Back Pain Treatment Trends Worth Reversing

It may just be the American way –pull out all the stops and try anything or everything at great expense when it comes to medical care.

Today’s post takes up how well the United States is doing at providing back pain care in accordance with evidence-based clinical practice guidelines for back pain (including neck pain). In original research and a commentary published online July 29, 2013 in JAMA Internal Medicine, John N. Mafi, MD, and coauthors from Beth Israel Deaconess Medical Center and Harvard Medical School, in Boston, MA, point out troubling trends in back pain care using nationally representative data from the Centers for Disease Control and Prevention’s National Ambulatory Care Survey and the National Hospital Ambulatory Care Survey.

Back pain is common, with surveys showing that 65% to 80% of Americans will report back pain at some point in their lifetime. So understanding what’s going on and managing it with the best science sounds good for patients. Back pain is a loaded category for sure: it involves how well patients can tolerate pain, patience because back pain is often temporary, yet it can be a springboard for all sorts of referrals. There are some relatively inexpensive ways to manage back pain that get a grip on back pain, but the study discussed here suggests that people want to throw everything at it and that the care people are getting is moving afield from science-based guidelines.

Prescribing Patterns

oxycontinBetween 1999 and 2010, opioid use for back pain climbed substantially from 19.3% to 29.1%, while recommended nonsteroidal anti-inflammatory drugs (NSAIDs: e.g. ibuprofen) and acetaminophen have declined by nearly half, from 36.9% to 24.5%.  The latter two drug categories are recommended as first-line for patients with back pain. Additionally, doctors in the south and west prescribed narcotic medications about 1.5 times more frequently than doctors nationally.

Not everyone gets opioids prescribed. The odds that women, black, Hispanic, and other racial/ethnic groups, and the uninsured were prescribed opioids was significantly lower. Commenting on this disparity, Richard Deyo, MD, MPH, Kaiser Permanent Professor of Evidence-Based Family Medicine, Oregon Health Sciences University, Portland, OR, said: “I think this is a situation where good insurance – and greater affluence – make overuse more likely. This may be a case where underinsurance has a protective effect!”


MRI machine

MRI machine

Subgroup analyses revealed that neurologists and orthopedic surgeons had a far greater odds of ordering CT and MRI: more than 3.5 times higher than primary care doctors. MRI scans and CT scans rose between 1999-2000, at 7.3% to 11.3%, in 2009-2010.


Physical therapy referrals remained constant over the ten-year period, but referrals to other doctors, especially neurologists and orthopedists, doubled by 6.8% in the first year of data collection to 14.0% in 2009-2010.

One Limitation: No Surgery Data

 The data are limited in that this data set cannot be used to see whether or not people got surgery.  However, lots of previous research suggests that with the cascade of advanced imaging and physician referrals, people are getting surgery more frequently.

What About Patients?

 In this study, trends in management of back pain suggest care is moving away from science-based medicine. Many of us have endured back pain that feels acute or chronic. Some of us know people who have had back surgery, seen lots of doctors, and gotten imaging studies. As I write this post, the news is calling attention to premiums perhaps not being that high as predicted with Obamacare. But you have to wonder: if these patterns of overuse to no good end for patients persist, the costs are going to get thrown back to patients. I’ve said this before, but I think we are at a standstill. We need to move beyond documenting overuse and inappropriate use and come up with ways to get doctors and patients on board with what works and does not.

Cardiovascular Care and the Bush Effect

Pres Bush at NIH

It’s too soon to tell whether former President George W. Bush’s stent to open his coronary artery will change how Americans receive cardiovascular care, but I certainly have my worries. If the argument to aggressively search for cardiac disease in asymptomatic people wins out, I see my healthcare premiums rising precipitously and continuing in that direction. It’s not just the premiums either, but putting healthy people into this perennial-patient or at-risk status for no good reason.

