Needless back treatments driven by misallocation of funding

Ineffective and harmful tests and interventions are prioritised over low-tech, but more effective, therapies

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Australian-led research has created headlines by suggesting the misallocation of resources is driving patients with low back pain towards “dubious” and potentially harmful tests and treatment, and away from more effective low-tech options.  

Low back pain is the leading cause of disability worldwide, and yet there is a “global epidemic of inappropriate tests and treatment” for the condition, according to the authors of a new series in The Lancet. 

The authors called for changes to funding within the health system away from unnecessary, ineffective and harmful tests and interventions, such as scans, X-rays, opioids, injections and surgery, and towards low-tech, but evidence-based, options. 

“The majority of cases of low back pain respond to simple physical and psychological therapies that keep people active and enable them to stay at work,” study author and Monash University Professor, Rachelle Buchbinder, said.  

Unfortunately, what was more often promoted and reimbursed was “more aggressive treatments of dubious benefit”, she said. 

Australia currently spends around $4.8 billion a year on managing the condition, and the problem only looks set to worsen as the population ages and grows more overweight. 

According to guidelines, primary care is the best place to manage patients’ low back pain. 

But a growing number of people are calling an ambulance as a first resort, instead of seeing their GP, physiotherapist or chiropractor. 

A high proportion of patients were being treated in emergency departments, the paper said. 

Study author Professor Chris Maher, director of Musculoskeletal Health Sydney at the University of Sydney, said the first-line advice was to educate patients and recommend they kept active and at work. 

However, research suggested the education of patients was suboptimal in primary care, he noted.

Many patients were told to stay off work until they were pain free, which might actually delay recovery.

Other research has shown that two in three patients were prescribed medicine at their first visit to a clinician. 

Professor Maher said the solution lay in changing the way funding was allocated. 

In Australia, patients have access to five allied health visits under Medicare, but this is fewer than would likely be necessary for a typical exercise or psychological program for chronic low back pain. On the other hand, funding is easier to secure for surgeries and medicines.

The authors noted that chiropractors were widely encouraging patients with acute low back pain to have imaging, and up to one in three physiotherapists also gave outdated advice and information. 

“More care does not mean better care,” Professor Maher said. 

“More aggressive treatments for low back pain have little proven benefit and have the potential to make things significantly worse for patients.”

The Lancet, online 22 March