilization of CT was 81.3 days (32). No studies were identified that reported utilization of CT

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for LBP in a Medicare population.

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Utilization of spinal MRI and/or CT

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Two of the four studies measuring utilization of MRI and/or CT for LBP reported the CPT codes

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used to identify relevant claims; one included only lumbar MRI or CT, while the other also

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included cervical and thoracic MRI, with or without contrast (11;13). In commercial health

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plans, utilization of MRI and/or CT was 10.9% over 24 months and 16.1% over 12-36 months

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for nonspecific LBP (30;31). Utilization of MRI and/or CT appeared to increase with the number

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of episodes of LBP, from 4.6% for those with only 1 episode of LBP (i.e. 30-day period with

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claim for utilization of health services related to LBP) to 37.3% for those with 6 or more

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episodes of LBP (30). Utilization of MRI and/or CT was higher for those with (24.2%) than

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without (11.1%) claims for opioids, higher for those with acquired (20.4%) than congenital

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(3.4%) conditions related to LBP, and similar for those with (17.5%) and without (17.3%)

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neurologic findings (31). In Medicare, utilization of MRI and/or CT was 16.3% over 12 months

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in those with nonspecific LBP and 10.4% over 36 months for uncomplicated acute LBP (11;13).

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Utilization of MRI and/or CT was lower among those with (7.3%) than without (11.0%) dual

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Medicare-Medicaid eligibility, and lower for those below (9.8%) than above (11.3%) median

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income (13). Use of MRI and/or CT was much higher among patients of clinicians whose

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compensation was partially related to patient satisfaction incentives (17.1%) (13).

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DISCUSSION

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The search strategy identified over 1,000 citations related to utilization of health services for

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LBP - the majority from Medline - indicating some level of interest in this topic by researchers.

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Many of those studies were excluded from this review because they did not identify the ICD-9

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diagnosis codes used to determine that utilization was in fact related to LBP. Although

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assumptions can be made about the likely indication for spinal diagnostic imaging in the absence

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of ICD-9 diagnosis codes, it is difficult to compare and interpret findings from studies that did

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not adequately describe the population of interest. For example, a national sample of Medicare

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fee-for-service (FFS) part B data reported that utilization of spinal CT varied from 0.3% to 2.4%

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of all enrollees in different regions across the country, while another study reported that use of

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spinal CT occurred in 1.1% of all Medicare patients, which was lower than the 1.4% and 3.0%

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reported in studies that focused on those with LBP (10;21). Similarly, spinal MRI was used by

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0.8% to 5.9% of all Medicare members, compared to 11.6% of those with LBP (10;21).

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Measuring the reported utilization of health services without analyzing specific ICD-9 diagnosis

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codes related to their use makes it challenging for stakeholders to interpret findings, identify

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changes in use over time, and ascertain the appropriateness according to evidence-based CPGs,

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particularly for relatively high-cost health services such as MRI and/or CT for LBP (35).

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Although all of the studies included in this review seemed intent on measuring utilization of

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diagnostic imaging for nonspecific LBP (i.e. excluding LBP from serious spinal pathology and

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specific causes), wide variation was noted in the 76 different ICD-9 diagnosis codes used to

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identify this clinical construct. For instance, one study included only two ICD-9 codes (724.2

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lumbago and 724.5 unspecified backache), while three studies cited a list of nearly 70 diagnoses

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to identify administrative claims related to mechanical LBP (11;29-31). However, it was unclear

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exactly which ICD-9 codes had been used in some studies since ranges (e.g. 737.10-737.30)

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were reported rather than listing each diagnosis to minimize confusion (33). Some of the studies

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that cited the list of ICD-9 diagnosis codes proposed by Cherkin et al. listed 53 codes, while

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others listed 66, making it unclear if the original list had been interpreted correctly (31).

