Back Pain and Health Care Costs

David Leonhardt makes a good point. Controlling health care costs - one of our most important domestic policy problems - will require our politicians to make hard (and unpopular) decisions.

In Idaho Falls, Idaho, anyone suffering from the sort of lower back pain that may conceivably be helped by the fusing of two vertebrae is quite likely to have the surgery. It's known as lumbar fusion, and the rate at which it is performed in Idaho Falls is almost five times the national average. The rate in Idaho Falls is 20 times that in Bangor, Me., where lumbar fusion is less common than anywhere else.

These numbers come from the wonderful Dartmouth Atlas of Health Care. The Dartmouth researchers adjust the numbers to take into account age, race and sex, which is another way of saying that there is no good explanation for the huge variations they find. Doctors in the Idaho Falls area are probably just being more aggressive than doctors elsewhere.

But it's not clear that their patients are any better off. The evidence for lumbar fusion is incredibly mixed. It seems to help people with certain kinds of pain, but many others recover just as well without the surgery. Of course, doctors are almost always better off if the surgery is done: The typical hospital bill for lumbar fusion is roughly $50,000.

This is about as good an example as you can find of the health care mess. The number of lumbar fusions performed in this country has more than tripled since the early 1990s, and Medicare now spends more than $600 million a year on the procedure. It's one reason your health insurance bill has gone up.

But I think Leonhardt's example is almost too easy. Spinal fusion surgery is so expensive - and its therapeutic benefits are so limited - that I hope we can at least screw up the courage to crack down on the doctors of Idaho Falls. Here's a much tougher question: should people with back pain get an MRI?

At first glance, the answer seems obvious: of course they should. MRI's are a diagnostic test (not an experimental surgery), and I don't want my doctor's diagnostic process to be constrained by some government bureaucrat. But the medical evidence paints a far murkier picture.

A large study published in JAMA randomly assigned 380 patients with back pain to undergo two different types of diagnostic analysis. One group received X-rays, which provide the doctor with a relatively crude picture of the back. X-rays can reveal tumors or vertebrae fractures, but can't detect abnormalities in the spinal discs. (They are also relatively cheap.) The other group got diagnosed using MRI's, which give the doctor much more information about the underlying anatomy. These doctors could see the pinched nerves and herniated discs and inflamed tendons that were supposedly causing the pain.*

Which group fared better? Did better pictures lead to better treatments? There was no difference in patient outcome: the vast majority of people in both groups got better. But stark differences emerged when the study looked at how the different groups were treated. Nearly 50 percent of MRI patients were diagnosed with some sort of disc abnormality, and this diagnosis led to intensive medical interventions. The MRI group had more doctor visits, more injections, more physical therapy and were more than twice as likely to undergo surgery. Although these additional treatments were expensive, they had no measurable benefit for the patient. In fact, the MRI's may even make things worse. The conclusion of recent report in The New England Journal of Medicine was sobering: "Incidental findings [of disc abnormalities by MRI's] may lead to overdiagnosis, anxiety on the part of patients, dependence on medical care, a conviction about the presence of disease, and unnecessary tests or treatments." The report concludes that MRI should only be used under specific circumstances, when doctors are examining "patients for whom there is a strong clinical suggestion of underlying infection, cancer, or persistent neurologic deficit."

Clearly, more evidence is needed before we stop using MRI's to diagnose people with back pain. But I think this simple case study illustrates just how hard it will be to enact reforms that control health care costs. Most patients, I imagine, won't be happy to hear that they can't get an MRI to image their pain. And most doctors, I imagine, won't be pleased about being constrained by some government cost-control office. But if we are ever going to fix our system, then such disputes will be necessary. You can't always get what you want, but sometimes you get what you need.

*A well-known study published in The New England Journal of Medicine in 1994 imaged the spinal regions of ninety-eight people with no back pain or any back related problems. The pictures were then sent to doctors who didn't know that the patients weren't in pain. The end result was shocking: two-thirds of normal patients exhibited "serious problems" like bulging, protruding or herniated discs. In 38 percent of patients, the MRI revealed multiple damaged discs. These structural abnormalities are often used to justify expensive treatments like surgery, and yet nobody would advocate surgery for people without pain. The doctors concluded that, in most cases, "the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental."


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Oh god, here come the chiropractors demanding insurance coverage... After 40 X-rays and a some bogus tests that the scientologists rejected as too fake-looking, they'll say you need "subluxations" "adjusted".

