Study finds overutilization of imaging for headache in U.S.

Study finds overutilization of imaging for headache in U.S.

By Wayne Forrest, AuntMinnie.com staff writer

March 18, 2014Neuroimaging was ordered for 12% of outpatient headache visits over the four-year period and accounted for approximately $1 billion a year in healthcare costs, researchers from the University of Michigan Health System found.

Lead author Dr. Brian Callaghan and colleagues attributed the use of CT and MRI for diagnosing headaches and migraines to patient demand and defensive medicine on the part of physicians.

“Optimizing headache neuroimaging practices should be a major national priority,” they wrote (JAMA Intern Med, March 17, 2014).

Sources of headaches

For the most part, headaches are caused by benign conditions, Callaghan and colleagues noted. Only 1% to 3% of patients undergoing neuroimaging exams for chronic headaches show significant abnormalities, according to past studies.

“However, little is known about recent headache neuroimaging utilization, associated expenditures, and temporal trends in the U.S.,” the authors wrote.

The group used the National Ambulatory Medical Care Survey (NAMCS) to gather information about all outpatient office-based care in the U.S. NAMCS details geographic regions, physician practices based on specialty, and patient visits within each practices.

Callaghan and colleagues also reviewed all headache visits for patients 18 years or older through the Healthcare Cost and Utilization Project (HCUP) classification system.

The researchers then estimated the proportion of headache visits from which a CT or MRI was ordered from 2007 through 2010 based on all headache visits, all migraine visits, and visits with a primary diagnosis of headache or migraine. Neuroimaging payments were calculated using the Medicare Physician Fee Schedule (MPFS).

Headache office visits

There were a total of 51.1 million headache visits during the four-year period, including 25.4 million office visits for migraine headaches, the group found.

Of all visits, 88% were by patients younger than 65 and 78% were by women. Primary care physicians received the most visits (55%), followed by neurologists (20%), other specialists (13%), and nonprimary care generalists (12%).

Neuroimaging with CT or MRI was conducted in 12.4% of all headache visits and in 9.8% of migraine visits, according to Callaghan and colleagues.

“Headache neuroimaging utilization was higher if the headache or migraine diagnosis was listed as the primary diagnosis for the visit,” the authors wrote. “Total neuroimaging expenditures were estimated at $3.9 billion over four years, including $1.5 billion from migraine visits.”

The burgeoning use of CT and MRI for headaches was not confined to the 2007-2010 timeline of the study. The researchers also found that neuroimaging utilization for all annual visits related to headache increased from 5.1% in 1995 to 14.7% in 2010.

Neuroimaging for headache or migraine
Diagnoses Visits (in millions) Imaging payments
(in millions)
Total MRI CT MRI or CT
All headache 51.1 7.6 5.1 12.4 $3,910
All migraine 25.4 6.0 3.8 9.8 $1,530
Primary headache 29.2 10.1 6.2 15.9 $2,910
Primary migraine 16.1 7.2 4.5 11.7 $1,160

“Since 2000, multiple guidelines have recommended against routine neuroimaging in patients with headaches because a serious intracranial pathologic condition is an uncommon cause,” the authors wrote. “Consequently, the magnitude of per-visit neuroimaging use found in this study suggests considerable overuse.”

Guidelines have not curtailed the use of neuroimaging because patient demands and defensive medicine may be driving referrals for CT and MRI scans, Callaghan and colleagues speculated.

If so, campaigns such as Choosing Wisely, which encourage patients to ask their doctors about the necessity and risk-benefit ratio of tests, “may be more effective than guidelines alone,” they added.

In addition, preauthorization of neuroimaging exams or shifting some of the cost to patients could help reduce the frequency of CT and MRI scans.

“Given that headache neuroimaging is common, costly, and likely substantially overused, interventions to curb utilization of these tests have the potential to substantially reduce healthcare expenditures while improving guideline concordance,” Callaghan and colleagues concluded. “Therefore, optimizing headache neuroimaging practices should be a major national priority.”


Copyright © 2014 AuntMinnie.com

Last Updated np 3/17/2014 3:11:13 PM

The imaging value chain – Top News – Rasu B. Shrestha, M.D., M.B.A.

