How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years

Aron Downie, Mark Hancock, Hazel Jenkins, Rachelle Buchbinder, Ian A. Harris, Martin Underwood, Stacy Goergen, Christopher Maher

Research output: Contribution to journalArticleResearchpeer-review

Abstract


Objectives To (1) estimate the proportion of patients seeking care for low back pain (LBP) who are imaged and (2) explore trends in the proportion of patients who received diagnostic imaging over time. We also examined the effect of study-level factors on estimates of imaging proportion.

Data sources Electronic searches of MEDLINE, Embase and CINAHL databases from January 1995 to December 2017.

Eligibility criteria for selecting studies Observational designs and controlled trials that reported imaging for patients presenting to primary care or emergency care for LBP. We assessed study quality and calculated pooled proportions by care setting and imaging type, with strength of evidence assessed using the GRADE system.

Results 45 studies were included. They represented 19 451 749 consultations for LBP that had resulted in 4 343 919 imaging requests/events over 21 years. Primary care: moderate quality evidence that simple imaging proportion was 16.3% (95% CI 12.6% to 21.1%) and complex imaging was 9.2% (95% CI 6.2% to 13.5%). For any imaging, the pooled proportion was 24.8% (95% CI 19.3%to 31.1%). Emergency care: moderate quality evidence that simple imaging proportion was 26.1% (95% CI 18.2% to 35.8%) and high-quality evidence that complex imaging proportion was 8.2% (95% CI 4.4% to 15.6%). For any imaging, the pooled proportion was 35.6% (95% CI 29.8% to 41.8%). Complex imaging increased from 7.4% (95% CI 5.7% to 9.6%) for imaging requested in 1995 to 11.4% (95% CI 9.6% to 13.5%) in 2015 (relative increase of 53.5%). Between-study variability in imaging proportions was only partially explained by study-level characteristics; there were insufficient data to comment on some prespecified study-level factors.

Summary/conclusion One in four patients who presented to primary care with LBP received imaging as did one in three who presented to the emergency department. The rate of complex imaging appears to have increased over 21 years despite guideline advice and education campaigns.

Trial registration number CRD42016041987.
LanguageEnglish
Number of pages12
JournalBritish Journal of Sports Medicine
DOIs
Publication statusE-pub ahead of print - 13 Feb 2019

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Emergency Medical Services
Low Back Pain
Meta-Analysis
Primary Health Care
Information Storage and Retrieval
Diagnostic Imaging
MEDLINE
Observational Studies
Hospital Emergency Service
Patient Care
Referral and Consultation
Databases
Guidelines
Education

Cite this

@article{75e02bb9eb4d495b8bceb48e948bdad5,
title = "How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years",
abstract = "Objectives To (1) estimate the proportion of patients seeking care for low back pain (LBP) who are imaged and (2) explore trends in the proportion of patients who received diagnostic imaging over time. We also examined the effect of study-level factors on estimates of imaging proportion.Data sources Electronic searches of MEDLINE, Embase and CINAHL databases from January 1995 to December 2017.Eligibility criteria for selecting studies Observational designs and controlled trials that reported imaging for patients presenting to primary care or emergency care for LBP. We assessed study quality and calculated pooled proportions by care setting and imaging type, with strength of evidence assessed using the GRADE system.Results 45 studies were included. They represented 19 451 749 consultations for LBP that had resulted in 4 343 919 imaging requests/events over 21 years. Primary care: moderate quality evidence that simple imaging proportion was 16.3{\%} (95{\%} CI 12.6{\%} to 21.1{\%}) and complex imaging was 9.2{\%} (95{\%} CI 6.2{\%} to 13.5{\%}). For any imaging, the pooled proportion was 24.8{\%} (95{\%} CI 19.3{\%}to 31.1{\%}). Emergency care: moderate quality evidence that simple imaging proportion was 26.1{\%} (95{\%} CI 18.2{\%} to 35.8{\%}) and high-quality evidence that complex imaging proportion was 8.2{\%} (95{\%} CI 4.4{\%} to 15.6{\%}). For any imaging, the pooled proportion was 35.6{\%} (95{\%} CI 29.8{\%} to 41.8{\%}). Complex imaging increased from 7.4{\%} (95{\%} CI 5.7{\%} to 9.6{\%}) for imaging requested in 1995 to 11.4{\%} (95{\%} CI 9.6{\%} to 13.5{\%}) in 2015 (relative increase of 53.5{\%}). Between-study variability in imaging proportions was only partially explained by study-level characteristics; there were insufficient data to comment on some prespecified study-level factors.Summary/conclusion One in four patients who presented to primary care with LBP received imaging as did one in three who presented to the emergency department. The rate of complex imaging appears to have increased over 21 years despite guideline advice and education campaigns.Trial registration number CRD42016041987.",
keywords = "lower back, diagnosis, MRI, radiography, primary care",
author = "Aron Downie and Mark Hancock and Hazel Jenkins and Rachelle Buchbinder and Harris, {Ian A.} and Martin Underwood and Stacy Goergen and Christopher Maher",
year = "2019",
month = "2",
day = "13",
doi = "10.1136/bjsports-2018-100087",
language = "English",
journal = "British Journal of Sports Medicine",
issn = "0306-3674",
publisher = "BMJ Publishing Group",

}

How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years. / Downie, Aron; Hancock, Mark; Jenkins, Hazel; Buchbinder, Rachelle; Harris, Ian A.; Underwood, Martin; Goergen, Stacy; Maher, Christopher.