I don’t want to live in a world where we speak of how elevated each of our risk status is for cardiovascular disease, a stroke, or heart attack, as if it is a badge of courage. I learned recently that I have only a 4% risk of having a heart attack or stroke in the next ten years, apparently strong enough for my primary care physician to recommend a statin to lower my risk even further.

A month ago, I went for a routine physical at my primary care physician’s office. I got recommended immunizations, but there were aspects of the visit that troubled me. Once you are in a gown sitting at the exam table, you are fair game for consenting to a procedure right there, on the spot. How stupid I was not to pull out my smartphone to check whether a test was warranted. My doctor had moved from an academic medical center to open a new group practice.

Cardiovascular Testing Flourishing

I got hornswoggled into a carotid ultrasound test. The test evaluates blockages in your neck. What led to this test was my admission after persistent questioning (I am really well) that I very occasionally feel dizzy. Suddenly, the specter of a looming stroke was in the cards, perhaps a blockage in my neck. My blood pressure was 120/80 in both arms. When I asked the technician performing the test why it was being done, she said: “to prevent a stroke.” Now who would want to have a disabling stroke? It was a compelling argument on the surface.

Other contributing factors that were too daunting to address was the fact that a cardiologist sat in the office and owned the equipment. Who needs a fight with my doctor over whether the test is warranted and might be motivated by a conflict of interest? At another physician practice, on a rainy day, I once was offered a stress EKG, because: “He’s got the time. He had some cancellations because of the rain today.” The rationale: it was a few months after my mother died. I had occasional pounding in my chest.

Had I pulled out my smartphone and looked at the American Board of Internal Medicine Foundation Choosing Wisely site or a handful of other sites either time, I would have immediately learned that a carotid ultrasound test or stress EKG was unwarranted. I recommend readers bookmark this site and challenge their doctors before undergoing tests like these. It is a valuable reference. I should have known better. (Note: at press time, the link on the website was broken. It will be inserted as soon as ABIM Foundation fixes it.)

With my insurance, I only got stuck with a relatively small copay, but what would happen if everyone who walked in the door was seen unwittingly as a candidate for this procedure, stress EKGs, and more? Make no mistake about it, it’s happening. You tolerate it, fellow Americans, you are going to have to pay for it. Don’t be surprised if your premiums go up and if healthcare costs wipe you out. I may not pay for this kind of test this year, but it won’t be long before the economists make sure Americans fork out for these tests.

Oddly enough, when I returned home, in my mailbox, I found a glossy, oversize postcard from a teaching hospital touting its cardiovascular disease prevention program. They are popping up everywhere, offering a potpourri of risk assessment for heart attacks, strokes, and vascular disease, risk factor identification, treatment programs to reduce risk factors, secondary prevention, and screening before starting sports and exercise programs.

I don’t think that Bush was needed to propel overuse of cardiovascular procedures further over the top. It has been well on its way, but Bush’s stent underscores the trend. In this blog, in many posts, I have pointed to the numerous ways overuse is hazardous for your health, financial wellbeing, and more. It will be up to those concerned with overuse to devise new strategies to stop this train. Right now, it seems unstoppable.

















Patient POV’s Most Popular and Important Posts in 2012

Here they are: the most popular and important posts on Patient POV this year:

The Top 10 Reasons Why Warren Buffett’s to Treat Prostate Cancer Bugs Me

This post got me on the radio for the very first time in my life a very short segment on Ira Flatow’s Science Friday. I love radio and hope you support programming like this today and through the year ahead. And yes, I’d love it if you contacted me for paid  speaking or writing engagements this year.

MR Imaging, Electronic Test-Ordering Create Waste

Despite rough times economically, we have a love affair with new technologies that are overused proving a colossal waste of money and resource use.

Are Dense Breast, Right-to-Know Laws Helpful?

Legislators just can’t say “no” to this and unless the public can be convinced otherwise, in 2013, we will see more of these laws pass in many more states. Sadly, just as this post went up, Governor Jerry Brown authorized a dense-breast law in California.

