Imaging Utilization for the Initial Evaluation of Low Back Pain in the Primary Care Setting; a National Cohort Analysis

From the 2019 HVPAA National Conference

Dr. Jina Pakpoor (Johns Hopkins School of Medicine), Dr. Michael Raad (Johns Hopkins Medical Institute), Mr. Andrew Harris (Johns Hopkins Medical Institute), Dr. Varun Puvanesarajah (Johns Hopkins Medical Institute), Mr. Joseph Canner (Johns Hopkins Medical Institute), Dr. Rohini Nadgir (Johns Hopkins Department of Radiology), Dr. Amit Jain (Johns Hopkins Medical Institute)


Low back and neck pain represent the third greatest burden on US health care spending at an estimated $87.6 billion annually, falling behind only diabetes and ischemic heart disease, and are among the most common causes of all physician visits in the US. High-value care guidelines from multiple medical societies, including the American College of Radiology and the American College of Family Physicians, recommend against imaging for the initial evaluation of low back pain in the absence of red flag symptoms. Overutilization of diagnostic imaging for this purpose has been widely recognized as a significant source of increased healthcare spending, with national initiatives such as the 2012 ‘Choosing Wisely’ campaign aimed at reducing unnecessary imaging for low back pain.


In light of the possible impact on targeted interventions and evaluations of current educational initiatives, we aimed to determine the current temporal and geographic trends of imaging use in the primary care setting for the initial evaluation of low back pain in the United States.


Using a national commercial insurance claims database, we identified patients between 18-64 years old who presented to a primary care provider for the first visit with an associated diagnosis of low back pain between 2011- 2016, following a minimum time period of 1 year of continuous insurance enrollment. Patients were identified via International Classification of Diseases codes and the use of diagnostic imaging was identified by Current Procedural Terminology codes. Geographic regions were based on the location of patient residence. Potentially confounding variables were predetermined prior to analysis, including age, sex, employment status, type of health plan, and geographic region. These patient demographic factors were analyzed and controlled for on multivariate analysis


627,118 encounters met inclusion criteria. Imaging acquisitions increased over time, from 14% of encounters in 2011 to 16% in 2016 (p<0.001), Figure 1. Radiographs represented 96% of ordered imaging, Computed Tomography 2% and Magnetic Resonance Imaging 3%. The likelihood of having any imaging for low back pain varied significantly by US census region and by US state (p<0.001), Figure 2. The greatest use of imaging was in the Midwest (13.9%) and the South (18.5%), and lowest in the Northeast and West regions (6.2% and 13.6%).


Imaging utilization for new low back pain in the primary care setting has continued to increase in recent years, with radiographs seeing the highest increase compared with other imaging modalities. Advanced imaging has remained at a relatively stable low rate of acquisitions by the primary care provider, and reassuringly, the majority of encounters do not have imaging acquired.

Clinical Implications

Our findings speak of a need for evaluating and developing current educational efforts and intiatives targeted toward primary care providers to reverse the overall trend. Geographically targeted education and health-policy efforts may reduce the regional differences observed, with a likely opportunity present to learn from states with greater guideline compliance.


What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog