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Wednesday, August 31st 2011

Too Much Care

Trying to define what is appropriate care and what is appropriate cost effective care is the long sought goal. Even the government has gotten into the business. The online Medicare Hospital Compare Quality of Care shows reported ‘quality’ metrics as reported by hospitals that participate in Medicare. One of the new statistics they’ve made available is the number of lumbar MRI scans health systems perform for back pain before conservative therapies are attempted for the back pain. Here is the write up on the NPR Shots Blog,

Back surgery is one of the best documented examples of expensive medical treatments that drive up health care costs while not always helping patients, and sometimes even hurting them.

And the latest Medicare data show that doctors frequently order MRI back scans for patients who haven’t tried recommended treatments such as physical therapy. An MRI often prompts surgery.

In 2009, 32 percent of Medicare patients with lower back pain who received a spine MRI at a hospital outpatient imaging center hadn’t tried a more conservative — and cheaper — treatment than surgery, according to data published on Medicare’s Hospital Compare website this month.

The point made at NPR is a little misplaced. I’m not sure we should blame MRIs for creating unnecessary surgeries. And that’s conceding much of spine surgery is unnecessary. If we want to reduce the use of ineffective spine surgery the idea isn’t to reduce the number of MRIs, its to educate and disincentivize ineffective spine surgery.

That aside it remains that I agree that lumbar MRI is an overused test. Since the vast majority of axial back pain does not respond to surgical or procedural intervention there is probably very little gained from most lumbar MRIs in terms of directing therapy. A course of conservative therapies for back pain is probably in order prior to any MRI. IF that fails, if radicular symptoms develop or if symptoms worsen then a lumbar MRI may be considered.

Despite saying that I contribute to the problem of MRI overuse.


Data From HHS At One of The Teaching Hospitals I’m At

At some of the teaching facilities I’m at I review a number of outpatient consult requests for back pain. I routinely refuse consults until MRI scans are available. This is because I’m looking for surgically amenable disease which is really the only issue, as the spine surgeon consultant, I can comment on. But I personally know the vast majority of the lumbar MRIs I review will not have surgically amenable disease. What I should really probably be saying on consults that come to me without MR imaging is that conservative therapy is in order prior to a reconsult with an MRI.

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