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Journal of General Internal Medicine

, Volume 16, Issue 1, pp 14–23 | Cite as

Finding cancer in primary care outpatients with low back pain

A comparison of diagnostic strategies
  • Jerry D. Joines
  • Robert A. McNutt
  • Timothy S. Carey
  • Richard A. Deyo
  • Roya Rouhani
Original Articles

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.

Key words

low back pain decision analysis cost-effectiveness analysis 

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Copyright information

© Blackwell Science Inc 2001

Authors and Affiliations

  • Jerry D. Joines
    • 6
    • 2
  • Robert A. McNutt
    • 3
  • Timothy S. Carey
    • 1
    • 2
  • Richard A. Deyo
    • 4
  • Roya Rouhani
    • 5
  1. 1.the Cecil G. Sheps Center for Health Services ResearchUSA
  2. 2.the Department of MedicineUniversity of North Carolina at Chapel HillChapel Hill
  3. 3.Department of MedicineCook County HospitalChicago
  4. 4.Department of Medicine, Department of Health Services, and Center for Cost and Outcomes ResearchUniversity of WashingtonSeattle
  5. 5.Center for Distance Learning and TelehealthUniversity of Texas Health Science CenterSan Antonio
  6. 6.Internal Medicine Training ProgramMoses H. Cone Memorial HospitalGreensboro

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