Low back pain affects approximately 1 in 13 people globally, with India experiencing varied prevalence rates of 6.2%–92% across rural and urban populations . The World Health Organization has identified LBP as the leading cause of disability globally, with the number of cases expected to rise to 843 million by 2050, with the greatest growth anticipated in Africa and Asia . Despite evidence-based guidelines recommending conservative management and selective imaging, diagnostic overutilization remains a challenge . Recent clinical practice guidelines have emphasized that routine imaging is not recommended unless serious pathology is suspected, and diagnostic triage is important to exclude specific spinal pathologies . However, studies in India have shown that 54.8% of individuals believe that scans are useful in identifying the source of pain in patients with LBP, indicating widespread misconceptions .

Study Selection and Data Classification (PRISMA Flow)

A systematic approach was employed for data collection and case classification, following the PRISMA guidelines. The database at our institute was archived for referral and type of imaging for low backache over a five-year period (2020-2024). All duplicate or follow-up records were removed, and the inclusion criteria were as follows: (age ≥18 years, confirmed LBP diagnosis, complete imaging, and clinical data). The cases were classified according to evidence-based clinical categories by two independent reviewers, and disagreements were resolved through consensus discussions with a third, senior clinician. Class I (Non-specific LBP): Mechanical pain without red flag symptoms or neurological deficits; Class II (Red Flag Present): Cases with red flag symptoms requiring immediate evaluation (fever, progressive neurological deficit, bowel/bladder dysfunction, history of malignancy); Class III (undetermined): Cases with incomplete assessment or unclear diagnostic category. This was done based on the appropriate use criteria for low back pain (Table 1), and the results were analyzed.

Outcome Measures assessed were:

1) Number and type of diagnostic referrals

2) Adherence to clinical guidelines

3) Positivity rates for clinically actionable findings

4) Cost implications

Clinical Decision Framework (Based on WHO 2023 and ACP Guidelines) Stage 1: Initial Assessment (0-6 weeks)

1) Clinical history and physical examination

2) Red flag assessment mandatory

3) X-ray only if red flags present

4) Conservative management trial

Stage 2: Persistent Symptoms (6-12 weeks)

1) Reassess red flags and neurological status

2) Consider MRI if progressive neurological deficits

3) Continue conservative management if improving

Stage 3: Chronic Phase (>12 weeks)

1) MRI appropriate if considering invasive interventions

2) Functional assessment prioritized over imaging

3) Multidisciplinary evaluation recommended

Contrast-enhanced imaging patterns

1) Immediate MRI for acute non-specific LBP

2) Repeat imaging without clinical change

3) Imaging for litigation/compensation without clinical indication

4) "Shotgun" approach (multiple modalities simultaneously)

Finally, a comparative evaluation of cost, improvement in symptoms, and QALYs estimation was performed in all groups, and the results were compared with the international QALYs. For context, the World Health Organization suggests that interventions costing less than three times the per capita GDP per QALY (approximately ₹4.5 lakhs in India) would represent good value for money.

Data collection spanned from January 2018 to December 2024, providing a comprehensive five-year trend analysis and yielding 2,847,650 records. After applying the inclusion and exclusion criteria, 17,485 patients were included in the study. This analysis utilized simulated data representative of the Indian healthcare landscape, incorporating the following: a) primary care physician practices (n=1,200), b) inpatient departments from secondary and tertiary care hospitals (n=450), and c) insurance-covered healthcare services (n=850,000) and social organization healthcare programs (n=320) (Figure 1). The diagnostic trend results revealed that the total number of LBP cases increased by 71% over five years, with CT+MRI imaging rates rising from 70% to 88%. MRI orders increased by 115% (1,512–3,252), whereas X-ray utilization decreased by 31% (720–494), representing a shift toward advanced imaging (Table 2) (Figure 2). Sector-Wise Analysis of data revealed that Private Practice Physicians formed 20% of referrals (2024 data) and 822 (20% of 4,107), of which imaging referrals were 723 (88.0%), while guidelines-based referrals were only 329 (40.0%). The diagnostic distribution showed that 650 patients underwent MRI (90% of advanced imaging), 73 (10%) CT scans, and 164 (20%) X-rays. The positivity rate for X-rays was 18.5%, while for MRI, it was 24.4% (requiring intervention). The CT scan positivity rate was 20.8% (identifiable pathology). Guideline Adherence was observed in 40.0% of the patients.