Scientific progress slogs along at a snails pace because doing good science is hard and requires devoted scentists who don't have anything to gain by showing a particular effect. Many erroneous trends in medicine could have been avoided by doing studies like the one in JAMA. But these studies take time, money and honest scientists.
If we want to make a change to the health care system, lets get more scientists doing clinically relevant research as well as training MD's in new practice guidelines. MD's work very hard and do not always have time to read all the literature. Likewise, scientists work hard on specific molecules and animal models and often lose track of clinical relevance. Two words: KNOWLEDGE TRANSLATION

A particularly interesting item, as my wife had this procedure exactly a week ago.

This followed about 3 years of deteriorating function and increasing discomfort, despite exercises, staying active, etc. The back specialist was one who views surgery as a last resort. Following a few X-rays over the years and one MRI, he recommended surgery.

The surgery also involved a fair bit of tidying-up of arthritic damage. The whole thing amounted to amounted to 4+ hours of surgery, 2 days in intensive care, and 2 further days in hospital. Even after a week, she can notice decreased nerve-related pain and numbness and some better function (although there is still post-operative pain to deal with).

As a lay observer (but admittedly an emotionally-involved one), this seems to me to have been a responsible approach which balanced patient condition with cost.

We're in Canada, so this did not involve some of the angst or administration which might have occurred in the US.

By Scott Belyea (not verified) on 08 Jun 2007 #permalink

Last year I had an MRI for back pain. I was very much on the fence about it; I didn't think anything would really come of it (it didn't), and even the doctor didn't seem all that enthusiastic. But it was clear that it was more or less standard for him to order one. It's hard to say no when it's (a) essentially "free", and (b) you don't really know what your doctor expects to get from it, or what problems may be revealed.

But it wouldn't have taken much of a push to make me turn down the treatment. I think if I had been operating on some kind of consumer driven health care (that is, a spending account of my own), I probably would have told him to just do the X-rays. Having to comprehend the sticker price, even if it's subsidized somehow, might be able to introduce the proper tension between over and under treatment.

By Eric Wallace (not verified) on 08 Jun 2007 #permalink

Nice post. For all the talk of evidence-based medicine, its worth rememerbing that it's very tough for medicine to just follow the evidence. There are just so many counter-pressures.

A couple of years ago, I was experiencing severe back pain. The doctor wasn't sure what was wrong. She suggested an MRI. But first, she sent me for physical therapy evaluation. The physical therapist put her finger on the EXACT spot of my pain, and said, is that where it hurts? It turned out to be just a pulled muscle which she had seen hundreds of times. I did not need the MRI after all. Even though it would have cost me very little with my insurance, I HATE being inside that machine, and overall, I appreciated getting a low-tech diagnosis that I trusted, and that saved me a little time and mental anguish.

The human body is very complicated (duh) and biological processes and systems do not function according to any kind of superficial logic, and often operate in ways that are actually counter-intuitive. A good doctor is not only well-trained, but also, I believe, needs to acquire experience over time, and then also, would have some sort of "mysterious" knack or talent, almost like artistic creativeness, for diagnosing and treating illness.

My wife also had the procedure about 9 years ago and she is still in pain. The degenerated disc problem was dealt with in that the lumbar fusion took some of the pressure off. So it's hard to say if the pain is coming from the original unremedied pathology or if the surgery added some new aspect to her pain. In any case, she had a lumbar fusion and she still has pain, so obviously it didn't go as planned.
But if we knew then what we know now (about not being able to strongly correlate imagery-based anatomical "problems" with pain), she would certainly have reconsidered surgery. We too are from Canada, so cost really is not an issue. The issue is needless diagnostics and surgery. Every additional surgery adds risk (paralysis, enhanced pain, etc). Why are MRI's still used as diagnostic tools leading to surgery, if studies have been done indicating that MRI's are not good predictors of pain? Why can't physicians follow the evidence? In my opinion, it's because they are too busy treating sick people. Like I said in a previous post, if we want to improve health care, we have to improve communication between research and clinic.

Chiropractors provide great relief (for "decrepitoldfool") so why be so down on them? They may not all be great, but neither are medical doctors. While I am in total agreement that over testing and over diagnosing are problems, I suffered ENORMOUSLY a few years ago and had surgery to remove a bone spur pinching my sciatic nerve. I would do it again in a heartbeat!
I've had back pain since I was a teenager, sometimes a little, sometimes a lot, but always there. Surgery was only suggested twice - once by a nut job who didn't believe I was in pain anyway and once for the above-mentioned bone spur.
Meanwhile, I continue to walk, do karate and yoga, and work out on a regular basis. And my back continues to hurt.