A Medical Device Daily

The American Pain Society (Glenview, Illinois) last week reported an expansion of its clinical practice guideline on the diagnosis and treatment of chronic low back pain to include recommendations on surgery and other interventional treatments — previewed at symposium at the APS Annual Scientific Meeting.

A key part of the APS guideline reports on a multidisciplinary panel review and analysis of evidence related to diagnosis and treatment of low-back pain with a number of interventional procedures and surgeries.

"Prior to finalizing the guideline, APS conducts extensive peer review, and has sent the guideline to more than 20 experts in surgery, interventional pain medicine, primary care, and other disciplines for comments and feedback," Chou said.

The expanded, evidence-based APS guideline includes some of the following statements and opinions developed by the organization and the experts consulted:

• Invasive diagnostics, such as provocative discography, facet joint block and sacroiliac joint block tests, have not been proven to be accurate for diagnosing various spinal conditions, and their ability to effectively guide therapeutic choices and improve ultimate patient outcomes is uncertain.

• Epidural stenois injections are an option for short-term pain relief for persistent radiculopathy (radiating low back pain caused by a herniated disc). Other interventional therapies, such as local injections, prolotherapy, botulinum toxin (botox) injection, facet joint injection, sacroiliac joint injection, radiofrequency denervation and intradiscal electrothermal therapy are not supported by convincing, consistent evidence of benefits from randomized trials.

• Surgery to treat radiculopathy and spinal stenosis is effective, though the benefits diminish over time.

• Effectiveness of surgery for non-radicular low back pain is less certain, with some studies showing no benefits compared to intensive interdisciplinary rehabilitation. In addition, a significant proportion of patients experience suboptimal outcomes including persistent pain or functional deficits following surgery. The expert panel reaffirmed previous recommendation that all low-back pain patients stay active and talk honestly with their physicians about self care and other interventions.

Recommendations from the first APS Clinical Practice Guideline on Low Back Pain were intended for primary care physicians and appeared in the Oct, 2, 2007, issue of the Annals of Internal Medicine. For diagnosis, the first APS low-back pain guideline advises clinicians to minimize routine use of X-rays or other diagnostic tests except for patients known or believed to have underlying neurological or spinal disorders. It recommended that medications used should be appropriate for the severity of pain and impairment, and clinicians should weigh carefully potential benefits and risks of any drug and explain them.

The APS says that low-back pain is the fifth most common reason for doctor's office visits and that one in four adults report having it last a least a day. It estimates that low-back pain costs more than $26 billion in direct healthcare costs annually in the U.S.

Update on smoking cessation treatments

An updated clinical practice guideline released today by the U.S. Public Health Service has identified new medication treatments and counseling methods that it considers effective for helping people quit smoking. While the guidelines focus on the use of drugs, several of these therapies are also device-related such as the use of drug delivery devices or patches and the telephone.

"Treating Tobacco Use and Dependence: 2008 Update" was developed by a 24-member, private-sector panel of national tobacco treatment experts that reviewed more than 8,700 research articles published between 1975 and 2007. The review found that there are now seven medications approved by the FDA as smoking cessation treatments that "dramatically" increase the success of quitting.

The medications are: bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline.

The 2008 PHS guideline update also found evidence that counseling by itself or especially in conjunction with medication can greatly increase a person's success in quitting.

In particular, quitlines were found to be effective and can reach a large number of people.

Rear Admiral Steven Galson, MD, acting U.S. surgeon general, said, "[W]e now have some of the best evidence-based treatments available for tobacco cessation."

AHRQ Director Carolyn Clancy, MD, said, "The 2008 PHS guideline update reinforces recommendations for making effective treatments available to smokers and other tobacco users."

Tobacco cessation treatments also are highly cost-effective and coverage for these treatments has been seen as improving quit rates.

Ronald Davis, MD, president of the American Medical Association (AMA; Chicago), said, "[W]hat we do with today's recommendations can help to dramatically reduce the estimated 5 million smokers who will die over the next decade if we don't help treat them."

APTA fears effect of cuts on care

Pending cuts to the Medicare physician fee schedule could severely hamper the ability of physical therapists to serve the rehabilitation needs of seniors and people with disabilities, according to the American Physical Therapy Association (APTA; Alexandria, Virginia). The association says that cuts will drive up costs while decreasing the quality of care.

In testimony last week before a hearing of the U.S. House Committee on Small Business, Tom DiAngelis, VP of APTA's Private Practice Section, said that a scheduled 10.6% cut in Medicare physician payments could have "an especially devastating impact on PTs in private practice," faced with the rising costs of running a small business. The hearing on "Medicare Physician Fee Cuts: Can Small Practices Survive?" (Medical Device Daily, May 9, 1008), provided an opportunity for the committee to examine the potential impact of fee cuts, salted to go into effect July 1.

Physical therapists, in particular, are being hit especially hard, according to DiAngelis, given the 10.6% reduction, plus "an arbitrary annual cap of $1,810 per beneficiary on outpatient services," also beginning July 1.

"This cap will not save the Medicare program money," added DiAngelis.