The imaging value chain

By Shrestha, Rasu B
Proquest LLC

Imaging, in more ways than one, is the posterchild for healthcare reform. It always has been, and it seems, it always will be for at least some time to come. With unprecedented margin compression, efficiency pressures and quality of care pressures, it seems radiology is being attacked on all fronts. The only remaining hope, quite likely, may be for us to truly look within, and reevaluate the imaging value chain.

It may be high time for us to rethink what’s not working in the excesses of healthcare delivery, and relate this to the value we as imagers bring to the continuum of care for our patients. It has been said that healthcare inthe United States is in a predictable collision course between patient needs and economic reality. The spiraling costs of healthcare in the United States (U.S.) is nonsustainable, and it has perhaps been rightly stated that “advanced imaging is the bellwether for the excesses of fee-for-service medical care.”1 The U.S. spends more on healthcare services than any other country, exceeding $2.6 trillion, or about 18% of our gross domestic product, yet Americans have had a shorter life expectancy than people in almost all of the peer countries.2 What’s worse, this spending is increasing at a rate faster than inflation and the economy as a whole. While there are many reasons for this, one of the key reasons cited is that we tend to pay doctors, hospitals and other medical providers in ways that reward doing more, rather than being efficient in the way healthcare as a whole is delivered. Here’s what is not working: our predominantly fee-for-service system that reimburses for each test, procedure or visit, alongside medical systems that lack integration, propagate unnecessary tests and overdiagnosis. The U.S. did 100 magnetic resonance imaging (MRI) tests and 265 computed tomography (CT) tests for every 1000 people in 2010-more than twice the average in other OECD (Organization for Economic Co-operation and Development) countries.3

Healthcare reform – Finally driving value?

But reform in one way or another has been trying to address these excesses for a while now. When policymakers see that legislation, such as the Deficit Reduction Act (DRA) of 2005 and the Patient Protection and Affordable Care Act (PPACA) of 2010, actually flatten imaging growth and expenditures, it encourages them to add more cuts. Despite an exceptional run in the late 1990’s and early 2000’s with Medicareoutpatient imaging volumes experiencing growth rates from 10% to 15% annually, there has been a distinct slowing in the growth of discretionary noninvasive diagnostic imaging in the Medicare fee-for-service population since 2005, with the slowdown being most pronounced in MRI and nuclear medicine.4 Current trends also point to declines in hospitalbased imaging in almost all modalities. The previous ‘age of growth’ in imaging has given way to an ‘age of accountable care,’ with increased scrutiny, greater price sensitivity and focus on full cost of care that rewards imaging appropriateness.5

The Centers for Medicare and Medicaid Services (CMS) has also finalized the expansion of Multiple Procedure Payment Reduction (MPPR), and this clearly has an impact in reimbursement. CMS will apply MPPR to the professional payments of certain advanced imaging services, such as CT, MRI, and ultrasound, primarily in situations when multiple-imaging services are furnished to the same patient in the same session, on the same day, by the same practitioner. The imaging procedures, which carry the highest professional payment, will be paid in full, while professional payments for other services will be reduced by 25% (Services).6

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Healthcare reform continues to be broadly adopted, and as the spotlight shifts from volume to value, imaging continues to be in the headlines. In his State of the Union speech last year,7 President Barack Obamaremarked, “We’ll bring down costs by changing the way our government pays for Medicare, because our medical bills shouldn’t be based on the number of tests ordered or days spent in the hospital-they should be based on the quality of care.”

According to a recent study that retrospectively analyzed a large group of CT and MRI examinations for appropriateness using evidence- based guidelines, approximately 26% to 30% of the imaging tests ordered were deemed either unnecessary or inappropriate.8 The American College of Physicians (ACP), the largest U.S. medical specialty group, found that excessive testing costs a staggering $200 billion to $250 billion per year.9

Refocusing and creating value-based competition

In their book “Redefining Health Care,” Michael Porter and Elizabeth Olmsted Teisberg shed new light on why decades of reform have only worsened the problems of our healthcare system with what they call the propagation of dysfunctional competition.10 They argue that the root cause of the woes of our healthcare system is not a lack of competition, but the sustenance of competition at the wrong level-where competition is both too broad and too narrow. Porter and Teisberg convincingly argue that competition is too broad because it currently takes place at the level of health plans, networks, hospital groups and clinics-and not in addressing particular medical conditions.