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Other differences noted in the studies reviewed that may have influenced utilization included

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patient eligibility criteria, duration of observation, CPT codes, and other requirements. For

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example, one study included only patients seen by PCPs participating in a community-based

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survey, while another focused on comparing utilization for patients seen by PCPs or orthopedic

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surgeons (13;20). One Medicare study reported utilization of MRI within 6 months of the index

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visit for LBP, while another Medicare study measured utilization over a 36-month period,

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making it difficult to compare findings when duration varied 6-fold (20). The studies measuring

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utilization of x-rays for LBP differed in their inclusion of cervical, full-spine, and sacral films,

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which may have impacted their results (11;13;32). Studies also differed in the length of time

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required without any claims for LBP to identify the index visit, which varied from 6 to 12

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months in three studies and was not specified in four studies.

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Some of the different methods used to identify claims related to spine pain in administrative

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databases were recently examined by researchers at the Department of Veterans Affairs (VA)

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(36). The authors found five previous studies with ICD-9 diagnosis codes related to different

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types of LBP and neck pain (including the one by Cherkin et al.), as well as two classification

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systems from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and

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Utilization Project (HCUP). Data from the VA were then used to compare the number of patients

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identified as having spine pain in the period 2002-2009 using different methods, as well as a

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more comprehensive approach combining all diagnosis codes. Although considerable overlap

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was found in these methods, discrepancies in their scope affected the number of patients

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identified. Authors recommended that future studies on utilization of health services for LBP

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should specify clear objectives, ICD-9 diagnosis codes, exclusions (e.g. co-morbidities, serious

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pathology), and other methods to facilitate comparison and interpretation. Enhanced

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standardization for studies related to utilization of health services for LBP could potentially build

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on previous reporting guidelines for retrospective database studies (37).

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Standardizing the methods used in studies focused on measuring utilization of health services for

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LBP may help mitigate some of the limitations associated with administrative data, but their

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accuracy nevertheless depends on the information submitted by clinicians and administrators

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(32). For example, spinal x-rays taken for symptoms of LBP in a patients with a history of

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prostate cancer could be coded with the primary ICD-9 diagnosis code “724.2 lumbago”, which

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would have been captured in many of the studies reviewed, while those coded “233.3 carcinoma

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in situ of prostate” would not have been included.

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Retrospective studies of claims data also contain sparse information that may influence

2

utilization and appropriateness, such as duration of LBP, symptom severity, functional

3

limitations, co-morbidities, severity and distribution of neurologic findings, clinical presentation,

4

patient preferences, beliefs, and expectations, and health plan management (13;25;30). For

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example, utilization of x-rays was lower in patients with (22.6%) and without neurologic

6

findings (32.8%) (31). This finding may be viewed positively and suggests that clinicians were

7

aware that x-rays are unable to identify the source of neurologic compression responsible for the

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patient’s clinical presentation, and therefore did not order them (31). Conversely, this may also

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suggest that utilization of x-rays was too high for LBP without neurologic findings. Similarly, a

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lower observed rate of MRI utilization in those with nonspecific LBP (8.5%) than any type of

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LBP (18.0%) may suggest that clinicians were aware of recommendations from evidence-based

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CPGs against advanced diagnostic imaging for nonspecific LBP (32). However, an audit of

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clinical records previously reported that 26% of x-rays and 66% of MRI and/or CT ordered for

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acute LBP were deemed inappropriate according to criteria outlined in evidence-based CPGs,

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making this hypothesis unlikely (38).

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Numerous factors may influence the use of diagnostic imaging for LBP, including patient

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expectations, beliefs, and preferences. For example, some patients may believe that diagnostic

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imaging is necessary to provide a diagnosis and validate their symptoms, and will perceive its

20

absence as an indication of poor quality care (39). Clinicians may therefore feel pressure to order

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diagnostic imaging to ensure patient satisfaction (40). One study that examined indirect financial

22

incentives available to clinicians based on patient satisfaction reported that utilization of x-rays

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for LBP was higher when those incentives were present (13). The role of other financial

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incentives was also explored in another study, which compared utilization of MRI for LBP in

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physicians with or without an ownership interest in imaging equipment and reported that use was

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nearly twice when this potential financial incentive was present (20). The role of these financial

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and non-clinical factors should be explored further to understand how they may influence

5

utilization of diagnostic imaging for LBP.

