Imaging incidence and type in primary care patients with low back pain: a cross-sectional study on new referrals to an Australian specialist spinal surgical centre
Isaac J. Tennant
1 * , Yun-Hom Yau 1 2 3 , Derek Yull 1 2 , Peter Murphy 2 , Ian R. Whittle 1 2 4
1 Faculty of Health and Medical Sciences, University of Adelaide, SA, Australia.
2 The International Spine Centre, Norwood, SA 5067, Australia.
3 The Spinal Unit, Royal Adelaide Hospital, Adelaide, SA 5000, Australia.
4 The Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, Scotland, UK.
Journal of Primary Health Care 15(3) 262-266 https://doi.org/10.1071/HC22127
Published: 8 March 2023
© 2023 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of The Royal New Zealand College of General Practitioners. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)
Abstract
Introduction: Low back pain (LBP) is common and a significant cause of morbidity. Many patients receive inappropriate imaging for LBP in primary care.
Aim: To explore the incidence and type of spinal imaging conducted for LBP patients referred from general practice for specialist surgical opinion, and evaluate whether imaging conformed to clinical guidelines.
Methods: Audit of a sequential cohort (n = 100) of new LBP patients referred from primary care for specialist opinion at a suburban Australian capital city independent Spinal Centre.
Results: In the 6 months before referral, 90% (95% CI 83–95%) of patients underwent spinal imaging. Imaging was performed in 95% of those who did and 79% of those who did not meet guidelines for radiological investigation. 35% of patients were inappropriately imaged and 3% inappropriately not imaged. Spinal computed tomography (CT) imaging was used in 52% of patients, magnetic resonance imaging (MRI) in 42% and image-guided lumbar spinal interventional procedures in 28%.
Discussion: Most patients with LBP referred for surgical opinion have diagnostic radiological investigations whether or not it is indicated by clinical guidelines. The more frequent use of spinal CT compared to MRI may be due to idiosyncrasies of the Australian Medicare Benefits Schedule (MBS) rebate system. The findings of this pilot study provide support for the changes recommended by the 2016 MBS Review Taskforce on LBP that permit GP access to subsidised lumbar MRI, while constraining access to lumbar CT, and provide novel data about spinal imaging and practice in this cohort of patients.
Keywords: back pain, clinical guidelines, general practitioners, health financing, health funding, health policy, musculoskeletal disease, neurosurgeons, New Zealand health strategy, primary health care.
References
[1] Hoy D, March L, Brooks P, et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis 2014; 73 968–74.| The global burden of low back pain: estimates from the Global Burden of Disease 2010 study.Crossref | GoogleScholarGoogle Scholar |
[2] Walker BF, Muller R, Grant WD. Low back pain in Australian adults: prevalence and associated disability. J Manipulative Physiol Ther 2004; 27 238–44.
| Low back pain in Australian adults: prevalence and associated disability.Crossref | GoogleScholarGoogle Scholar |
[3] Koes BW, van Tulder MW, Thomas S. Diagnosis, and treatment of low back pain. BMJ 2006; 332 1430–4.
| Diagnosis, and treatment of low back pain.Crossref | GoogleScholarGoogle Scholar |
[4] Balagué F, Mannion AF, Pellisé F, et al. Non-specific low back pain. Lancet 2012; 379 482–91.
| Non-specific low back pain.Crossref | GoogleScholarGoogle Scholar |
[5] National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. National Institute for Health and Care Excellence; 2016.
[6] Orthopaedic Spinal Services CALHN. Spinal imaging recommendations. Adelaide, SA: Government of South Australia; 2015. Available at https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/clinical+programs+and+practice+guidelines/medical+conditions/orthopaedics/lumbar+disorders/clinical+resources+for+lumbar+disorders/spinal+imaging+recommendations [Accessed 2 April 2022].
[7] Jenkins HJ, Downie AS, Maher CG, et al. Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis. Spine J 2018; 18 2266–77.
| Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis.Crossref | GoogleScholarGoogle Scholar |
[8] Downie A, Hancock M, Jenkins H, et al. 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. Br J Sports Med 2020; 54 642–51.
| 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.Crossref | GoogleScholarGoogle Scholar |
[9] Jarvik JG, Gold LS, Comstock BA, et al. Association of early imaging for back pain with clinical outcomes in older adults. JAMA 2015; 313 1143–53.
| Association of early imaging for back pain with clinical outcomes in older adults.Crossref | GoogleScholarGoogle Scholar |
[10] Lin EC. Radiation risk from medical imaging. Mayo Clin Proc 2010; 85 1142–6.
| Radiation risk from medical imaging.Crossref | GoogleScholarGoogle Scholar |
[11] Australian Government Department of Health and Aged Care. Medicare Benefits Schedule Book. Canberra: Commonwealth of Australia; 2021.
