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Figure 1. Improvement in pain (A) and function (B) among patients with low back pain who received immediate lumbar imaging (intervention) vs usual care (control). Adapted from Chou et al with permission from the publisher. CT indicates computed tomography; MR, magnetic resonance; RDQ, Roland-Morris Disability Questionnaire; SF-36, 36-Item Short Form Health Survey; VAS, visual analog scale.

Figure 1. Improvement in pain (A) and function (B) among patients with low back pain who received immediate lumbar imaging (intervention) vs usual care (control). Adapted from Chou et al7 with permission from the publisher. CT indicates computed tomography; MR, magnetic resonance; RDQ, Roland-Morris Disability Questionnaire; SF-36, 36-Item Short Form Health Survey; VAS, visual analog scale.

Figure 2. Estimation of patients receiving routine imaging for low back pain in 1 year.

Figure 2. Estimation of patients receiving routine imaging for low back pain in 1 year.

1.
Good Stewardship Working Group.  The “Top 5” lists in primary care: meeting the responsibility of professionalism.  Arch Intern Med. 2011;171(15):1385-139021606090PubMedGoogle ScholarCrossref
2.
 TrailBlazer Health Enterprises, LLC. Medicare fee schedule. 2009. http://www.trailblazerhealth.com/Tools/Fee%20Schedule/MedicareFeeSchedule.aspx. Accessed April 6, 2012
3.
Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002.  Spine (Phila Pa 1976). 2006;31(23):2724-272717077742PubMedGoogle ScholarCrossref
4.
Ivanova JI, Birnbaum HG, Schiller M, Kantor E, Johnstone BM, Swindle RW. Real-world practice patterns, health-care utilization, and costs in patients with low back pain: the long road to guideline-concordant care.  Spine J. 2011;11(7):622-63221601533PubMedGoogle ScholarCrossref
5.
Chou R, Qaseem A, Owens DK, Shekelle P.Clinical Guidelines Committee of the American College of Physicians.  Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians [published correction appears in Ann Intern Med. 2012;156(1, pt 1):71].  Ann Intern Med. 2011;154(3):181-18921282698PubMedGoogle Scholar
6.
Webster BS, Cifuentes M. Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes.  J Occup Environ Med. 2010;52(9):900-90720798647PubMedGoogle ScholarCrossref
7.
Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis.  Lancet. 2009;373(9662):463-47219200918PubMedGoogle ScholarCrossref
8.
Kerry SH, Hilton S, Dundas D, Rink E, Oakeshott P. Radiography for low back pain: a randomised controlled trial and observational study in primary care.  Br J Gen Pract. 2002;52(479):469-47412051211PubMedGoogle Scholar
9.
Djais N, Kalim H. The role of lumbar spine radiography in the outcomes of patients with simple acute low back pain.  APLAR J Rheumatol. 2005;8:45-50Google ScholarCrossref
10.
Modic MT, Obuchowski NA, Ross JS,  et al.  Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome.  Radiology. 2005;237(2):597-60416244269PubMedGoogle ScholarCrossref
11.
Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial.  BMJ. 2001;322(7283):400-40511179160PubMedGoogle ScholarCrossref
12.
Gilbert FJ, Grant AM, Gillan MG,  et al; Scottish Back Trial Group.  Low back pain: influence of early MR imaging or CT on treatment and outcome–multicenter randomized trial.  Radiology. 2004;231(2):343-35115031430PubMedGoogle ScholarCrossref
13.
Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain?  JAMA. 1992;268(6):760-7651386391PubMedGoogle ScholarCrossref
14.
van Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Spinal radiographic findings and nonspecific low back pain: a systematic review of observational studies.  Spine (Phila Pa 1976). 1997;22(4):427-4349055372PubMedGoogle ScholarCrossref
15.
Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain.  N Engl J Med. 1994;331(2):69-738208267PubMedGoogle ScholarCrossref
16.
de Schepper EI, Damen J, van Meurs JB,  et al.  The association between lumbar disc degeneration and low back pain: the influence of age, gender, and individual radiographic features.  Spine (Phila Pa 1976). 2010;35(5):531-536Google ScholarCrossref
17.
Jarvik JG, Hollingworth W, Martin B,  et al.  Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial.  JAMA. 2003;289(21):2810-281812783911PubMedGoogle ScholarCrossref
18.
Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery.  Spine (Phila Pa 1976). 2003;28(6):616-62012642771PubMedGoogle Scholar
19.
Berrington de González A, Mahesh M, Kim KP,  et al.  Projected cancer risks from computed tomographic scans performed in the United States in 2007.  Arch Intern Med. 2009;169(22):2071-207720008689PubMedGoogle ScholarCrossref
20.
 Centers for Disease Control and Prevention. National Ambulatory Medical Care Survey: 2008 summary table. 2009. http://www.cdc.gov/nchs/data/ahcd/namcs_summary/namcssum2008.pdf. Accessed April 6, 2012
21.
Pham HH, Landon BE, Reschovsky JD, Wu B, Schrag D. Rapidity and modality of imaging for acute low back pain in elderly patients.  Arch Intern Med. 2009;169(10):972-98119468091PubMedGoogle ScholarCrossref
22.
Deyo RA, Bigos SJ, Maravilla KR. Diagnostic imaging procedures for the lumbar spine.  Ann Intern Med. 1989;111(11):865-8672530926PubMedGoogle Scholar
23.
Campbell EG, Regan S, Gruen RL,  et al.  Professionalism in medicine: results of a national survey of physicians.  Ann Intern Med. 2007;147(11):795-80218056665PubMedGoogle Scholar
24.
Gallagher TH, Lo B, Chesney M, Christensen K. How do physicians respond to patient's requests for costly, unindicated services?  J Gen Intern Med. 1997;12(11):663-6689383133PubMedGoogle ScholarCrossref
25.
Deyo RA, Diehl AK, Rosenthal M. Reducing roentgenography use: can patient expectations be altered?  Arch Intern Med. 1987;147(1):141-1452948466PubMedGoogle ScholarCrossref
26.
Staiger TO, Jarvik JG, Deyo RA, Martin B, Braddock CH III. BRIEF REPORT: Patient-physician agreement as a predictor of outcomes in patients with back pain.  J Gen Intern Med. 2005;20(10):935-93716191141PubMedGoogle ScholarCrossref
27.
Paterniti DA, Fancher TL, Cipri CS, Timmermans S, Heritage J, Kravitz RL. Getting to “no”: strategies primary care physicians use to deny patient requests.  Arch Intern Med. 2010;170(4):381-38820177043PubMedGoogle ScholarCrossref
28.
Schectman JM, Schroth WS, Verme D, Voss JD. Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain.  J Gen Intern Med. 2003;18(10):773-78014521638PubMedGoogle ScholarCrossref
29.
Blackmore CC, Mecklenburg RS, Kaplan GS. Effectiveness of clinical decision support in controlling inappropriate imaging.  J Am Coll Radiol. 2011;8(1):19-2521211760PubMedGoogle ScholarCrossref
30.
Iglehart JK. Health insurers and medical-imaging policy–a work in progress.  N Engl J Med. 2009;360(10):1030-103719264694PubMedGoogle ScholarCrossref
31.
Khorasani R. Can radiology professional society guidelines be converted to effective decision support?  J Am Coll Radiol. 2010;7(8):561-56220678724PubMedGoogle ScholarCrossref
32.
Lehnert BE, Bree RL. 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(3):192-19720193924PubMedGoogle ScholarCrossref
33.
Pearson SD. Caring and cost: the challenge for physician advocacy.  Ann Intern Med. 2000;133(2):148-15310896641PubMedGoogle Scholar
34.
Snyder L.American College of Physicians Ethics, Professionalism, and Human Rights Committee.  American College of Physicians Ethics Manual: sixth edition.  Ann Intern Med. 2012;156(1, pt 2):73-10422213573PubMedGoogle Scholar
Special Article
Less Is More
July 9, 2012