Healthcare System Fail: Let’s Get Serious About Disparities

Let’s give more than lip service to  healthcare disparities in 2013. This story, IMHO, is emblematic of what happens when many minorities land in the healthcare system. Disparities didn’t end with Rebecca Skloot’s exposure of deficits in informed consent in The Immortal Life of Henrietta Lacks. We have to stay on the case.

Seeking a Second, More Specialized Opinion for a Rare Genetic Disease by Ricki Lewis

This is a critically important issue that many people know much about. I am grateful that Ricki Lewis, PhD, author of The Forever Fix: Gene Therapy and the Boy Who Saved It, DNA Science blogger, genetics counselor, dear friend, and so much more, brought this issue up in a guest post. If only we had a more rational healthcare system, so people with rare disorders were routed to the doctors most familiar with these conditions.

Why Sanofi’s Zaltrap Deal Won’t Help Patients (originally published in the Scientific American Guest Blog – thank you @Boraz)

Despite all the rhetoric about value-based healthcare, patients have yet to enter in to getting value-based care in their terms. Let’s stay on this moving forward.

Warning Signs: First Edition

I may be using this format more in 2013: a way to point up trends, some worrisome, some positive. Alert me if you think something is worth ink that I might not see.

Finally, a big thanks to people who have talked to me about these issues and helped me to articulate what matters to patients. Let’s talk more in the new year. And a plug I rarely make: I need more paid work. This blog is a labor of love. It has not monetized. Feel free to contribute via PayPal to keep it going. If you are in a position to bolster the Patient POV, looking for a good writer or speaker, please get in touch at patientpov “at” gmail “dot” com, via twitter to lauranewmanny. Also, follow me on Facebook here.

Happy New Year to All, and to All A Good Night!



Are Dense-Breast, Right-to-Know Laws Helpful?

Doctor reviews a digital mammogram of a dense breast and points to a potential cancer. Credit: National Cancer Institute.

In a victory for the dense-breast patient movement, Governor Jerry Brown (D-CA) signed legislation last week requiring that doctors who discover that women have dense breasts on mammography must inform women that:

  • dense breasts are a risk factor for breast cancer;
  • mammography sees cancer less well in dense breasts than in normal breasts; and
  • women may benefit from additional breast cancer screening.

The California law goes into effect on April 1, 2013. It follows four states (Connecticut, Texas, Virginia, and New York) with similar statutes. All have enjoyed solid bipartisan support. Rarely do naysayers or skeptics speak up.

Young women who are leading the charge often bring lawmakers the story of a young constituent, diagnosed with a very aggressive, lethal cancer that was not shown on film-screen mammography. The Are You Dense? patient advocacy group engages patients on Facebook, where women share their experiences with breast cancer, organize events, and lobby for legislation. Individual radiologists work with the advocacy groups, but many radiology groups and breast surgeons do not endorse these laws.

A Closer Look at Breast Cancer Data

Living in an age when information is viewed as an entitlement, knowledge, and power, many physicians find it hard to argue against a patient’s right to know. Can sharing information be a mistake? Some epidemiologists think so. Otis W. Brawley, MD, FACP, Chief Medical & Scientific Officer, American Cancer Society, says: “I really worry when we legislate things that no one understands. People can get harmed.” Numerous issues have to be worked out, according to Brawley. For one, he explains: “There is no standard way to define density.” Additionally, “even though studies suggest that density increases the risk of cancer, these cancers tend to be the less serious kind, but even that is open to question,” Brawley says. “We in medicine do not know what to do for women who have increased density.”

A study of more than 9,000 women in the Journal of the National Cancer Institute revealed that women with very dense breasts were no more likely to die than similar patients whose breasts were not as dense. “When tumors are found later in more dense breasts, they are no more aggressive or difficult to treat,” says Karla Kerlikowske, MD, study coauthor, and professor of medicine and epidemiologist at the University of California San Francisco. In fact, an increased risk of death was only found in women with the least dense breasts.

