Established in 1927 by the American College of Physicians


1 February 2011 Annals of Internal Medicine Tip Sheet

Below is information about articles being published in the January 18 issue of Annals of Internal Medicine, including two early release articles. The information is not intended to substitute for the full articles as sources of information. Attached is an embargoed PDF of the full Annals table of contents. All information regarding highlighted articles and those in the TOC are under strict embargo until 5:00 p.m. on Monday, January 17. Annals of Internal Medicine attribution is required for all coverage. For an embargoed copy of a study, contact Angela Collom at or 215-351-2653.

1. ACP Issues Advice for High-Value Health Care for Diagnostic Imaging for Low Back Pain

Recommendations are first in a series of papers to help physicians and patients identify misused medical treatments and to practice high-value health care

Video available for diagnostic imaging for low back pain*

The American College of Physicians (ACP) has found strong evidence that routine imaging for low back pain with X-ray or advanced imaging methods such as CT scan or MRI does not improve the health of patients.

In "Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care from the American College of Physicians," published in the February 1 issue of Annals of Internal Medicine, ACP recommends that routine or advanced imaging studies should only be performed in selected higher-risk patients who have severe or progressive neurologic deficits, are suspected of having a serious or specific underlying condition, or are candidates for invasive interventions.

"Low back pain is one of the most common reasons for a patient to see a physician and many patients with low back pain receive routine imaging that is not beneficial and may even be harmful," said Amir Qaseem, MD, PhD, MHA, FACP, director of clinical policy for ACP. "Unnecessary imaging can lead to a series of unnecessary additional tests, interventions, follow ups, and referrals that do not improve patient outcomes."

ACP's Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care also states:

ACP's recommendations are based on a systematic review conducted for the Diagnosis and Treatment of Low Back Pain joint clinical practice guideline from ACP and the American Pain Society, and a subsequent meta-analysis.

2. Preserving High-Value, High-Quality Care

In a related paper, "High-Value, Cost-Conscious Health Care: Concepts for Clinicians to Evaluate the Benefits, Harms, and Costs of Medical Interventions," also published in the February 1 issue of Annals, ACP explains the purpose of its Advice for High-Value Health Care series: to slow the unsustainable rate of health care costs while preserving high-value, high-quality care.

"Efforts to control expenditures should not focus solely on the costs, but rather on the value of health-care interventions," said co-author Paul Shekelle, MD, PhD, FACP, chair of ACP's Clinical Guidelines Committee. "The best way to maintain effective and efficient care is to identify and eliminate wasteful practices, and to demonstrate which interventions provide high-value, which means their benefit is sufficient to justify their harms and costs."

The distinction between cost and value (an assessment of whether an intervention provides health benefits, does have acceptable level of harms, and is worth what it costs) is critical, ACP says; high-cost interventions may provide good value because the benefits may be large and therefore justify the harms and costs. Conversely, low-cost interventions may be of little or no value if they provide little benefit.

In the paper, ACP outlines three key concepts necessary for understanding how to assess the value of health-care interventions:

Health benefit can be measured in many ways, including cases detected or averted, life years gained, or quality-adjusted life years gained. For interventions that provide additional benefit at additional cost, ACP recommends assessing their value to patients and society with cost-effectiveness analysis.

3. Black Patients Less Likely Than White Patients to Die After Stroke

Compared to white patients, black patients have a significantly higher risk for stroke. It is commonly believed that blacks have less access to quality care and treatments, resulting in a higher death rate from stroke. However, recent studies suggest that blacks may actually have a better survival rate after stroke than whites. Researchers studied administrative records for 164 New York hospitals to examine racial differences in stroke mortality and to explore the potential reason for these differences. Within those records, the authors identified 5,319 black and 18,340 white patients that were hospitalized for acute ischemic stroke. They found that black patients had a lower in-hospital mortality rate (5.0%) compared to white patients (7.4%). The black patients also had consistently lower 30-day to one-year all-cause mortality than white patients. The researchers found that black patients were more likely to undergo aggressive life-sustaining interventions than white patients. Black patients also had longer hospital stays, higher hospital spending, and lower hospice admission.

4. Increased Hospital Spending Improves Patient Survival Rates

Studies have shown that regions with high Medicare spending do not have better health outcomes. However, few studies have examined the relationship between hospital spending monies spent on inpatient physician visits, hospital room charges, laboratory testing, diagnostic imaging, medication administration, and procedures and inpatient mortality. Researchers reviewed discharge records for 2,545,352 patients hospitalized in 208 California hospitals between 1999 and 2008 with one of six major medical conditions (acute myocardial infarction, CHF, acute stroke, gastrointestinal hemorrhage, hip fracture, and pneumonia) to determine the association between hospital spending and patient mortality. After adjusting for socioeconomic factors and patients who have additional life-threatening conditions, such as AIDS or cancer, the researchers found that as hospital spending increased, the risk of dying in the hospital from the condition that resulted in hospitalization, decreased.

* Satellite Feed Dates, Times, and Coordinates for "Diagnostic Imaging for Low Back Pain" Video News Story

Date: Monday, January 31, 2011
Time: 10:30 AM - 10:45 AM Eastern; 9:30 AM - 9:45 AM Central; 8:30 AM - 8:45 AM Mountain; 7:30 AM - 7:45 AM Pacific
C-Band Satellite: AMC 1
Transponder: 9
Downlink: 3880 (H) Audio: 6.2 & 6.8

Date: Monday, January 31, 2011
Time: 2:00 PM - 2:15 PM Eastern; 1:00 PM - 1:15 PM Central; 12:00 PM - 12:15 PM Mountain; 11:00 AM - 11:15 AM Pacific
C-Band Satellite: AMC 1
Transponder: 9
Downlink: 3880 (H) Audio: 6.2 & 6.8

Date: Tuesday, February 1, 2011
Time: 1:30 PM - 1:45 PM Eastern; 12:30 PM - 12:45 PM Central; 11:30 AM - 11:45 AM Mountain; 10:30 AM - 10:45 AM Pacific
C-Band Satellite: AMC 1
Transponder: 9
Downlink: 3880 (H) Audio: 6.2 & 6.8

This story is available on the Pathfire DMG on the News/Video News Feeds Section at D S Simon Productions
Tab: Medical Story Slug: Low back pain guidelines Story Number: ACP65

To view the video, obtain a copy of press materials or script, or request a hard copy tape, please go to