Application of “Less Is More” to Low Back Pain

Author Affiliations
Author Affiliations: Department of Medicine, University of Connecticut Health Center, Farmington (Dr Srinivas); Departments of Family Medicine and Internal Medicine and Center for Research in Occupational and Environmental Toxicology, Oregon Health & Science University, Portland (Dr Deyo); and Department of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland (Dr Berger).
Arch Intern Med. 2012;172(13):1016-1020. doi:10.1001/archinternmed.2012.1838
Abstract

An initiative of the National Physicians Alliance, the project titled “Promoting Good Stewardship in Clinical Practice,” developed a list of the top 5 activities in primary care for which changes in practice could lead to higher-quality care and better use of finite clinical resources. One of the top 5 recommendations was “Don't do imaging for low back pain within the first 6 weeks unless red flags are present.” This article presents data that support this recommendation. We selectively reviewed the literature, including recent reviews, guidelines, and commentaries, on the benefits and risks of routine imaging in low back pain. In particular, we searched PubMed for systematic reviews or meta-analyses published in the past 5 years. We also assessed the cost of spine imaging using data from the National Ambulatory Medical Care Survey. One high-quality systematic review and meta-analysis focused on clinical outcomes in patients with low back pain and found no clinically significant difference in pain or function between those who received immediate lumbar spine imaging vs usual care. Published data also document harms associated with early imaging for low back pain, including patient “labeling,” unneeded follow-up tests for incidental findings, irradiation exposure, unnecessary surgery, and significant cost. Routine imaging should not be pursued in acute low back pain. Not imaging patients with acute low back pain will reduce harms and costs, without affecting clinical outcomes.

The National Physicians Alliance project titled “Promoting Good Stewardship in Clinical Practice” developed 5-item lists of evidence-based, quality-improving, resource-sparing activities in the fields of family medicine, internal medicine, and pediatrics. Each item is supported by the evidence, benefits patients by improving treatment or decreasing risks, and, where possible, reduces the costs of care.

The lists were published on August 8, 2011, in the Archives.1 The present article is the second in a series detailing the recommendations from the top 5 lists for family medicine and internal medicine. Herein, we justify the recommendation against routine imaging in patients with acute low back pain.

Methods

A detailed description of the methods used to derive the top 5 lists is given elsewhere.1Quiz Ref IDThe full item discussed herein for internal medicine was worded as follows: “Don't do imaging for low back pain within the first 6 weeks unless red flags are present.”1(p1388) Red flags were defined as “severe or progressive neurological deficits” or serious underlying conditions, such as cancer or osteomyelitis.1

We searched the recent literature for population-based estimates of the incidence of acute low back pain, the frequency of physician visits for this problem, and the use of imaging. To document the potential benefits and risks of routine imaging for acute low back pain, we searched the literature using PubMed for articles published in the past 5 years using the terms lower back pain, low back pain, imaging, and either systematic review or meta-analysis. We also assessed the cost of spine imaging using data from the National Ambulatory Medical Care Survey and used estimates of the prevalence of imaging for low back pain to arrive at an estimate of the number of patients receiving such imaging in 1 year. Thereafter, we used 2009 Medicare reimbursements for lumbar spine imaging to calculate the associated cost savings.2

Results
Incidence of low back pain and imaging

Quiz Ref IDLow back pain has a lifetime prevalence of approximately 80% and is the fifth most common reason for all physician visits in the United States.3 Approximately one-quarter of US adults reported having low back pain lasting at least 1 whole day in the preceding 3 months.3