In: British Journal of Sports Medicine, 13.02.2019.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years

AU - Downie,Aron

AU - Hancock,Mark

AU - Jenkins,Hazel

AU - Buchbinder,Rachelle

AU - Harris,Ian A.

AU - Underwood,Martin

AU - Goergen,Stacy

AU - Maher,Christopher

PY - 2019/2/13

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N2 - Objectives To (1) estimate the proportion of patients seeking care for low back pain (LBP) who are imaged and (2) explore trends in the proportion of patients who received diagnostic imaging over time. We also examined the effect of study-level factors on estimates of imaging proportion.Data sources Electronic searches of MEDLINE, Embase and CINAHL databases from January 1995 to December 2017.Eligibility criteria for selecting studies Observational designs and controlled trials that reported imaging for patients presenting to primary care or emergency care for LBP. We assessed study quality and calculated pooled proportions by care setting and imaging type, with strength of evidence assessed using the GRADE system.Results 45 studies were included. They represented 19 451 749 consultations for LBP that had resulted in 4 343 919 imaging requests/events over 21 years. Primary care: moderate quality evidence that simple imaging proportion was 16.3% (95% CI 12.6% to 21.1%) and complex imaging was 9.2% (95% CI 6.2% to 13.5%). For any imaging, the pooled proportion was 24.8% (95% CI 19.3%to 31.1%). Emergency care: moderate quality evidence that simple imaging proportion was 26.1% (95% CI 18.2% to 35.8%) and high-quality evidence that complex imaging proportion was 8.2% (95% CI 4.4% to 15.6%). For any imaging, the pooled proportion was 35.6% (95% CI 29.8% to 41.8%). Complex imaging increased from 7.4% (95% CI 5.7% to 9.6%) for imaging requested in 1995 to 11.4% (95% CI 9.6% to 13.5%) in 2015 (relative increase of 53.5%). Between-study variability in imaging proportions was only partially explained by study-level characteristics; there were insufficient data to comment on some prespecified study-level factors.Summary/conclusion One in four patients who presented to primary care with LBP received imaging as did one in three who presented to the emergency department. The rate of complex imaging appears to have increased over 21 years despite guideline advice and education campaigns.Trial registration number CRD42016041987.

AB - Objectives To (1) estimate the proportion of patients seeking care for low back pain (LBP) who are imaged and (2) explore trends in the proportion of patients who received diagnostic imaging over time. We also examined the effect of study-level factors on estimates of imaging proportion.Data sources Electronic searches of MEDLINE, Embase and CINAHL databases from January 1995 to December 2017.Eligibility criteria for selecting studies Observational designs and controlled trials that reported imaging for patients presenting to primary care or emergency care for LBP. We assessed study quality and calculated pooled proportions by care setting and imaging type, with strength of evidence assessed using the GRADE system.Results 45 studies were included. They represented 19 451 749 consultations for LBP that had resulted in 4 343 919 imaging requests/events over 21 years. Primary care: moderate quality evidence that simple imaging proportion was 16.3% (95% CI 12.6% to 21.1%) and complex imaging was 9.2% (95% CI 6.2% to 13.5%). For any imaging, the pooled proportion was 24.8% (95% CI 19.3%to 31.1%). Emergency care: moderate quality evidence that simple imaging proportion was 26.1% (95% CI 18.2% to 35.8%) and high-quality evidence that complex imaging proportion was 8.2% (95% CI 4.4% to 15.6%). For any imaging, the pooled proportion was 35.6% (95% CI 29.8% to 41.8%). Complex imaging increased from 7.4% (95% CI 5.7% to 9.6%) for imaging requested in 1995 to 11.4% (95% CI 9.6% to 13.5%) in 2015 (relative increase of 53.5%). Between-study variability in imaging proportions was only partially explained by study-level characteristics; there were insufficient data to comment on some prespecified study-level factors.Summary/conclusion One in four patients who presented to primary care with LBP received imaging as did one in three who presented to the emergency department. The rate of complex imaging appears to have increased over 21 years despite guideline advice and education campaigns.Trial registration number CRD42016041987.

KW - lower back

KW - diagnosis

KW - MRI

KW - radiography

KW - primary care

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DO - 10.1136/bjsports-2018-100087

M3 - Article

JO - British Journal of Sports Medicine

T2 - British Journal of Sports Medicine

JF - British Journal of Sports Medicine

SN - 0306-3674

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