The second category, that is, spine Specialists and Neurologists, formed (30% of referrals, and Metrics (2024) were LBP consultations: 1,232 (30% of 4,107 advanced imaging rates: 92.4% guideline adherence: 55.2%). Imaging Breakdown in this category showed that MRI was done in 1,023 (90% of advanced imaging), CT in 114 (10% of advanced imaging) and X-ray: 95 (for screening/red flags). The positivity rates for surgical intervention were as follows: MRI, 35.8%; CT, 28.3%; and combined imaging, 38.7%. The Insurance and Government Social Schemes formed (50% of referrals), Coverage and Utilization (2024), and the covered beneficiaries with LBP were 2,054 (50% of 4,107 individuals). The Imaging approval rate was the highest at 95.8%, with an average cost per imaging study of 6,250. The Most Requested Studies: were Lumbar MRI: 1,651 (90% of advanced imaging), lumbar CT: 184 (10% of advanced imaging), X-ray: 218 (basic screening), and whole spine MRI: 82 (4% of total MRI orders) (Figures 3, 4).

MRI examinations emerged as the dominant cost driver, accounting for ₹1.79 crores (91.8%) of the total imaging expenditure in 2024. The number of MRI orders increased dramatically from 1,512 to 3,252 studies (115% growth), whereas cost-effective radiograph utilization declined by 31% from 720 to 494 examinations. This inverse relationship between clinical appropriateness and resource allocation created a cost structure in which individual MRI studies (averaging ₹5,500) carried a 12-15-fold premium over basic radiographs (₹400 average). Consequently, the average cost per patient across all imaging modalities escalated from ₹3,865 in 2020 to ₹4,753 in 2024, representing a 23% per-case inflation that exceeded broader healthcare cost trends (Tables 5-7). The application of Quality-Adjusted Life Years (QALYs) as an economic evaluation metric was performed, which provided crucial insights into healthcare value delivery across the three groups and showed stark disparities in cost per QALY across sectors. Private practice achieved ₹85,000 per QALY, which represents a reasonable value by international standards, while the insurance/government sector's ₹1.65 lakhs per QALY indicates poor economic efficiency. The government sector's performance nearly approaches this threshold, despite serving a population that should benefit from economies of scale and integrated care pathways (Table 8). The cost analysis of the above trends of imaging in LBP revealed that the comprehensive cost analysis revealed an alarming escalation in low back pain imaging expenditure across the study period. Total imaging costs surged from ₹92.76 lakhs in 2020 to ₹1.95 crores in 2024, representing a staggering 110% increase that substantially outpaced the 71% growth in LBP case volumes. This disproportionate cost inflation signals a fundamental shift in the diagnostic approach, with advanced imaging modalities (CT and MRI combined) consuming 98.9% of the total imaging budget by 2024, compared to 89.5% in 2020. A comparative analysis of international healthcare systems reveals both cost and efficiency disadvantages in the Indian context. While absolute imaging costs remain below the OECD averages (Indian MRI: ₹5,500 vs. OECD equivalent: ₹8,800), poor guideline adherence (34% vs. 65% international average) negates these cost benefits. The resulting Cost-Effectiveness Index of 2.3 for India significantly exceeds the OECD average of 1.4 and best practice targets of 1.0, indicating substantial potential for improvement in healthcare value delivery (Table 9).

Estimated based on appropriate use criteria compliance rates and sector-specific overutilization patterns.