Imaging for acute low back pain is common. Quiz Ref IDRecent data show that 42% of patients with back pain receive imaging within 1 year, mostly plain radiography.4 Of these, 60% had imaging on the same day as the index diagnosis of back pain and 80% within 1 month of the diagnosis.4 Medicare data indicate that almost one-third of patients identified with the diagnosis code of lumbar pain had diagnostic radiography within 28 days.4 Although magnetic resonance (MR) imaging and computed tomography (CT) are significantly more costly than standard lumbar radiography, their use as modalities for spinal imaging in low back pain is increasing. For example, Medicare provides far greater reimbursement for MR imaging than for conventional radiography, with a ratio of reimbursement to cost of 2.3 for MR imaging vs 0.9 for conventional radiography.5 In the case of lumbar spine imaging, between 1994 and 2005 MR imaging covered by Medicare increased 307%.6

Evidence of benefit

Our literature search identified only one systematic review published in the past 5 years that provides data on outcomes related to imaging of acute low back pain. This meta-analysis, by Chou et al,7 focused on clinical outcomes in patients with acute low back pain and found no clinically significant difference in pain or function between those who received immediate lumbar spine imaging vs usual care (Figure 1). The authors concluded that “lumbar imaging for low back pain without indications of serious underlying conditions does not improve clinical outcomes.”7(p463)

Evidence of harm

More than 85% of patients seen at primary care practices have low back pain that cannot be attributed to a specific disease or an anatomic abnormality,13 and it is well known that imaging of asymptomatic patients often reveals anatomic abnormalities, such as herniated discs.14,15 One of the risks of routinely imaging uncomplicated acute low back pain is patient “labeling”; no evidence exists that labeling patients with low back pain with a specific anatomic diagnosis improves outcomes.

Degenerative disc disease is associated with low back pain, although the strength of the association varies with the definition.16 In a study10 of patients with back pain who underwent MR imaging and were then randomized to (1) disclosure of MR imaging findings to the patient and physician or (2) withholding of the findings, patients who were told that the MR imaging showed benign degenerative disc disease had a diminished sense of well-being compared with patients who were not told their MR imaging results.

In another study,11 patients who underwent lumbar radiography for back pain of at least 6 weeks' duration reported more pain and worse overall health status after 3 months than those who did not undergo radiography. The patients who underwent imaging also were more likely to seek follow-up care.

Quiz Ref IDThe performance of MR imaging for acute low back pain may be associated with deleterious outcomes. In a randomized controlled trial17 comparing MR imaging with standard lumbar radiography for low back pain, patients in the MR imaging arm of the trial were more than twice as likely to undergo surgical interventions than patients in the lumbar radiography arm (risk difference, 0.34; 95% CI, −0.06 to 0.73).

For work-related acute low back pain, another study6 found that patients who underwent MR imaging within the first month had more than an 8-fold increased risk for surgery and more than a 5-fold increase in subsequent total medical costs compared with matched control patients who did not undergo early MR imaging. Regions with higher use of advanced imaging for low back pain also have an increased rate of spinal surgical procedures for low back pain; greater use of imaging is not associated with better patient outcomes.18

Other risks of routinely imaging patients with acute low back pain include unnecessary irradiation exposure (for lumbar radiography and CT), especially in women, for whom lumbar radiography poses a risk to reproductive health. Based on the performance of 2.2 million lumbar CT investigations in the United States in 2007, a study19 projected an additional 1200 future cases of cancer.

Balance of benefit and risk

High-quality consistent evidence shows that imaging patients with acute low back pain of less than 6 weeks' duration and no red flag symptoms results in no clinical benefit but is associated with harms, including patient labeling, irradiation exposure, and unnecessary surgery.11 As already summarized, recent reviews6,17,18 showed no improvement in clinical outcomes associated with immediate imaging. Routinely imaging the low back in this setting provides no benefit to patients, except perhaps to increase a sense of patient satisfaction with his or her health care.

Estimated cost savings of the good stewardship recommendation

Based on the following assumptions, we estimated the cost savings that would accrue from avoiding routine imaging of low back pain. We estimated the number of patients in 1 year receiving routine imaging for low back pain based on estimates by Deyo et al3 that half of all US adults have an episode of acute low back pain during any given year. We also used estimates from the 2008 National Ambulatory Medical Care Survey20 about the number of patient visits for patient-reported symptoms of back pain. Furthermore, Pham et al21 found that, among all patients undergoing imaging within 28 days of diagnosis, 11.8% received MR imaging or CT, and 88.2% received lumbar radiography. Figure 2 summarizes the calculations to estimate that 3 802 800 patients receive imaging for routine low back pain in 1 year.

We used 2009 Medicare reimbursements for lumbar spine imaging ($41 for plain radiography, $264 for noncontrast CT, and $439 for noncontrast MR imaging) to calculate the associated cost savings per patient per year.2 Using the figure in the previous paragraph of approximately 4 million patients, we estimated that following the Good Stewardship recommendation would result in overall savings of $140 million from the elimination of unnecessary lumbar radiography and between $120 and $200 million from the elimination of unnecessary MR imaging and CT.Quiz Ref IDUsing the midpoint of the range of savings for MR imaging or CT ($160 million from eliminating CT / MRI + $140 million from eliminating plain films), we arrived at our final estimate of almost $300 million in annual savings.

The cost savings and estimates discussed herein are based on generalizations about the US population at large and do not consider regional variability or differences in imaging use according to practice size and population. In addition, these estimates ignore the societal cost of imaging, including the morbidity associated with patient labeling or the risk for unnecessary surgery.

Comment
Changing behaviors of physicians as stewards

Ample evidence supports the National Physicians Alliance recommendation that in the absence of red flag symptoms imaging is not warranted in acute low back pain of less than 6 weeks' duration. Similar guidelines that recommend against routine imaging have been in use for almost 3 decades.22 Nevertheless, a survey of US physicians found that more than one-third would order lumbar MR imaging for uncomplicated acute low back pain if a patient insisted on it even after the physician explained that it was unnecessary.23

Reasons why physicians may continue to order imaging for acute low back pain include medicolegal concerns, patient preferences, time pressures (which might make it easier to order an imaging procedure than to discuss the condition), and financial incentives. In randomized controlled trials,11,17 patients with low back pain expressed more satisfaction when they received routine lumbar imaging or advanced imaging, although clinical outcomes were not better than those for patients who did not undergo imaging.

How can physicians say no and still maintain the physician-patient relationship, a high level of patient satisfaction, and patient adherence? Physicians are cautious when rejecting patient requests for service, in part because of the perception that saying no to a request may lower patient satisfaction.24 However, most patients do not want unnecessary or potentially harmful tests, and patient education may bridge this gap.25

Evidence has shown that patient agreement with his or her physicians can predict important health outcomes. A study26 using a specific 3-item instrument in assessing patient agreement with the plan by the physician for his or her low back pain showed that higher agreement scores correlated with increased patient satisfaction and with improvement in measures of health status at 12-month follow-up. Data suggest that validating a patient's diagnosis of low back pain, gathering additional data about the reason the patient is requesting imaging, and providing information tailored to the patient's perspective may result in excellent patient satisfaction, despite denying the request for imaging.27

Strategies involving physician education by clinical leaders, audit, and feedback may be effective in reducing inappropriate lumbar imaging.28 A multifaceted intervention in a health care system reduced the rate of lumbar MR imaging by 23%; this program required clinicians to identify an approved indication before ordering advanced imaging, offered education on appropriate imaging, included periodic audits and feedback, and provided rapid physical therapy and consultation when imaging was not indicated.29Computer-based feedback on recent imaging investigations and ordering patterns of peers may also have some influence on the requesting of imaging tests.30 Some observers have recommended mandatory consultation by a radiologist when physician requests for imaging are inconsistent with guidelines.31,32 Effective intervention to reduce inappropriate imaging probably requires multiple simultaneous strategies.

Although physicians are usually loath to bring up the issue of cost in the examination room, today's health care climate may make this topic ripe for discussion. Pearson33 discusses the need for a shift in the paradigm of physician advocacy to one in which patients and physicians are part of a moral community that controls costs through group deliberation and decision making. An ethical grounding has recently been emphasized by the American College of Physicians, which included such considerations as part of the professional responsibility of physicians.34 Honesty about cost can ensure patient satisfaction in the delivery of high-quality ethical care.