Competition is also too narrow because it takes place at the level of discrete interventions or services- and not in addressing medical conditions over the full cycle of care, including monitoring and prevention, diagnosis, treatment and the ongoing management of the condition. Value in healthcare is created (or destroyed) at the medical condition level, not at the level of a hospital or physician practice. Their argument is a strong caution for us in radiology to take pause and reevaluate our value chain, and bring a defined set of frameworks to help capture the value that we bring to the sustainability of the healthcare delivery system at large.

Evaluating the entire imaging value chain

As radiologists, we are often much further down the chain of events that lead to the process of our patients getting a certain imaging study performed. By the time the patients’ studies end up on our picture archiving and communication systems (PACS) worklists, it’s too late to effect any change around ordering appropriateness and imaging utilization. We need to focus upstream, at the “scene of the crime” where the studies get ordered, and where ordering physicians interact with the computerized physician ordering system (CPOE) within their electronic medical record (EMR) system. A thought-provoking NEJM paper titled The Uncritical Use of High-Tech Medical Imaging,11 makes an interesting observation: imaging tests are most valuable when the probability of disease is neither very high nor very low but in the moderate range. Various imaging utilization management systems have been enforced in various forms by insurance companies and radiology benefit management (RBM) companies. Prior authorization, prenotification, and various forms of network strategies that focus on examination costs, total quality and practice guidelines have also had varying levels of success. Beyond more tailored tort reform, and an evolution in medical education and training, perhaps the most effective antidote to this trend is data – intelligent personalized data based on solid evidence-based medicine, presented tightly integrated into the decision support and physician order entry workflow. Ordering physicians want to do what is best for their patients, and presenting them with intelligent personalized data around image order entry appropriateness, alongside easy access to relevant priors will work wonders. This is difficult, but not impossible – and is a critical step towards meaningful value based imaging.

Introducing Term 25 for the

Evaluating the entire imaging value chain will shed light on the definitions of accountable care and value-based imaging. Accountable care entails a keen focus on quality, outcomes, and costs across the entire care continuum – and continuous quality improvement is a linchpin that will enable better clinical outcomes at lower costs. The focus needs to be on the total value for patients, not just on lowering costs. The focus for radiologists needs to be in addressing medical conditions as part of a broader integrated team, not individuals or as one specialty. Radiologists rarely have full control over the value delivered direct to patients (except perhaps for women’s imaging and interventional radiology), but we need to be fully aware of the care cycles around the patient-and ensure that we are able to affect care in an integrated manner both upstream and downstream to ensure good, measurable patient results, with accountability tightly coupled to results and outcomes.

The transformation of healthcare delivery entails evaluating and adapting the care delivery value chain (CDVC) in the practice of medicine across entire cycles of care around a particular medical condition, such as stroke or chronic kidney disease. What is interesting is that the simple act of delineating the various activities around the CDVC begins to reveal gaps, duplication of tasks, redundant testing, and numerous other inconsistencies that were previously assumed as normal practice. Our hope in reenergizing imaging then may lie in our capability to sincerely look within and reevaluate the entire imaging value chain, such that we incentivize a cohesive system that is measured by key clinical quality, service, and business growth metrics.

We need to focus upstream, at the “scene of the crime” where the studies get ordered.

References

1. Kane J. Health Costs: How the U.S. Compares With Other Countries. PBS Newhour. Updated October 22, 2012. Retrieved February 11, 2013. http://www.pbs.org/newshour/rundown/ 2012/10/health-costs-how-the-us-compares-with-othercountries. html.

2. Iglehart JK. Health insurers and medical-imaging policy-a work in progress. N Engl J Med. 2009;360:1030-1037.

3. U.S. health in international perspective: Shorter lives, poorer health. s.l. : Institute of Medicine (IOM),January 2013.

4. Levin DC, Rao VM, Parker L, et al. Bending the curve: The recent marked slowdown in growth of noninvasive diagnostic imaging. AJR Am J Roentgenol. 2011;196(1):W25-9.

5. Shrestha RB. Accountable care and value-based images: Challenges and opportunities. Appl Radiol. 2013;4:19-22.

6. 2012 Medicare Physician Fee Schedule Final Rule. Services, Centers for Medicare and Medicaid.http://www.cms.gov.

7. State of the Union 2013. The White House. http://www.whitehouse. gov/state-of-the-union-2013. February 12, 2013.

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8. Lehnert BE, Bree RL, et al. Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support? J Am Coll Radiol. 2010;7(6):466.

