Objective: To assess the utilization of diagnostic and therapeutic medical services for the management of acute low back pain in a primary care setting, and to determine whether such utilization conforms to suggested guidelines for the management of this condition.
Study design: A retrospective chart audit of consecutive cases of acute low back pain. Specific elements of the diagnostic and therapeutic approach were judged appropriate or inappropriate based on comparison with published recommendations supported by the medical literature.
Setting: The primary care adult practice of a university-affiliated health maintenance organization.
Patients: One hundred eighty-three patients presenting with acute low back pain of musculoskeletal origin.
Measurements and main results: According to suggested guidelines for the care of acute low back pain, 26% of plain lumbar x-rays (10/38), 66% of computed tomography (CT) and magnetic resonance imaging (MRI) scans (12/18), and 82% (23/28) of subspecialty referrals were categorized as inappropriate. Among patients without indications for these services, 12% (10/85) had received lumbar x-rays, 7% (12/168) had received lumbar MRI or CT scans, and 14% (23/168) had received subspecialty referrals. Underutilization of these services had occurred in 71% (70/98) of patients with an indication for plain lumbar radiography, and 47% (7/15) of patients with potential indications for surgical referral or CT/MRI scanning. Neither overutilization nor underutilization had led to adverse outcomes or delays in diagnosis in this small sample.
Conclusions: According to guidelines from the medical literature, the primary care physicians in this study both overutilized and underutilized diagnostic and referral services in cases of acute low back pain. It is necessary to determine whether underutilization of plain lumbar radiography adversely affects diagnostic accuracy and whether overutilization of other services improves important clinical outcomes, given the generally benign natural history of this condition.