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Another aspect that may sway clinicians to order diagnostic imaging is fear of litigation if they

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fail to identify rare but serious spinal pathology related to LBP, such as spinal tumor, infection,

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fracture, or cauda equina syndrome (41). Such fear may lead to the practice of defensive

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medicine whereby clinicians err on the side of overusing diagnostic imaging, despite its high

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costs and potential harms, to mitigate their legal liability (39). A study that recently examined

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use of diagnostic imaging among orthopedists in Pennsylvania attributed 19% of utilization and

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35% of costs to defensive medicine (42). The most common imaging modality ordered for

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defensive reasons was MRI, for which 39% of orders were classified as defensive. Orthopedists

15

who had been sued for medical malpractice in the past five years had a higher proportion of

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diagnostic imaging for defensive purposes (25%) than those who had not been sued (15%).

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Although malpractice tort reform has been proposed as a potential solution to address this

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problem, its impact on the utilization of diagnostic imaging for LBP remains unknown (43).

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20

Despite the limitations of claims data, they are often used to develop programs aimed at

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improving the quality of health care, or at reducing costs associated with unnecessary utilization.

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For example, the NCQA credentialed clinicians on a voluntary basis for its Back Pain

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Recognition Program (BPRP), and one of the 13 clinical measures was related to diagnostic 17

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imaging, which specified that a maximum 50% of patients with LBP should receive diagnostic

2

imaging within 6 weeks of onset in the absence of red flags for serious spinal pathology (44).

3

Although the validity of this 50% threshold is difficult to evaluate, it was the only numerical

4

benchmark uncovered on this topic. Given that the NCQA recently announced it was retiring its

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BPRP, it may be beneficial for other researchers or organizations to suggest an alternative

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standard and method of measurement that could be used in future studies on this topic to

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facilitate interpretation and comparison of findings in different populations and settings (45).

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Other methods proposed to address potential overuse of health services include those targeting

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patient demand, such as decision aids, shared decision making, and public education campaigns.

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For instance, the American Board of Internal Medicine (ABIM) Foundation recently launched its

12

Choosing Wisely® campaign to help patients choose health care that is supported by scientific

13

evidence and clinically necessary (46). This campaign is supported by various professional

14

societies, including the American Academy of Family Physicians (AAFP) and the American

15

College of Physicians (ACP). The use of diagnostic imaging for LBP without red flags was the

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first item on the list from the AAFP, while diagnostic imaging for non-specific LBP was the

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second item on the ACP list (46). Future studies should measure the impact of this campaign on

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patient demand and subsequent utilization of diagnostic imaging for LBP.

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Clinician behavior can also be targeted through informal or continuing medication education

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(CME) to share findings from recent CPGs, given that audits of clinical records reported that

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diagnostic imaging guidelines were followed in only 2% of patients with chronic LBP (47). A

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study previously reported that education of PCPs about CPGs for the assessment and 18

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management of LBP through CME presentations reduced utilization of MRI by 28% and CT by

2

81% without decreasing patient satisfaction with care (48). However, these findings were

3

obtained in a group practice HMO shortly after the educational intervention, and may not be

4

applicable in other settings. Education can also be enhanced through informal decision aids or

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more formal clinical decision support (CDS) systems that provide feedback to clinicians on the

6

perceived appropriateness of the health service being ordered at the point of entry. For example,

7

a decision instrument based on five clinical criteria had a 99.0% sensitivity to detect cervical

8

spine injury later confirmed by radiographs for patients following blunt trauma; similar

9

instruments could likely be developed for LBP (49). Another study examined the effects of a

10

mandatory CDS prior to obtaining authorization for lumbar MRI in a large multidisciplinary

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health network (12). Utilization of lumbar MRI for patients with LBP decreased from 12.7% in

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the year before CDS was implemented to 9.3% the following year, a net reduction of 27%.