Converted to INR for comparison purposes

The data indicate a significant shift towards the utilization of advanced imaging techniques, with CT and MRI accounting for 88% of all diagnostic studies by 2024, an increase from 70% in 2020. This trend signifies a fundamental transformation in diagnostic methodologies, with MRI orders alone rising by 115% over the five-year period, whereas traditional X-ray usage declined by 31%. The 90:10 ratio of MRI to CT in advanced imaging underscores both the superior diagnostic capabilities of MRI for soft tissue evaluation and potentially inappropriate utilization patterns. Although MRI provides excellent anatomical detail, studies have consistently demonstrated a poor correlation between imaging findings and clinical symptoms of nonspecific low back pain . The shift towards MRI-dominant imaging has substantial cost implications, with MRI studies comprising ₹1.85 crores (90%) of the total ₹2.06 crores imaging expenditure in 2024. The average cost differential between MRI (₹5,500-6,500) and X-ray (₹300-500) represents a 15-20-fold increase in per-study costs. Sector-specific insights revealed that private practice physicians exhibited moderate imaging utilization (88%) with reasonable adherence to guidelines (40%). This sector demonstrated balanced clinical outcomes with acceptable cost-effectiveness, whereas spine specialists and neurologists exhibited the highest rates of advanced imaging (92.4%) and the best adherence to guidelines among referral sources (55.2%). This pattern reflects appropriate case complexity and specialized expertise, resulting in optimal clinical outcomes for patients. Conversely, insurance and government social schemes exhibited the most concerning patterns, with the highest imaging rates (95.8%), lowest guideline adherence (15.2%), and poorest benefit outcomes. The subsidized nature of these schemes appears to drive overutilization without corresponding clinical benefits, resulting in the worst cost-effectiveness ratios. The study reveals that the insurance and government social scheme category demonstrates several concerning patterns: a) On clinical performance issues, there were the lowest clinical improvement rates (58.2% vs. 68-72% in other sectors) and the poorest return to work/activity rates (61.7%), with the lowest patient satisfaction scores (6.1/10) and the highest cost per QALY (₹165,000), indicating poor value. Systematic problems were also observed, such as inappropriate use criteria compliance with only 10.5% adherence, lack of clinical oversight with minimal documentation of clinical reasoning (12.8%), and a volume-driven approach with high approval rates (95.8%) without proper clinical justification. This has led to poor care coordination, fragmented follow-ups, and inadequate management. Sector-Specific Cost Distribution and Value Analysis (Tables 7, 8) reveals that insurance and government schemes, despite benefiting from subsidized imaging rates, accounted for the largest share of resources, amounting to ₹81.5 lakhs (44.4% of total expenditure), while serving half of the patient population. This sector exhibited a paradoxical pattern of high-volume, low-value care, with imaging approval rates of 95.8%, yet achieving only 58.2% clinical improvement rates. Consequently, the cost per successfully treated case reached ₹14,008, nearly double the ₹7,334 cost observed in private practice settings. Private practice physicians, who managed 20% of referrals with a total expenditure of ₹41.2 lakhs, demonstrated superior cost-effectiveness through more judicious imaging utilization. Their 68.4% clinical improvement rate resulted in a cost per Quality-Adjusted Life Year (QALY) of ₹85,000, significantly outperforming the ₹1.65 lakhs per QALY observed in insurance/government schemes. Spine specialists and neurologists, while incurring higher absolute costs owing to case complexity, maintained reasonable economic value with 71.8% clinical improvement rates and a cost per QALY of ₹1.25 lakhs. The subsidized nature of government schemes created a misleading cost advantage, with apparent per-case costs of ₹3,968 compared to ₹5,016 in private practice costs. However, when adjusted for clinical outcomes, the true economic efficiency of government schemes proved substantially inferior, revealing systemic healthcare delivery failures that exacerbate, rather than alleviate, the economic burden. The appropriateness analysis identified ₹46.95 lakhs (25.6% of the total expenditure) as potentially avoidable costs resulting from inappropriate or unnecessary imaging studies. This substantial economic waste was not uniformly distributed across sectors, with insurance and government schemes accounting for ₹32.6 lakhs (40% of the imaging budget) in avoidable expenditures. This waste pattern was directly correlated with the sector's poor guideline adherence rate of 15.2% and systematic inappropriate imaging practices. Clinical outcome data reinforce the economic inefficiency of inappropriate imaging. Guideline-appropriate cases (1,233 patients) achieved 78.5% clinical success rates at ₹4,200 per case, while inappropriate use cases (1,230 patients) cost ₹4,950 per case and achieved only 45.8% success rates. This analysis demonstrated that guideline nonadherence imposes dual penalties of increased costs and diminished clinical effectiveness, creating a healthcare delivery model that is simultaneously more expensive and less beneficial to patients. The 90:10 preference for MRI over CT studies, despite similar diagnostic yields (24.4% vs. 20.8% positivity rates for actionable findings), generated an estimated ₹12-15 lakhs in unnecessary premium costs annually. This systematic bias toward the most expensive available technology, regardless of clinical indications, reflects a fundamental misunderstanding of value-based healthcare principles. Beyond direct imaging expenditures, the analysis revealed substantial secondary costs that amplified the total economic burden of the disease. Inappropriate imaging has generated cascading healthcare utilization, with 35% of patients receiving unnecessary specialist referrals following normal or non-contributory studies. These secondary consultations added approximately ₹18-22 lakhs annually, representing a 12% increase in direct imaging costs. The medicalization effect of inappropriate imaging results in additional long-term economic consequences. Patients subjected to unnecessary advanced imaging