[12] Medicare Benefits Schedule Review Taskforce. First Report from the Diagnostic Imaging Clinical Committee - Low Back Pain. Australian Government Department of Health and Aged Care, Commonwealth of Australia; 2016.
[13] Whittle IR, Yull D, Yee J, et al. Can the use of General Practitioners with an extended role in spinal practice expedite assessment and management of patients referred to spinal surgeons: preliminary experience and challenges. Prim Health Care Res Dev, 2023; 24 e9
| Can the use of General Practitioners with an extended role in spinal practice expedite assessment and management of patients referred to spinal surgeons: preliminary experience and challenges.Crossref | GoogleScholarGoogle Scholar |
[14] Williams CM, Maher CG, Hancock MJ, et al. Low back pain and best practice care: a survey of general practice physicians. Arch Intern Med 2010; 170 271–7.
| Low back pain and best practice care: a survey of general practice physicians.Crossref | GoogleScholarGoogle Scholar |
[15] Britt H, Miller GC, Henderson J, et al. General practice activity in Australia 2012–13. Sydney University Press; 2013.
[16] National Health and Medical Research Council. National Statement on Ethical Conduct in Human Research. Canberra: Commonwealth of Australia, Australian Research Council and Universities Australia; 2007 [updated 2018].
[17] Peurois M, Bouton C, Bègue C, et al. Influence of low back pain characteristics on the healthcare procedures prescribed by general practitioners for adult patients: ancillary analysis of the French ECOGEN study. Rev Epidemiol Sante Publique 2022; 70 133–9.
| Influence of low back pain characteristics on the healthcare procedures prescribed by general practitioners for adult patients: ancillary analysis of the French ECOGEN study.Crossref | GoogleScholarGoogle Scholar |
[18] Jenkins HJ, Hancock MJ, Maher CG, et al. Understanding patient beliefs regarding the use of imaging in the management of low back pain. Eur J Pain 2016; 20 573–80.
| Understanding patient beliefs regarding the use of imaging in the management of low back pain.Crossref | GoogleScholarGoogle Scholar |
[19] Lysdahl KB, Hofmann BM. What causes increasing and unnecessary use of radiological investigations? A survey of radiologists’ perceptions. BMC Health Serv Res 2009; 9 155
| What causes increasing and unnecessary use of radiological investigations? A survey of radiologists’ perceptions.Crossref | GoogleScholarGoogle Scholar |
[20] Alsaleh K, Ho D, Rosas-Arellano MP, et al. Radiographic assessment of degenerative lumbar spinal stenosis: is MRI superior to CT? Eur Spine J 2017; 26 362–7.
| Radiographic assessment of degenerative lumbar spinal stenosis: is MRI superior to CT?Crossref | GoogleScholarGoogle Scholar |
[21] Australian Commission on Safety and Quality in Health Care. Low Back Pain Clinical Care Standard. Sydney, NSW: Australian Commission on Safety and Quality in Health Care; 2022.
[22] Australian Government Department of Health and Ageing. Medicare Benefits Schedule Book. Canberra: Commonwealth of Australia; 2011.
[23] Accident Compensation Corporation. GP Referred MRI Operational Guidelines. Wellington, New Zealand: ACC; 2020.
[24] Accident Compensation Corporation. Service schedule for general practitioner (GP) referred magnetic resonance imaging (MRI). Wellington, New Zealand: ACC; 2020.
[25] Robson J. GP MRI service rolled out as wait times fall. ACC Chief Clinical Officer & Head of Health Partnerships. Media Releases, 23 June 2022.
[26] Logan GS, Dawe RE, Aubrey-Bassler K, et al. Are general practitioners referring patients with low back pain for CTs appropriately according to the guidelines: a retrospective review of 3609 medical records in Newfoundland using routinely collected data. BMC Fam Pract 2020; 21 236
| Are general practitioners referring patients with low back pain for CTs appropriately according to the guidelines: a retrospective review of 3609 medical records in Newfoundland using routinely collected data.Crossref | GoogleScholarGoogle Scholar |
[27] Oliveira CB, Maher CG, Pinto RZ, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J 2018; 27 2791–803.
| Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview.Crossref | GoogleScholarGoogle Scholar |
