The Lancet Series call to action to reduce low value care for low back pain: an update

Low back pain is a common problem affecting all age groups from children to the elderly. While highly disabling in only a very small proportion of those affected, its high prevalence means that in 2015, low back pain was responsible for 60·1 million disability-adjusted life-years; a 54% increase since 1990, with the biggest increase seen in low-income and middle-income countries. In the latest data from the Global Burden of Disease Project published in 2017, the global point prevalence of low back pain was 7.8%, meaning that 577 million people are affected at any one time., Focusing on Africa, a 2018 systematic review (65 studies) found the lifetime, annual, and point prevalence of low back pain was 47% (95% confidence interval [CI] 37-58), 57% (95% CI 51-63) and 39% (95% CI 30-47), respectively, comparable or higher than what has been observed in population studies in high income countries.

Low back pain remains the leading global cause of disability overall and in both males and females, accounting for 7.6% or 42.5 million years lived with disability across all age groups, topping the list of causes of disability in 126 of 195 countries and territories in 2017. It is also very costly. For example, a recent study estimated that US$134.5 billion was spent on health care for low back and neck pain in 2016 in the United States, the most out of 154 conditions studied, and this had increased by 6.7% annually between 1996 and 2016.

The Lancet Series call to action to reduce low value care for low back pain: an update

Many patients with low back pain are still receiving the wrong care

A 2018 systematic review that included 14 studies mostly from the United States (6 studies), United Kingdom (3 studies), and other high-income countries found that overall more than 50% of people with low back pain seek care annually and 30% have sought care within the past month. Proportions were similar irrespective of whether the study included workers or the general population, but rates did vary by setting, eg, 67% (95% CI 50-84) in the United States vs 48% (95% CI 33-63) in Europe. These data are very concerning as much of modern back pain care is ineffective and some care is harmful.

The surge in global low-value care for low back pain that includes presentations to emergency departments, liberal use of diagnostic imaging, opioids, spinal injections, and surgery has also led to skyrocketing medical and human costs. A 2012 study in a US Veterans Affairs Health Care facility found that 59% of outpatient lumbar spine scans were inappropriate. This suggests that unnecessary lumbar spine magnetic resonance imaging scans for people not suspected of having a serious condition cost $US300 million per year in the United States. This is supported by a 2019 systematic review (14 studies) which found evidence that imaging is associated with higher medical costs, increased health care utilization, and more work absence compared with nonimaged groups. Despite little evidence to support its use for most back conditions, and a 20% failure rate, another US study estimated that $US12.8billion was spent on spinal fusion surgery in 2011, the highest aggregate hospital costs of any surgical procedure.

Much of the money spent on low back pain is wasted, and better system level and policy solutions are needed

The Lancet Series identified promising solutions that included focused implementation of best practice, the redesign of clinical pathways, integrated health and occupational care, changes to payment systems and legislation, and public health and prevention strategies. Yet, we also indicated that most were not yet ready for widespread implementation as the evidence underpinning them was inadequate.

Targeted efforts to reduce overuse of imaging for low back pain, a major source of healthcare waste and even iatrogenesis, have not met with much success to date., Lowering imaging rates is challenging, and strategies must be targeted towards the population/patients, clinicians, and health care administrators. Patients request imaging expecting to obtain a diagnosis for their pain; clinicians order imaging because of entrenched beliefs and habits, perceived pressure from patients, fear of litigation and financial incentives,; and health systems continue to offer liberal access to imaging probably because of public demand and pressure from clinicians.

Major international clinical guidelines have moved away from medicalized management of low back pain and prioritized nonpharmacological approaches as first-line care.

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The Lancet  

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Bastiaan Meijer