The Health Ministry is trying to reduce the number of patients with backaches referred for computed tomography (CT ) scans in order to identify the source of the pain. According to the recommendation, which relied on a recently published medical study, the risks of radiation exposure entailed in the scans might be higher than the benefits of diagnosis they offer.
According to the new policy coming into place, the ministry asks physicians to to refrain from referring patients to CTs if they have been suffering lower back pain for less than six weeks; instead, they are requested to refer them to physiotherapy. The exception would be cases of patients with acute symptoms that would indicate the need for an immediate CT.
The National Council for Community Health, which advises the Health Ministry, considered the subject of reducing the scans lately, in response to the request of the ministry's director general, Prof. Ronni Gamzu. This followed the publication, in the May 26, 2011, issue of the British Medical Journal, of an article that suggested five medical activities that should be reduced. That article in turn was based on a poll among the U.S.-based National Physicians Alliance, which asked its 22,000 members to propose ways to reduce expenses in their country's health system without harming the quality and safety of patients' treatment. Other NPA recommendations included refraining from habitual prescription of antibiotics to patients suffering from sinusitis; holding off on complex diagnostic heart examinations among patients with a low risk of heart disease; avoiding Pap smear screening of patients under 21; and refraining from using DXA (dual-emission X-ray absorptiometry ), for detection of osteoporosis among women under the age of 65, and men under 70, who are not at risk.
Gamzo instructed the council to discuss, at this point, the implementation of only the first recommendation. The trend in the West to reduce CT testing began several years, as part of the effort both to reduce patients' exposure to radiation, and to lower reduce costs. Two studies published in December 2009 in the Archives of Internal Medicine revealed that CT scans increase cancer risks more than previously thought. According to one of the studies, in 2007 72 million CT tests were carried out in the U.S., and despite the assumption that the amount of radiation exposure was negligible, the study revealed that 20 percent of the patients were exposed to medium levels of radiation (3-20 millisieverts ), and in 2 percent of the cases - 1.4 million - exposed to high levels (20-50 mSv ).
This led to the prediction that 29,000 Americans would develop cancer within 20-30 years as a consequence of the tests, with a mortality rate of 50 percent among them. The second study revealed significant gaps - by a factor as high as 13 - in the radiation exposure rates from different machines. The standard set by the U.S. Food and Drug Administration allows for levels of 1-10 mSv, which raises the risk of deadly cancer to 1 out of 2000 patients.
A poll carried out among Israeli doctors showed that while most general practitioners (89% ) would not recommend CT tests for simple lower back pain, most orthopedists would. In general, the number of CT scans ordered in Israel is relatively high, and it is assumed that many physicians request them as part of "defensive medicine," intended to stave off malpractice suits.
Some of those doctors participating in the national council discussion claimed reducing CT scans for back pain would make it more difficult to diagnose signs indicating tumors, whiled others claimed that administering the tests in itself often serves to lower anxiety among patients suffering from severe lower back pain. An alternative view expressed was that CT results often are clinically meaningless, and that the test could constitute unnecessary treatment. Other participants expressed their support for adopting the NPA recommendation calling for reduced use of DXA testing, which exposes patients to radiation levels four times higher than that of CTs.
Dr. Amnon Lahad, a family medicine practitioner and the chair of the council, told Haaretz that "the recommendation was accepted by the council, but isn't a sweepign recommendation. One shouldn't avoid CTs altogether, but rather reduce the number of referrals. A CT test is necessary mostly when a severe backache is accompanied by weakness in the limbs, which might indicate neurological damage, or by other signs that might indicate cancer such as fever and loss of weight."
The Health Ministry is expected to follow up with new guidelines for GPs and orthopedists.
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