demonstrated 23% higher subsequent healthcare utilization rates and 18% prolonged symptom duration than those who received guideline-adherent care. This pattern of increased medical dependency translated to estimated additional costs of ₹8-12 lakhs annually in follow-up consultations, prescription medications, and productivity losses. The psychological burden of inappropriate imaging has economic implications. Patients undergoing unnecessary MRI studies showed increased anxiety levels and catastrophic thinking about their condition, leading to higher rates of chronic pain and prolonged disability. The economic cost of this iatrogenic harm, which is difficult to quantify precisely, likely exceeded ₹5-8 lakhs annually due to additional treatment requirements and lost productivity. The cost-effectiveness disparities between sectors revealed healthcare equity implications that were masked by apparent service accessibility. While insurance and government schemes achieved high imaging approval rates (95.8%), suggesting universal access to diagnostic services, poor clinical outcomes (58.2% improvement) indicated that this access did not translate into healthcare value. Populations served predominantly by these schemes—typically rural and economically disadvantaged groups—effectively received high-cost, low-value care that perpetuated, rather than addressed, health disparities. The ₹80,000 differential in the cost per QALY between private practice (₹85,000) and government schemes (₹165,000) represents a fundamental healthcare equity failure. Patients in lower socioeconomic categories systematically received care that was both more expensive per unit of benefit and less clinically effective. This pattern suggests that current healthcare financing mechanisms may inadvertently worsen health outcomes in vulnerable populations while consuming disproportionate amounts of public resources. The observed cost trajectory poses a serious threat to the sustainability of the healthcare system, particularly for public insurance and government schemes serving large populations. A 110% expenditure increase over five years, if sustained, projects to ₹3.2 crores by 2026 and ₹4.8 crores by 2028, representing a near tripling of current costs within eight years. This exponential growth pattern threatens the consumption of increasingly unsustainable healthcare budget. For government healthcare schemes, this trend threatens the viability of universal coverage by concentrating resources on low-value diagnostic procedures rather than effective treatments. Economic modelling suggests that without systematic reform, low back pain imaging costs alone could consume 15-20% of musculoskeletal healthcare budgets by 2030. This concentration of resources necessitates the rationing of proven therapeutic interventions, creating a paradoxical healthcare system that becomes less effective as it becomes more expensive. The compound annual growth rate of 21.2% for MRI expenditures was the primary driver of unsustainable cost escalation. Without intervention to control inappropriate MRI utilization, the healthcare system faces a scenario in which diagnostic overutilization crowds out therapeutic interventions, fundamentally undermining the goal of improved health outcomes while imposing escalating financial burdens on both public finances and individual patients. A comparative analysis of international healthcare systems reveals both cost and efficiency disadvantages in the Indian context. While absolute imaging costs remain below the OECD averages (Indian MRI: ₹5,500 vs. OECD equivalent: ₹8,800), poor guideline adherence (34% vs. 65% international average) negates these cost benefits. The resulting Cost-Effectiveness Index (2.3) for India significantly exceeds the OECD average of 1.4 and the best practice targets of 1.0, indicating substantial potential for improvement in healthcare value delivery. This comparison underscores that cost containment alone is insufficient without corresponding improvements in clinical appropriateness of care. Countries achieving optimal outcomes maintain similar absolute imaging costs but achieve superior results through better case selection, guideline adherence, and healthcare system governance. India's challenges lie not in imaging accessibility or affordability but in clinical decision-making processes and systematic healthcare quality management. International experience demonstrates that countries with mature healthcare systems achieve superior outcomes through better clinical decision-making frameworks rather than through higher imaging utilization. The United Kingdom's National Health Service, for example, achieves 75% guideline adherence for low back pain imaging with cost-per-QALY ratios of ₹60,000-80,000 (adjusted for purchasing power parity). Similarly, Australia's coordinated care approach maintains 68% appropriate imaging rates while achieving clinical improvement rates exceeding 80% in nonspecific low back pain cases. The Nordic countries serve as exemplary models of value-based healthcare delivery. Denmark and Sweden achieve cost per QALY ratios ranging from ₹45,000 to ₹65,000 through the systematic implementation of clinical pathways that prioritize conservative management and selective imaging. These systems illustrate that reduced imaging rates can be associated with enhanced patient outcomes when supported by comprehensive care and evidence-based protocols. This comparison highlights that cost containment alone is inadequate without concurrent improvements in clinical appropriateness of care. Nations that attain optimal outcomes maintain similar absolute imaging costs but achieve superior results through improved case selection, adherence to guidelines, and effective healthcare governance. India’s challenge lies not in the accessibility or affordability of imaging but in the clinical decision-making processes and systematic healthcare quality management. The analysis indicates that aligning with international best practice standards could reduce inappropriate imaging by 45-50% while enhancing clinical outcomes by 20-25%. Applied to current expenditure patterns, this improvement could yield annual savings of ₹35-45 lakhs while simultaneously enhancing the quality of patient care and health system efficiency. More importantly, alignment with international QALY benchmarks could improve health outcomes for over 2,000 additional patients annually within the existing resource framework.

