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Finding cancer in primary care outpatients with low back pain

A comparison of diagnostic strategies

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Abstract

OBJECTIVE: To compare strategies for diagnosing cancer in primary care patients with low back pain. Strategies differed in their use of clinical findings, erythrocyte sedimentation rate (ESR), and plain x-rays prior to imaging and biopsy.

DESIGN: Decision analysis and cost effectiveness analysis with sensitivity analyses. Strategies were compared in terms of sensitivity, specificity, and diagnostic cost effectiveness ratios.

SETTING: Hypothetical.

MEASUREMENTS: Estimates of disease prevalence and test characteristics were taken from the literature. Costs were represented by the Medicare reimbursement for the tests and procedures employed.

MAIN RESULTS: In the baseline analysis, using magnetic resonance imaging (MRI) as the imaging procedure prior to a single biopsy, strategies ranged in sensitivity from 0.40 to 0.73, with corresponding diagnostic costs of $14 to $241 per patient with average cost effectiveness ratios of $5,283 to $49,814 per case of cancer found. Incremental cost effectiveness ratios varied from $8,397 to $624,781; five strategies were dominant in the baseline analysis. Use of a higher ESR cutoff point (50 mm/hr) improved specificity and cost effectiveness for certain strategies. Imaging with MRI, or bone scan followed in series by MRI, resulted in fewer unnecessary biopsies than imaging with bone scan alone. Cancer prevalence was an important determinant of cost effectiveness.

CONCLUSIONS: We recommend a strategy of imaging patients who have a clinical finding (history of cancer, age ≥ 50 years, weight loss, or failure to improve with conservative therapy) in combination with either an elevated ESR (≥50 mm/hr) or a positive x-ray, or using the same approach but imaging directly those patients with a history of cancer.

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This project was partially supported by the North Carolina Back Pain Project (Agency for Health Care Policy and Research Grant HS06664), the Back Pain Outcome Assessment Team (Agency for Health Care Policy and Research grants HS06344 and HS08194), and National Research Service Award 5-T32-PE-14001 from the Health Resources and Services Administration through the Primary Care Research Fellowship Program at the University of North Carolina.

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Joines, J.D., McNutt, R.A., Carey, T.S. et al. Finding cancer in primary care outpatients with low back pain. J GEN INTERN MED 16, 14–23 (2001). https://doi.org/10.1111/j.1525-1497.2001.00249.x

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