9. Stemming the tide of overtreatment in U.S. healthcare. Reuters. February 16, 2012.http://www.reuters.com/article/ 2012/02/16/us-overtreatment-idUSTRE81F0UF20120216.

10. Porter ME, Teisberg EO. Redefining Health Care: Creating Value-Based Competition on Results. Harvard Business School Press. 2006.

11. Bruce J, Hillman BJ, JeffC Goldsmith JC, et al. The Uncritical Use of High-Tech Medical Imaging. N Engl J Med. 2010;363.

Rasu B. Shrestha, MD, MBA

Dr. Shrestha is Vice P r e s i d e n t , M e d i c a l Information Technology, University of Pittsburgh Medical Center, Pittsburgh, PA; and Medical Director, Interoperability & Imaging Informatics, Pittsburgh, PA.

Disclosures: Dr. Shrestha is a Founding Member Executive Advisory Program at GE Healthcare, is on theMedical Advisory Board of Nuance, Inc., and Vital Images, Inc., as well as on the Editorial Board of Applied Radiology, and the Advisory Board of KLAS Research.

Copyright: (c) 2014 Anderson Publishing Ltd.
Wordcount: 1811

Actually, High-Tech Imaging Can Be High-Value Medicine | The Health Care Blog

Lub-SHHRRR. Lub-SHHRRR. Lub-SHHRRR.

“Can you hear it?” she asked with a smile. The thin, pleasant lady seemed as struck by her murmur as I was. She was calm, perhaps amused by the clumsy second-year medical student listening to her heart.

“Yes, yes I can,” I replied, barely concealing my excitement. We had just learned about the heart sounds in class. This was my first time hearing anything abnormal on a patient, though it was impossible to miss—her heart was practically shouting at me.

Her mitral valve prolapse—a fairly common, benign condition—had progressed into acute mitral regurgitation. She came to the hospital short of breath because her faulty valve was letting blood back up into her lungs.

Though it was certainly frightening, surgery to fix the valve could wait a few weeks. But before doing anything, the surgical team wanted a picture of the blood vessels in her heart.

If the picture showed a blockage, the surgeons would have to perform two procedures: one to fix the blockage, and another to fix her valve. If her vessels were healthy, though, the surgeons could use a simpler approach focused just on her valve.

So she came to the interventional cardiologist who was teaching me for the day. Coronary angiograms are the interventionalists’ bread-and-butter procedure, done routinely to look for blockages and to guide stent placement. They involve snaking a catheter from the groin or arm through major blood vessels and up to the heart.

Under fluoroscopy (like a video X-ray), the cardiologists shoot contrast medium into the arteries, revealing the anatomy in exquisite detail.

The images are recorded electronically and accompanied by the cardiologist’s interpretation for anyone else who opens her medical record.

Though routine, these catheterizations aren’t trivial. Whenever you enter a blood vessel, you introduce the risk of bleeding and infection. Fluoroscopy is radiation, and contrast medium can damage the kidneys. And let’s not forget cost—reimbursing the interventional cardiologist, a radiology technician, and nursing staff costs Medicare almost $3,000 per case.

So I asked the cardiologist if such an invasive approach was really necessary.


I knew the rationale—the surgeons needed to know if any of her vessels were blocked, so they could incorporate repairing them into their surgical plan. In a young, otherwise healthy patient, the likelihood of a blockage was low. But in open-heart surgery, “unlikely” isn’t enough. They needed to know her anatomy definitively.

I still wondered if there was a less invasive approach to get the same information.

I knew I was entering delicate territory, since these catheterizations are how he makes his living. So I was surprised to hear his answer when I asked if CT angiography would’ve done the trick: “Probably, but the surgeons aren’t comfortable with it. They only trust catheterizations.”

CT angiography (CTA) is a noninvasive way to get detailed information about the anatomy of the heart. It’s like a regular CT scan, except that pictures are taken after an injection of contrast medium. The total costs to Medicare were about $500 in 2009.

recent study shows that in low-risk patients with a positive stress test, starting with CTA (and catheterizing only when CTA is positive) can save an average of $789 per patient, with a small increase in radiation exposure but little change in accuracy.

Now, I’m just a medical student. I’m in no position to decide when interventions are necessary or needless. And I certainly won’t tell a cardiothoracic surgeon what information they need to operate.

