下背痛初期的影像檢查不必要 會有傷害


  【24drs.com】屬於「Promoting Good Stewardship in Clinical Practice」的全國醫師聯盟反對發生下背痛的最初6週內進行影像檢查,除非有警訊。現在,新文獻與財務分析可以支持並解釋此項建議。
  
  康乃狄克健康中心醫學系Shubha V. Srinivas醫師等人進行的分析,精心涵蓋了30年的臨床指引史,指出大多數下背痛案例可以在極少臨床介入下自行緩解。
  
  不過,線上登載於6月4日內科醫學誌、屬於「Less is More」系列研究一部分的這些分析結果,也幫助維持了「明智抉擇」這項活動的優點,這是一個多科別協會所提出的活動,鼓勵醫師和病患對於不一定適用每種狀況改善臨床結果的昂貴醫療科技做出聰明選擇。
  
  下背痛初期避免影像檢查的這項建議,包括在全國醫師聯盟「少即是多之健康照護活動」的「Top 5」清單內,發表於2011年8月8日版內科醫學誌。
  
  這次的文獻回顧中,Srinivas醫師等人報告指出,下背痛影像檢查相當常見。2011年的研究( Spine J. 2011;11:622-632)指出,42%的下背痛病患在疼痛發生1年內進行影像檢查(主要是一般X光),整體而言,6成病患在診斷當日就進行影像檢查,8成病患在1個月內進行。
  
  Srinivas醫師等人也指出,另一篇回顧結論指出,下背痛腰部影像檢查但無嚴重潛在狀況者,並不會改善臨床結果( Lancet. 2009;373:463-472)。
  
  再者,Srinivas醫師等人估計,藉由限制下背痛最初6個月內的影像檢查,每年可省下近3億美元,除非有特別嚴重狀況,如嚴重或漸進式神經缺損、或者懷疑有嚴重潛在狀況如骨髓炎時。
  
  他們推測,初期下背痛影像檢查的唯一好處只是滿足病患需求和獲得臨床處置的情緒需要。基於這個問題,他們的文章標題訂為「Getting to 'No': Strategies Primary Care Physicians Use to Deny Patient Requests」,作為如何否定下背痛病患無嚴重狀況時的影像檢查的範例( Arch Intern Med. 2010;170:381-388)。
  
  美國內科基金會執行副理事長Daniel Wolfson受邀發表評論時提到這個主題。他寫道,Srinivas醫師等人確認了實行中的指引問題,也比較了實務上的效益,但是他們沒有提供解決方案。
  
  所以,Wolfson考慮了美國內科基金會委員會、9個醫療專科協會和消費者報告的資料,列出它們在科學上質疑的醫療實務清單,提醒大眾注意。
  
  「明智抉擇」這項活動的特色是「醫師和病患應質疑的5件事情」清單,用以教育每個協會的醫師會員和他們的病患:臨床適當性和檢查及治療之費用。這份清單在4月4日時同步宣佈。
  
  Wolfson表示,「明智抉擇」檢視這類活動是否可以將臨床建議付諸實踐。
  
  與Srinivas醫師的文章一致,這份清單受到美國家庭醫師協會和美國外科醫師學院的支持,兩者都反對在下背痛最初的6週內進行影像檢查,除非懷疑有警訊時。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=6847&x_classno=0&x_chkdelpoint=Y
  

Early Imaging of Low Back Pain Unnecessary, Harmful

By James Brice
Medscape Medical News

June 5, 2012 — As part of its "Promoting Good Stewardship in Clinical Practice," the National Physicians Alliance recommended against imaging for low back pain within the first 6 weeks of onset unless red flags are present. Now, a new literature and financial analysis supports and explains that recommendation.

In one sense, the analysis by Shubha V. Srinivas, MD, MPH, from the Department of Medicine, University of Connecticut Health Center, Farmington, and colleagues covers well-traveled ground from the 30-year history of clinical guidelines indicating that most cases of lumbar back pain resolve themselves with minimal clinical intervention.

However, the findings of the analysis, published online June 4 in the Archives of Internal Medicine, as part of the "Less is More" series, also help maintain momentum for Choosing Wisely, a multi–medical society initiative designed to encourage physicians and their patients to make smart choices about the use of expensive medical technologies that do not deliver improved clinical outcomes in every situation.

The recommendation to avoid early imaging for low back pain was included in the National Physicians Alliance’s list of " 'Top 5' Health Care Activities for Which Less Is More" which was published in the August 8, 2011, issue of the Archives of Internal Medicine.

In the current literature review, Dr. Srinivas and colleagues report that imaging for lower back pain is extremely common. A 2011 study ( Spine J. 2011;11:622-632) indicated that 42% of patients with back pain undergo imaging (mainly plain radiography) within a year of the onset of pain. Of that total, 6 of 10 patients had imaging on the same day as their diagnosis. Eight of 10 underwent imaging within a month.

Dr. Srinivas and colleagues also note that another review concluded that lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes ( Lancet. 2009;373:463-472).

Furthermore, Dr. Srinivas and colleagues estimated that nearly $300 million could be saved annually by restricting imaging during the first 6 weeks of lumbar back pain to specific severe indications, including severe or progressive neurological deficits or when serious underlying conditions, such as osteomyelitis, are suspected.

They surmised that the only benefit of authorizing early low back imaging would be to cater to the patient's demands and emotional need for clinical action. With that issue at hand, they cited an article titled, "Getting to 'No': Strategies Primary Care Physicians Use to Deny Patient Requests" as an example of how to deny imaging to patients with lower back pain without inciting rebellion ( Arch Intern Med. 2010;170:381-388).

Daniel Wolfson, MHSA, executive vice president of the American Board of Internal Medicine Foundation, Philadelphia, Pennsylvania, picked up on this theme in an invited commentary.

"Srinivas et al recognize the problem of translating guidelines and comparative effectiveness research into practice, but they do not offer solutions," he wrote.

So, Wolfson has offered for consideration the efforts of the American Board of Internal Medicine Foundation, along with 9 medical specialist societies and Consumer Reports, to bring their lists of scientifically questionable medical practices to the attention of the general public.

Choosing Wisely features "Five Things Physicians and Patient Should Question," lists, which are geared to educating each society's physician members and their patients about the clinical appropriateness and costs of popular medical tests and therapies. The lists were announced simultaneously April 4.

"Choosing Wisely will test whether this type of campaign will spur translation of clinical recommendations into practice," Wolfson said.

Consistent with Dr. Srinivas's article, lists supported by the American Academy of Family Physicians and the American College of Physicians both advise against imaging of low back pain within the first 6 weeks unless red-flag conditions are suspected.

The authors and commentator have disclosed no relevant financial relationships.

Arch Intern Med. Published online June 4, 2012.

    
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