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The availability of other health services, including chiropractic and complementary and

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alternative medical therapies such as massage or acupuncture, has also been found to impact

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utilization of diagnostic imaging for LBP. One study compared utilization of spinal MRI and x-

17

rays among 700,000 health plan members with chiropractic benefits and 1 million members

18

without this coverage through their managed care plan (50). Utilization of MRI for patients with

19

LBP was considerably lower among patients with (4.3%) than without (6.9%) chiropractic

20

coverage; similar findings were also reported for x-rays (1.8% vs. 2.3%). Authors postulated that

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chiropractic care may have been substituted for other health services, resulting in decreased use

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of diagnostic imaging and other health services, though this hypothesis could not be confirmed.

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Study limitations

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This review has a number of limitations that should be acknowledged, including the limited

3

search strategy and eligibility criteria that limited the studies reviewed to those published in

4

English since the year 2000 based on third-party claims data for payers in the US that specified

5

the ICD-9 diagnosis codes used in their analyses. This narrow focus may have excluded

6

potentially relevant studies that may nevertheless have reported interesting findings. In addition,

7

all of the studies included in this review were based on claims data with imperfect accuracy,

8

incomplete clinical information, and may be influenced by other factors (e.g. administrative,

9

financial, or other requirements). Inferences about the appropriateness, clinical necessity, or

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perceived overuse of health services based solely on claims data are therefore speculative. It is

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also difficult for third-party payers to discuss the topic of health care utilization without raising

12

the possibility that financial conflicts of interest are influencing their opinions. Nevertheless, this

13

review reports on a topic that appears to be of interest to many in the spine community, and

14

whose importance may continue to grow.

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CONCLUSIONS

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The reported utilization of various diagnostic imaging modalities for LBP, including x-rays, CT,

18

and MRI, varied across the studies reviewed. However, differences in the methodology used by

19

these studies impeded interpretation and meaningful comparisons, making it difficult to

20

determine if previously reported utilization of diagnostic imaging for LBP is appropriate.

21

Standardizing the methods for performing and reporting analyses of claims data related to

22

utilization could facilitate efforts by third-party payers, health care providers, and researchers to

23

identify and address the perceived overuse of diagnostic imaging for LBP in future studies.

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FIGURE 1. Flow diagram of studies in this review

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Table 1. Study characteristics LBP sample Rate

Data Utilization

Type of imaging

Inclusion

Illinois 165,569 18-64 Colorado >410,000 ≥18

13,760 8.3%

2002-2004 19 months

MRI

1. LBP of mechanical causes

1. infection 2. accidental causes

16,567 4.0%

1996-2001 24 months

x-rays MRI/CT

1. major existing conditions (e.g. neoplasm, infection, pregnancy, trauma)

x-rays MRI CT MRI/CT x-rays MRI CT

1. LBP diagnosis in 1997 or 1998 2. first contact in ambulatory or hospital setting 3. no LBP in previous 12 months 4. enrolment for 24 months after index LBP 1. LBP due to mechanical causes

1. LBP diagnosis during 2004-2006 2. coverage >6 months before index LBP claim 3. coverage >12 months after index LBP claim

1. other LBP diagnosis during observation period

Exclusion

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Commercial (29) Employersponsored (30) 1 Staff model HMO

Location Sample size Age

SC

Reference Plan type

Pennsylvania 255,958 ≥18

17,148 6.7%

2001 12 months

(32) NR

National ≥8,000,000 18-64

211,551 2.6%

2004-2006 12-36 months

Pennsylvania NR ≥65

34,408 2 NR

2000-2002 12 months

x-rays MRI/CT

1. nonspecific LBP

1. lumbar spinal stenosis

National 496,529 ≥65

35,039 7.1%

2000-2002 36 months

x-rays MRI/CT

1. uncomplicated acute LBP 2. seen by PCP 4 participating in Community Tracking Study Physician Surveys 3. enrolled for >6 months after LBP

National NR ≥65

740,467 6 NR

1. LBP in previous 6 months 2. care in >1 state 3. hospice or nursing homes 4. neurologic deficit 5. end-stage renal disease 6. trauma, cancer, infection 7. index visit by radiologist 1. LBP in previous 12 months 2. Medicare eligible