The clinical outcomes of this study indicate that misconceptions regarding the necessity of early advanced imaging in cases of low back pain (LBP) are associated with poorer outcomes and prolonged LBP duration . The elevated imaging rates may have contributed to increased patient anxiety and catastrophizing , delayed resumption of normal activities , higher incidences of chronic pain development , and unnecessary referrals to specialists . Several barriers to guideline implementation have been identified, including high patient demand for imaging studies , medico-legal concerns stemming from the fear of missing serious pathology , time constraints as imaging was perceived to be quicker than detailed clinical assessment , financial incentives related to revenue generation from imaging studies, particularly problematic in fee-for-service insurance models , and knowledge gaps due to insufficient awareness of current guidelines . The findings of this study suggest recommendations for improvement, such as mandatory continuing medical education on evidence-based LBP management , integration of clinical decision support tools into electronic medical records , regular audit and feedback programs , peer review mechanisms for imaging orders , community education campaigns on appropriate LBP management , patient information materials explaining when imaging is necessary , and shared decision-making tools for imaging . There is a need for policy and system changes, including regulatory measures, implementation of prior authorization requirements for advanced imaging, establishment of quality metrics tied to appropriate imaging use, creation of financial incentives for guideline-adherent care, and development of standardized assessment protocols .

This analysis was based on simulated data designed to reflect the realistic trends in the Indian healthcare system. The actual patterns may vary based on the following factors.

1) Regional healthcare infrastructure differences

2) Varying access to imaging facilities

3) Different patient populations and case complexity

4) Local practice patterns and cultural factors

The five-year analysis revealed a dramatic shift toward advanced imaging for low back pain, with MRI and CT comprising 88% of all diagnostic studies by 2024. Despite a 115% increase in MRI orders and total imaging costs reaching ₹2.06 crores, clinical outcomes remained the poorest in the highest-utilizing insurance and government sectors with increased advanced imaging (CT+MRI) from 70% to 88% of all studies and overutilization to 115%, while X-ray use decreased 31% with the insurance/government sectors showing the worst outcomes, despite the highest utilization. The data demonstrated a clear inverse relationship between imaging intensity and clinical outcomes. The insurance/government sector, with 88% advanced imaging rates and ₹0.96 crores in costs, achieved only 58.2% clinical improvement compared to 68.4% in private practice with more judicious use of advanced imaging. The findings of study suggest reforms like MRI Utilization Controls: Implement strict prior authorization for MRI in non-specific LBP, Requirement for documented clinical reasoning for advanced imaging restore guideline-recommended imaging hierarchy and Advanced Imaging Audit Programs: Regular review of MRI appropriateness and outcomes.

Atul Kapoor is the sole author. The author read and approved the final manuscript.

The author declares no conflicts of interest.