A 33-year-old man comes to the office due to back pain. He has a 2-week history of moderate pain in the lumbar area that started after a long day of yard work. There is no associated fever, motor weakness, or urinary symptoms. The patient has no history of acute trauma and medical history is unremarkable. Examination shows normal lower extremity strength, sensation, and reflexes. Straight-leg raising test is negative. The patient says, "My brother had similar pain last year and his MRI scan showed a bulging disc. Can you order that test for me?" The clinician offers options for symptomatic relief but recommends against performing any imaging studies. Which of the following is the most likely effect of this recommendation?

Question

A 33-year-old man comes to the office due to back pain.  He has a 2-week history of moderate pain in the lumbar area that started after a long day of yard work.  There is no associated fever, motor weakness, or urinary symptoms.  The patient has no history of acute trauma and medical history is unremarkable.  Examination shows normal lower extremity strength, sensation, and reflexes.  Straight-leg raising test is negative.  The patient says, "My brother had similar pain last year and his MRI scan showed a bulging disc.  Can you order that test for me?"  The clinician offers options for symptomatic relief but recommends against performing any imaging studies.  Which of the following is the most likely effect of this recommendation?

Quizplus · Accepted Answer

11ec160b_3685_4e73_9249_3b1e0a543f61_MD0001_00 This patient has acute, uncomplicated low back pain (LBP) with no "red-flag" features (eg, fever, neurologic deficits) to suggest a serious cause. Uncomplicated LBP usually resolves spontaneously, and management is directed toward providing temporary symptomatic relief. Imaging (eg, x-ray, MRI scan) is generally not recommended because it does not improve outcomes or provide necessary information for optimal management. Overutilization refers to provision of unnecessary services that are not expected to improve patient outcomes or meaningfully change management. Patient-centered health care requires care to be delivered with respect to the patients' concerns, preferences, and priorities, but does not require unnecessary testing or treatment if patient input is otherwise solicited and respected when appropriate. MRI in uncomplicated LBP increases overutilization and is therefore not recommended for this patient. (Choice A) Spinal MRI often identifies nonspecific abnormalities (eg, bulging intervertebral discs) that are not relevant to management but can lead to further unnecessary and potentially harmful diagnostic studies and interventions. Because of the frequency of such abnormalities, even in asymptomatic individuals, it is often not clear whether they are the actual cause of pain or merely an incidental finding. Deferring imaging therefore decreases, rather than increases, diagnostic uncertainty. (Choice B) Fragmentation of health care refers to breaking up care across multiple providers and facilities without adequate cross communication. Declining to order unnecessary tests does not lead to fragmentation. (Choice C) Health care disparity refers to differences in access to care or outcomes due to socioeconomic or demographic factors. Careful and appropriate use of diagnostic studies does not increase disparity. (Choice D) Malpractice liability risk correlates most closely with provider-patient communication and perceived level of concern. Appropriate use of diagnostic studies, especially as it conforms to evidence-based guidelines, does not increase malpractice risk. (Choice E) Clinical standardization refers to consistency of management decisions within and across provider groups. Care that conforms to established guidelines increases, not decreases, standardization. Educational objective: Overutilization refers to provision of services that are not expected to improve patient outcomes or meaningfully change management. Patient-centered health care requires care to be delivered with respect to patients' concerns, preferences, and priorities, but does not require unnecessary testing or treatment if patient input is otherwise solicited and respected when appropriate. __________ References: Managing inappropriate utilization of laboratory resources. (http://www.ncbi.nlm.nih.gov/pubmed/30096052) Mechanical low back pain. (http://www.ncbi.nlm.nih.gov/pubmed/30252425)

A 33-Year-Old Man Comes to the Office Due to Back