But I’m very familiar with an old standby in the health policy world and the popular media: that high-tech imaging, like CT scans, has contributed to runaway growth in the cost of American healthcare.

Advanced scans cost much more than older techniques, reveal “incidentalomas” thatmay cause more harm than good, and create a profit motive to drive their own use unnecessarily. I have no doubt that this is true much of the time. But reducing the issue down to one axiom is deceptive and simplistic.

It’s not enough to ask what the costs, benefits, and harms of an imaging study will be. We also need to understand what we’re comparing it to. A CT or an MRI will always be more expensive than an X-ray, and if we can get the same information from the latter, the more advanced images are indeed wasteful. But compared to catheterization, exploratory surgery—or worse, misdiagnosis—advanced imaging is a steal. It’s cheaper and often less harmful than the more invasive alternatives.

The crucial question is who should undergo imaging. If our patient were likely to have a blockage and need catheterization anyway, it wouldn’t make sense to start with CTA. But since her “pre-test probability” of a blockage was low, CTA could’ve averted a catheterization. This also doesn’t mean hospitals should go on imaging technology shopping sprees in order to save our system money.

They are huge upfront investments, carrying perverse incentives to churn patients through in order to break even on the initial cost. And we already have far more of these devices than our peers in the developed world. We could probably make do with fewer.

Of course, this is probably not why the surgeons didn’t trust CTA. Their job is to operate safely and proficiently, not to police our use of advanced imaging, and they had no financial incentive to request catheterization. My guess is that when the stakes are as high as when opening someone’s chest, they tend to trust what they know for certain to work. But preferences like these change over time.

Our patient’s angiography showed beautiful, intact coronary arteries. Her surgeons will probably go with the less invasive surgical approach, because they have no blockages to bypass. This is great news for her and her family. It would be even greater news if our policymakers and pundits took note of her story, and adopted a more nuanced approach to medical imaging.

Eventually the surgeons will come around too. The only dogma compatible with the realities of healthcare is: if it sounds too simple to be true, it probably is. High-cost and high-tech, in the right patients, can also be high-value.

Karan Chhabra (@KRChhabra) is a student at Rutgers Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives. He is also a co-founder of Project Millennial.

Back problems? Skip the imaging, skip the surgery

Back problems? Skip the imaging, skip the surgery

By Eric Barnes, AuntMinnie.com staff writer

February 28, 2014 — Back pain is a huge global problem that ranks among the top 10 causes of disability. Medicine has leapt to the rescue with billions of dollars worth of imaging and surgery to treat the suffering. However, neither option does patients much good most of the time, and it’s time to standardize care for the patient’s sake, said Total Radiology keynote speaker Dr. Michael Modic at last month’s 2014 Arab Health meeting in Dubai, United Arab Emirates.

The huge cost of back pain care is unsustainable over the long haul, especially in an era when doctors are “being paid less and … being subjected to more transparency than ever before,” said Modic, who is chairman of the Neurological Institute at the Cleveland Clinic.

What’s the solution? Not the one we’re currently chasing, he said. Imaging has little to no value for back pain, and surgery also has little value for most back conditions. The solution in the vast majority of cases is to skip imaging and surgery in favor of conservative management.

“With imaging we find we’re average in reproducibility, revealing a condition that has a very favorable natural history on its own, and we know that the value of imaging for conservative management is really low,” he said.

As for surgery, the definitive study on the topic found essentially no difference in outcomes between surgery and conservative management for a herniated disk, though surgery did help for symptomatic stenosis. Spinal fusion showed equal outcomes regardless of the treatment approach or cost.

When half of patients presenting with back pain are being imaged, and more than 1 million back surgeries are performed every year despite shaky evidence, something needs to change drastically, Modic said.

“We need to fundamentally take care of patients differently,” he said. “We need to standardize what we do [using] evidence-based data to reduce unnecessary variation and continually measure what we do. We can’t be 100 million practitioners across the planet practicing the way we feel rather than in a standardized fashion.”

Big problems

A large 2012 study revealed the extraordinary scope of the back problem. Disability-adjusted life-year (DALY) rankings show that between 1990 and 2010 the prevalence of back pain increased by 43% and neck pain increased by 41% (Lancet, December 15, 2012, Vol. 380:9859, pp. 2197-2223).

With people living longer, the sequelae of their back problems are growing more severe. Now taking sixth place among causes of disability, lower back pain showed one of the greatest increases over 20 years. “Today, lower back pain lives between AIDS and malaria in terms of disability, and I think that’s fairly significant,” Modic said.

Back pain generates major income for healthcare providers, he noted. Lower back pain is now the ninth most expensive medical condition to treat. Between 1997 and 2005, the cost of the average episode of care for lower back pain rose from $4,800 to $6,100 — a 65% increase over eight years. Unfortunately, though, it’s not making patients any better, he said.

Who does what and why

So is there too much surgery or too much imaging? That’s a harder question to answer, according to Modic. “What value do we bring with either one? In the U.S., surgery rates continue to increase, but not in a standardized fashion,” he said.

A 1996 study in the Journal of the American Medical Association (Verrilli and Welch, Vol. 275:15, pp. 1189-1191), for example, showed that population rates for diskectomy varied by 10-fold across hospital referral regions, and rates for spinal fusion differ by 15-fold. In some parts of the U.S., a patient with back pain is 15 times likelier to have a diskectomy than in other parts of the country, according to a survey in the Wall Street Journal. The reason is the complete lack of standardized care, Modic said.

In some locations such as Louisville, KY, surgery rates can be so high “that I would be afraid to stop at a red light” for fear of being referred, he added, noting that Louisville also had high rates of surgery for patients with back pain only. “If you go to other parts of country, the rate of surgery is incredibly less,” he said.

Imaging vs. surgery

In their study, Verrilli and Welch found a moderate to strong correlation between imaging and surgery, so the two are clearly associated, Modic said. Which came first is a chicken-or-the-egg question.

“Are we doing too much imaging because we’re doing too much surgery, or are we doing too much surgery because we’re doing too much imaging?” Modic said. One thing’s for sure, “if our imaging doesn’t affect [surgeons’] decision-making, we’re probably doing too much of it.”

The literature shows that clinicians and imaging produce excellent agreement (0.93) for level and location of injury, but only fair agreement (0.24) for comparing morphology. “What clinicians see and what radiologists see are two different things; there’s a huge gap between what we’re doing and what surgeons and clinicians see,” he said.

Dr. Michael Modic

Dr. Michael Modic from the Cleveland Clinic speaking at Total Radiology.

And the burden of disease is tremendous. When Boden and colleagues used MRI to examine 100 subjects (Journal of Bone and Joint Surgery, March 1990, Vol. 72:3, pp. 403-408), two-thirds of whom were asymptomatic, they found that 20% of those younger than 60 years had a herniation (HNP, herniated nucleus pulposus), and the figure rose to 36% for those 60 and older, Modic said.

“What is the importance of knowing whether a disk is degenerated or not, given that everybody in this room probably has a degenerated disk?” he asked. “What value is there in knowing a person has a stenotic canal? Do we really understand what impact it has on deciding what the patient will do? We’re pretty good at seeing herniation, but only fair at quantifying stenosis. Agreement is only poor to fair as to what’s causing the morphologic abnormality.”

Morphologic abnormalities don’t necessarily mean the patient will be in pain. Jensen and colleagues reported in the New England Journal of Medicine (July 14, 1994, Vol. 331:2, pp. 69-73) that 28% of people without back pain had a herniated disk, Modic said.

In their own study, Cleveland Clinic researchers followed for two years 246 patients who had a variety of functional pain issues. Sixty-four percent of those with back and leg pain had a herniation on imaging, and 57% of those with back pain had a herniation.

However, over six weeks there was complete resolution in 23% of those with herniation. Also, 13% of those with herniation developed a second herniation between the first and second studies (Radiology, November 2005, Vol. 237:2, pp. 597-604).

“There is no correlation between the number of herniations and how big they were and the patient’s symptoms, and whether they were herniated didn’t seem to correlate with how the patient did,” Modic said.

Imaging for disk herniation

Spine MRI of patients presenting with back and left-leg pain on December 27, 2010. Patients were treated conservatively and both pain and disk herniation resolved before repeat imaging on April 11, 2011. All images courtesy of Dr. Michael Modic.
Imaging for disk herniation

The study determined several factors that did not predict outcomes, including the kind of pain experienced by the patient and whether or not it went away. Nerve compression, stenosis, randomization, gender, and the type, level, and number of herniations — none of them mattered, he said.

