The clinical evidence is clear: While medical imaging can be an effective diagnostic tool, millions of Americans annually receive X-rays that are not medically necessary and can potentially harm their health.

The use of medical imaging has soared in the last 20 years as technology has advanced. More than 95 million tests – including X-rays, CT scans and MRIs – are being performed annually in the United States, at a cost of $100 billion a year, according to a report from America’s Health Insurance Plans. That number is expected to double by 2012, the AHIP report says.

Much of this growth is justified by the benefits of medical imaging, including fewer exploratory surgeries and improved diagnoses of a wide variety of diseases.

But as the AHIP report points out, recent studies show that 20% to 50% of these procedures should not be done because their results don’t help diagnose ailments or treat patients. These inappropriate tests waste between $3 to $10 billion a year, according to the AHIP report, thus driving up the cost of medical care for patients, insurers and the entire health care system.
The number of CT scans performed in America has grown sharply, from about three million in 1980 to about 62 million in 2007. In a recent report published in the Archives of Internal Medicine, a team of researchers concluded that 29,000 future cancers could be related to 70 million CT scans.

Faced with these facts, why do so many medical providers continue to refer for X-rays almost routinely, especially for such common conditions as lower back pain? The reasons are many and complicated. Many patients have become accustomed to getting X-rays and expect or even demand them, particularly when they’re experiencing joint or muscle pain. Concerns about malpractice suits lead many providers to err on the side of caution and over-prescribe X-rays.

Over-utilization of X-rays has been especially persistent in the diagnosis and treatment of musculoskeletal diseases and conditions. This medical category includes any disorder that affects the muscles, bones, joints and connective tissues, such as ligaments and cartilage. Musculoskeletal problems range from everyday aches and pains, to major debilitating diseases, such as rheumatoid arthritis and ruptured spinal discs.

The collective cost of treating these conditions is massive. Americans spend $510 billion annually on the diagnosis and treatment of musculoskeletal problems, with another $339 billion on indirect costs, such as lost work days.

Low back pain is the most prevalent musculoskeletal condition by far, affecting nearly everyone on the planet at some point, according to the World Health Organization. Every year, nearly 45 million people in the United States visit a health care provider because of lower back pain. It’s the most common reason that people seek chiropractic help and the No. 2 reason behind medical visits overall, just behind upper respiratory infections. 

When patients come to medical practitioners with complaints about low back pain, diagnostic imaging – commonly “plain film” or conventional X-rays – is often part of the diagnosis process. In fact, Americans spend $500 million annually for conventional X-rays of their lower backs. But medical science has shown many of these tests are simply unnecessary and inappropriate. Only 1 in 2,500 lumbar X-rays uncovers anything abnormal, such as a herniated disc or a tumor.

That’s because more than 85% of people suffer from “non-specific” back pain, meaning it can’t be clinically linked to a specific disease or spinal abnormality. Simply put, the likely cause can’t be diagnosed – even with X-rays.

Researchers do know that low back pain tends to increase as we age, can be triggered by strenuous activity and often goes away without treatment. However, it also can become chronic. Approximately 20% of patients who suffer from “non-specific” lower back pain describe it as severe or disabling, according to a 2008 study published in The Spine Journal.

The study noted that today, people with chronic low back pain can choose from “virtually endless” treatment options that are increasing every year. The authors – a large team of medical researchers from the University of California and the University of Ottawa – also noted the “often limited scientific evidence” behind these treatments.

To clear up the confusion, researchers and other medical specialists have laid out scientifically sound guidelines for diagnosing and treating musculoskeletal disorders. Based on the clinical evidence, these experts generally discourage clinicians from using imaging as the first course of action in treating patients.

The exception: patients with “red flag” symptoms, such as fever or blunt trauma, which demand immediate diagnosis and potential intervention, such as surgery.

In the absence of such severe symptoms, leading specialists recommend a measured, practical approach. For example, the American College of Physicians and American Pain Society jointly published clinical guidelines for the diagnosis and treatment of low back pain in 2007. Their recommended first step for clinicians: Conduct a focused health history and physically examine patients to help determine whether their pain is “unspecified” or associated with a more definitive spinal cause.

Recommendation No. 2 says, “Clinicians should not routinely obtain imaging or other diagnostic tests in patients with unspecified low back pain.”

Instead, experts agree clinicians should take a “watchful waiting” approach with these patients, advising them to stay active and providing them with information about effective self-care options. Those can include over-the-counter medications, such as acetaminophen or non-steroidal anti-inflammatory drugs.

For patients who do not improve with self-care options, providers should consider prescribing other therapies with proven benefits, such as spinal manipulation, physical therapy and acupuncture.

In the end, evidence-based guidelines are only as effective as their day-to-day application by providers treating patients. To improve both the quality and affordability of health care, everyone involved in the system – from providers to insurers and benefits managers – must adopt and adhere to policies that promote the appropriate use of X-rays and other imaging technologies.

Organizations that offer medical benefits must be vigilant in protecting their members from unnecessary X-rays. Oversight is essential to help ensure X-rays are used only when medically appropriate and to spare patients from unnecessary radiation exposure.

Rick Branson has been a doctor of chiropractic for 20 years and has served as director of clinical services at HSM since 2006.

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