Final thoughts

The “Less Is More” series is focused on areas in which responsible physician stewardship can help improve the quality and reduce the potential harms of care. Physicians should also consider costs, balancing the needs of individuals with those of society at large.

We believe that a thoughtful dispassionate approach to topics in medicine can reveal areas of practice that may have become standards of care but are not necessarily good standards of care. The Good Stewardship Working Group1 found that collaborative deliberation and decision making, together with a thorough study of the medical literature, can help physicians explain their rationale for evidence-based selective imaging.

Adhering to the Good Stewardship recommendation on low back pain will improve care, reduce harm, and decrease overall medical costs. Ensuring a frank and honest discussion of the benefits and risks of medical therapy and imaging can improve care and reduce costs for patients with low back pain.

Back to top
Article Information

Correspondence: Shubha V. Srinivas, MD, MPH, Department of Medicine, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06030 (ssrinivas@resident.uchc.edu).

Accepted for Publication: March 25, 2012.

Published Online: June 4, 2012. doi:10.1001/archinternmed.2012.1838

Author Contributions:Study concept and design: Srinivas, Deyo, and Berger. Acquisition of data: Srinivas and Berger. Analysis and interpretation of data: Srinivas, Deyo, and Berger. Drafting of the manuscript: Srinivas, Deyo, and Berger. Critical revision of the manuscript for important intellectual content: Srinivas, Deyo, and Berger. Administrative, technical, and material support: Srinivas. Study supervision: Berger.

Financial Disclosure: None reported.

Funding for Less Is More: Staff support for topics research funded by grants from the California Health Care Foundation and the Parsemus Foundation.