The trouble is what is known about dense breasts is murky. Asked whether he backs advising women that dense breasts are a risk factor for breast cancer, Anthony B. Miller, MD, Co-Chair of the Cancer Risk Management Initiative and a member of the Action Council, Canadian Partnership Against Cancer, and lead investigator of the Canadian National Breast Cancer Screening Study, says: “I would be very cautious. The trouble is people want certainty and chances are whatever we find, all we can do is explain.”

Women in their forties, who are most likely to have dense breasts (density declines with age) may want to seek out digital mammography. In studies comparing digital mammography to film-screen mammography in the same women, digital mammography has been shown to improve breast cancer detection in women with dense breasts. Findings from the Digital Mammographic Imaging Screening Study, showed better breast cancer detection with digital mammography. But digital mammography is not available in many areas.  Moreover, Miller explains: “We do not know if this will benefit women at all.  It is very probable that removal of the additional small lesions will simply increase anxiety and health costs, including the overdiagnosis of breast cancer, and have no impact upon mortality from breast cancer.”

Additional imaging studies sound attractive to people convinced that there is something clinically significant to find. But as I pointed out in my last post, many radiologists and breast physicians contend that there is no evidence that magnetic resonance imaging or any other imaging study aids breast cancer screening in women with dense breasts. Brawley notes: “These laws will certainly lead to more referral for MRI and ultrasound without clear evidence that women will benefit (lives will be saved.) It’s clear that radiologists will make more money offering more tests.” Miller adds: “A number of doctors are trying to capitalize on this and some of them should know a lot better.”

Many Advocates Question More Tests, Statutes

Even though the “Are You Dense?” campaign has been instrumental in getting legislation on the books across the county, other advocacy groups and patient advocates want research, enhanced patient literacy about risks and benefits of procedures. Many recall mistakes made that led women down the path of aggressive procedures. In that group is the radical Halsted mastectomy, used widely before systematic study, but once studied,  found no better than breast-conserving surgery for many cancers, and bone marrow transplants, also found to be ineffective, wearing, and costly.

Jody Schoger, a breast cancer social media activist at @jodyms who engages women weekly on twitter at #bcsm, had this to say on my blog about the onslaught of additional screening tests:

“What is needed is not another expensive modality… but concentrated focus for a biomarker to indicate the women who WILL benefit from additional screening. Because what’s happening now is an avalanche of screening, and its subsequent emotional and financial costs, that is often far out of proportion to both the relative and absolute risk for invasive cancer. I simply don’t think more “external” technology is the answer but one that evolves from the biology of cancer.”

Eve Harris @harriseve, a proponent of patient navigation and patient literacy, challenged Peter Ubel, MD, professor of business administration and medicine, at Duke University, on his view of the value of patient empowerment on the breast density issue. In a post on Forbes, replicated in Psychology Today, Ubel argued that in cases where the pros and cons of a patient’s alternatives are well known, for example, considering mastectomy or lumpectomy, patient empowerment play an important role. “But we are mistaken to turn to patient empowerment to solve dilemmas about how best to screen for cancer in women with dense breasts,” he writes.

Harris disagrees, making a compelling case for patient engagement:

“I think that we can agree that legislative interference with medical practice is not warranted when it cannot provide true consumer protection. But the context is the biggest culprit in this situation. American women’s fear of breast cancer is out of proportion with its incidence and its mortality rate. Truly empowering people—patients would mean improving health literacy and understanding of risk…”

But evidence and literacy take time, don’t make for snappy reading or headlines, and don’t shore up political points. Can we stop the train towards right-to-inform laws and make real headway in women’s health? Can we reallocate healthcare dollars towards effective treatments that serve patients and engage them in their care? You have to wonder.