Low-value care for back pain is common, but may be declining

By Judith Garber | February 20, 2022

If you’ve ever experienced back pain (and chances are, you have), you know how frustrating it can be to have few treatment options that help. Low back pain is one of the most common health problems in the world, impacting 577 million people (that’s 7.8% of the world’s population). Back pain is also the leading global cause of disability, in an unfortunate trend that has only grown over the past few decades.

In the face of discomfort and disability, it’s tempting for doctors and patients to try tests and procedures that aren’t proven to work, to feel as though they are taking action. Unfortunately, low-back pain can lead to ineffective and sometimes harmful low-value tests and procedures, like diagnostic imaging, opioids, spinal injections, and surgery.

A 2020 review on low-value care for back pain in The Lancet laid out some of the more shocking statistics on this phenomenon:

Nearly 60% of outpatient lumbar spine MRIs may be inappropriate, costing the US $300 million per year.
The US spends $12.8 billion a year on spinal fusion surgery (making it the most costly surgical procedure), even though there is little evidence to show that it improves back pain.
Low-value care for back pain is common in low- and middle-income countries as well as wealthier countries; in 2020, 77% of people in Central Ethiopia seeking care for low-back pain were given medication injections.

However, there is some promising evidence that shows the tide may be turning on low-value care for back pain. In a recent article in JAMA Network Open, researchers at the Enterprise Health Services Research and Anthem insurance company found that commercially-insured patients with back pain were less likely to use inpatient services, low-value surgery, opioids, and imaging in 2019 compared to in 2011.

The greatest absolute reduction in use was for imaging, which decreased from 74% to 60% of patients. The greatest relative reduction in use was for surgery, which decreased from 4.5% to 3.3% of patients. However, the use of low-value epidural injections for back pain did not change.

In The Lancet, the authors of the 2020 review call for ten policy changes to reduce low-value care for back pain. Here are a few of my favorite recommendations:

Insurers and other groups that pay for health care should stop covering ineffective and harmful back pain treatments.
New tests and treatments for low-back pain should not be approved or marketed until they are proven safe, effective, and cost-effective.
The medical and public health community should educate doctors and patients about the causes of low-back pain, how to manage symptoms, and disabuse the notion of an existing “cure” for back pain.
The World Health Organization should make global disability from back pain a priority in research and public policy.

If implemented, these would certainly help continue the encouraging trend shown in the Enterprise study.

To eliminate medication overload, serious cultural, educational, and policy changes are needed. This action plan offers recommendations for policymakers, health care institutions, clinicians, and patients across five key categories to reduce harm from multiple medication use. Suggested Citation: Eliminating medication overload: A national action plan. Working Group on Medication Overload. Brookline, MA: The Lown Institute, 2020. DOI: https://doi.org/10.46241/LI.YLBW4885

Pharmaceutical marketing is a significant factor in the growing public health crisis of medication overload, which puts millions of older adults at risk of preventable harm and premature death. This issue brief provides recommendations to reduce pharmaceutical industry influence by limiting pharma sales rep visits to clinicians and direct-to-consumer advertising.

This issue brief provides recommendations for clinical practice guidelines and electronic health records that would give clinicians the information they need to appropriately prescribe and deprescribe.