Only two factors affected outcomes: race (odds ratio [OR] 3.2) and the presence of herniation at baseline (OR 2.92), according to Modic. Caucasians were three times more likely to do well than noncaucasians (the figures were adjusted for socioeconomic group), he said.

The Cleveland Clinic study also found that patients who had a herniation were three times more likely to do well if they were managed conservatively.

“If you have a herniation, you have a morphologic disorder that has a favorable natural history — most herniations go away — whereas if you don’t have a herniation, you may have a more complicated multifactorial cause of pain, and its natural history may not be as favorable,” Modic said.

Finally, the study showed that the 50% of patients who knew about their herniation were unhappier about their health, compared with those who weren’t told of the imaging results.

“So, in this case, the presence of inflammation had a deleterious effect on patients’ perceptions of their health,” he said. Patients want the imaging exam, of course, but there is strong evidence that the information the study provides is not helpful to them.

Left radicular symptoms

Patient had left radicular symptoms at presentation but no herniation at MRI. At follow-up imaging, pain decreased significantly but disk herniation became visible.

“There is a huge number of patients we’re imaging every day, and the literature says not to image them,” Modic said. “So if they don’t have red flags, if they don’t have yellow flags, you need to look at the care model and fundamentally take care of patients differently.”

But skipping the imaging is easier said than done. Cleveland Clinic research has also shown that 40% of back pain patients were imaged on their first visit, according to Modic.

“The good news is that most of them were plain films. Now, I don’t know about you, but the value of a lumbar spine radiograph for me is to establish the presence of a spine,” he quipped. “That’s an important piece of information that a radiograph can provide; if you’re concerned this might be an alien species, a radiograph can help.”

In all seriousness, there is a wealth of evidence-based guidelines for patients in the acute and subacute phases, he said, and there is still plenty of room for innovation along the care pathways that have already been laid out and validated.

“But by and large we don’t follow the evidence-based guidelines that are out there,” Modic said. “We need to standardize what we do … reduce unnecessary variation and continually measure what we do.”

Surgical success

Like imaging, surgery isn’t routinely helpful either, Modic said. According to the Spine Patient Outcomes Research Trial (SPORT), among patients with herniation, there was no statistically significant difference in outcomes at two years postsurgery whether patients were treated with surgery or conservatively. At four years, there was a slight tendency toward better outcomes with surgery.

Stenosis was a slightly different story: Symptomatic stenosis patients undergoing surgery improved more than patients who were treated conservatively (Journal of the American Academy of Orthopedic Surgeons, March 2012, Vol. 20:3, pp. 160-166).

Spinal fusion is also problematic because of wide cost variations.

“Fusion has many meanings, and those meanings can cost between $8,000 and $80,000,” Modic said. “There was no difference between types of fusion and outcomes, but there was significant difference in cost.”

For example, a posterolateral fusion averaged $15,000 to $20,000, while a transforaminal lumbar interbody fusion came in at $90,000; there were no differences in outcomes. And while medical device companies have wielded influence in pushing their products, funding studies and even manipulating the results, outcomes have not justified the expense as of yet, he said.

“The right patient operated on will have a reduction in symptoms sooner than the patient with conservative management, [but] basically you’re going to get better whether you have surgery or not,” Modic said.

New world ahead

There’s one more reason why current care patterns are unsustainable, according to Modic. Reimbursement today is based on a fee-for-service model in most places and encourages overtreatment, but tomorrow’s payment model will rely on value — characterized by bundled payments based on episodes of care.

“We need to be incentivized to follow algorithms based on standardized care,” he said. “We need to somehow remove counterincentives financially in terms of what we do on a volume basis” and focus on providing value to the patient. “This is where things are really changing, not just in the United States but in the world.”

Currently, there is too much imaging and too much surgery, and the solution is standardized care, he said.

In that sense, “financial pressures are a good thing, driving us to do the right thing, not just economically but from the viewpoint of the patient,” Modic said. “I think we have a social responsibility to do what’s best for the patient.”

Imaging looms large on new list of low-value emergency exams, February 19, 2014

Whole-body MRI falls short in axial spondyloarthritis cases, November 7, 2013

JAMA IM: Lumbar spine MRI scans substantially overused, March 25, 2013

Gymnasts’ spines, footballers’ ankles, and golfers’ wrists take the strain, March 11, 2013

 

MRI not needed prior to steroid injection for lower back pain, December 13, 2011