References
1.
Good Stewardship Working Group.  The “Top 5” lists in primary care: meeting the responsibility of professionalism.  Arch Intern Med. 2011;171(15):1385-139021606090PubMedGoogle ScholarCrossref
2.
 TrailBlazer Health Enterprises, LLC. Medicare fee schedule. 2009. http://www.trailblazerhealth.com/Tools/Fee%20Schedule/MedicareFeeSchedule.aspx. Accessed April 6, 2012
3.
Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002.  Spine (Phila Pa 1976). 2006;31(23):2724-272717077742PubMedGoogle ScholarCrossref
4.
Ivanova JI, Birnbaum HG, Schiller M, Kantor E, Johnstone BM, Swindle RW. Real-world practice patterns, health-care utilization, and costs in patients with low back pain: the long road to guideline-concordant care.  Spine J. 2011;11(7):622-63221601533PubMedGoogle ScholarCrossref
5.
Chou R, Qaseem A, Owens DK, Shekelle P.Clinical Guidelines Committee of the American College of Physicians.  Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians [published correction appears in Ann Intern Med. 2012;156(1, pt 1):71].  Ann Intern Med. 2011;154(3):181-18921282698PubMedGoogle Scholar
6.
Webster BS, Cifuentes M. Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes.  J Occup Environ Med. 2010;52(9):900-90720798647PubMedGoogle ScholarCrossref
7.
Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis.  Lancet. 2009;373(9662):463-47219200918PubMedGoogle ScholarCrossref
8.
Kerry SH, Hilton S, Dundas D, Rink E, Oakeshott P. Radiography for low back pain: a randomised controlled trial and observational study in primary care.  Br J Gen Pract. 2002;52(479):469-47412051211PubMedGoogle Scholar
9.
Djais N, Kalim H. The role of lumbar spine radiography in the outcomes of patients with simple acute low back pain.  APLAR J Rheumatol. 2005;8:45-50Google ScholarCrossref
10.
Modic MT, Obuchowski NA, Ross JS,  et al.  Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome.  Radiology. 2005;237(2):597-60416244269PubMedGoogle ScholarCrossref
11.
Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M. Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial.  BMJ. 2001;322(7283):400-40511179160PubMedGoogle ScholarCrossref
12.
Gilbert FJ, Grant AM, Gillan MG,  et al; Scottish Back Trial Group.  Low back pain: influence of early MR imaging or CT on treatment and outcome–multicenter randomized trial.  Radiology. 2004;231(2):343-35115031430PubMedGoogle ScholarCrossref
13.
Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain?  JAMA. 1992;268(6):760-7651386391PubMedGoogle ScholarCrossref
14.
van Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Spinal radiographic findings and nonspecific low back pain: a systematic review of observational studies.  Spine (Phila Pa 1976). 1997;22(4):427-4349055372PubMedGoogle ScholarCrossref
15.
Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain.  N Engl J Med. 1994;331(2):69-738208267PubMedGoogle ScholarCrossref
16.
de Schepper EI, Damen J, van Meurs JB,  et al.  The association between lumbar disc degeneration and low back pain: the influence of age, gender, and individual radiographic features.  Spine (Phila Pa 1976). 2010;35(5):531-536Google ScholarCrossref
17.
Jarvik JG, Hollingworth W, Martin B,  et al.  Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial.  JAMA. 2003;289(21):2810-281812783911PubMedGoogle ScholarCrossref
18.
Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery.  Spine (Phila Pa 1976). 2003;28(6):616-62012642771PubMedGoogle Scholar
19.
Berrington de González A, Mahesh M, Kim KP,  et al.  Projected cancer risks from computed tomographic scans performed in the United States in 2007.  Arch Intern Med. 2009;169(22):2071-207720008689PubMedGoogle ScholarCrossref
20.
 Centers for Disease Control and Prevention. National Ambulatory Medical Care Survey: 2008 summary table. 2009. http://www.cdc.gov/nchs/data/ahcd/namcs_summary/namcssum2008.pdf. Accessed April 6, 2012
21.
Pham HH, Landon BE, Reschovsky JD, Wu B, Schrag D. Rapidity and modality of imaging for acute low back pain in elderly patients.  Arch Intern Med. 2009;169(10):972-98119468091PubMedGoogle ScholarCrossref
22.
Deyo RA, Bigos SJ, Maravilla KR. Diagnostic imaging procedures for the lumbar spine.  Ann Intern Med. 1989;111(11):865-8672530926PubMedGoogle Scholar
23.
Campbell EG, Regan S, Gruen RL,  et al.  Professionalism in medicine: results of a national survey of physicians.  Ann Intern Med. 2007;147(11):795-80218056665PubMedGoogle Scholar
24.
Gallagher TH, Lo B, Chesney M, Christensen K. How do physicians respond to patient's requests for costly, unindicated services?  J Gen Intern Med. 1997;12(11):663-6689383133PubMedGoogle ScholarCrossref
25.
Deyo RA, Diehl AK, Rosenthal M. Reducing roentgenography use: can patient expectations be altered?  Arch Intern Med. 1987;147(1):141-1452948466PubMedGoogle ScholarCrossref
26.
Staiger TO, Jarvik JG, Deyo RA, Martin B, Braddock CH III. BRIEF REPORT: Patient-physician agreement as a predictor of outcomes in patients with back pain.  J Gen Intern Med. 2005;20(10):935-93716191141PubMedGoogle ScholarCrossref
27.
Paterniti DA, Fancher TL, Cipri CS, Timmermans S, Heritage J, Kravitz RL. Getting to “no”: strategies primary care physicians use to deny patient requests.  Arch Intern Med. 2010;170(4):381-38820177043PubMedGoogle ScholarCrossref
28.
Schectman JM, Schroth WS, Verme D, Voss JD. Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain.  J Gen Intern Med. 2003;18(10):773-78014521638PubMedGoogle ScholarCrossref
29.
Blackmore CC, Mecklenburg RS, Kaplan GS. Effectiveness of clinical decision support in controlling inappropriate imaging.  J Am Coll Radiol. 2011;8(1):19-2521211760PubMedGoogle ScholarCrossref
30.
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