Routine referral for radiography of patients presenting with low back pain: is patients' outcome influenced by GPs' referral for plain radiography?

Kerry S, Hilton S, Patel S, Dundas D, Rink E, Lord J
Record ID 32000000883
Authors' objectives:

A study in general practice to compare short- and long-term outcomes for patients with low back pain who are referred or not referred for lumbar spine X-ray after first presentation.

Authors' results and conclusions: A total of 153 patients were recruited to the RCT, and 506 patients were recruited to the observational study. In the RCT, referral for X-ray led to a small improvement in patient psychological well-being over the next 12 months, but there were no differences in physical outcomes, further consultations or referrals to other health professionals. Patients referred for X-ray have higher costs in the short term than patients who are not, a difference that is almost entirely due to the cost of the X-ray itself. There were no significant differences in costs over a 1-year period. In the observational arm, referral for X-ray was associated with length of episode at presentation, which is an indicator of poor prognosis. Patients referred for X-ray had poorer physical outcomes at 6 weeks and 1 year; however, after adjustments were made for length of episode at presentation, effect sizes were similar to those in the RCT. In the observational arm, patients referred for X-ray had higher costs, both in the short term and in the long term. The poorer prognosis of patients referred for X-ray probably explains these differences. While the study may have less internal validity than a fully randomised study of the same size, the consistency of the findings from the RCT and the observational arm support the generalisability of the results to a wider population.
Authors' recomendations: There are few significant differences at 6 weeks or 1 year between patients who are referred for lumbar spine X-ray and those who are not. Patients who are referred appear to be in better mental health as measured within the SF-36 quality of life measure. Implications for healthcare: - Existing guidelines are sound. Early X-ray is not indicated, although it might still be considered when patient anxiety is a major feature. - This reinforces the message that the benefit from early X-ray is negligible and that the X-ray dose is high. - NHS costs at 6 weeks are higher among those referred for X-ray. - This study suggests that there is little evidence that early X-ray referral leads to less morbidity reflected in time off work.
Authors' methods: Randomised controlled trial
Project Status: Completed
URL for project:
Year Published: 2000
English language abstract: An English language summary is available
Publication Type: Not Assigned
Country: England, United Kingdom
MeSH Terms
  • Back Pain
  • Physicians, Family
  • Primary Health Care
  • Radiation
Organisation Name: NIHR Health Technology Assessment programme
Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK
Contact Name:
Contact Email:
Copyright: 2009 Queen's Printer and Controller of HMSO
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