Many patients with low back pain are still receiving the wrong care
A 2018 systematic review that included 14 studies mostly from the United States (6 studies), United Kingdom (3 studies), and other high-income countries found that overall more than 50% of people with low back pain seek care annually and 30% have sought care within the past month.5 Proportions were similar irrespective of whether the study included workers or the general population, but rates did vary by setting, eg, 67% (95% CI 50-84) in the United States vs 48% (95% CI 33-63) in Europe. These data are very concerning as much of modern back pain care is ineffective and some care is harmful.
The surge in global low-value care for low back pain that includes presentations to emergency departments, liberal use of diagnostic imaging, opioids, spinal injections, and surgery has also led to skyrocketing medical and human costs. A 2012 study in a US Veterans Affairs Health Care facility found that 59% of outpatient lumbar spine scans were inappropriate.3 This suggests that unnecessary lumbar spine magnetic resonance imaging scans for people not suspected of having a serious condition cost $US300 million per year in the United States. This is supported by a 2019 systematic review (14 studies) which found evidence that imaging is associated with higher medical costs, increased health care utilization, and more work absence compared with nonimaged groups.61 Despite little evidence to support its use for most back conditions,43 and a 20% failure rate,91 another US study estimated that $US12.8billion was spent on spinal fusion surgery in 2011, the highest aggregate hospital costs of any surgical procedure.92
Much of the money spent on low back pain is wasted, and better system level and policy solutions are needed
The Lancet Series identified promising solutions that included focused implementation of best practice, the redesign of clinical pathways, integrated health and occupational care, changes to payment systems and legislation, and public health and prevention strategies.30 Yet, we also indicated that most were not yet ready for widespread implementation as the evidence underpinning them was inadequate.
Targeted efforts to reduce overuse of imaging for low back pain, a major source of healthcare waste and even iatrogenesis, have not met with much success to date.26,52 Lowering imaging rates is challenging, and strategies must be targeted towards the population/patients, clinicians, and health care administrators. Patients request imaging expecting to obtain a diagnosis for their pain19; clinicians order imaging because of entrenched beliefs and habits, perceived pressure from patients, fear of litigation and financial incentives42,47; and health systems continue to offer liberal access to imaging probably because of public demand and pressure from clinicians.
Major international clinical guidelines have moved away from medicalized management of low back pain and prioritized nonpharmacological approaches as first-line care.
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