ChiroACCESS Article



Medical Physicians Ignore Low Back Pain Guidelines



This information is provided to you for use in conjunction with your clinical judgment and the specific needs of the patient.

ChiroACCESS Editorial Staff

  

ChiroACCESS



Published on

February 10, 2010

Text Size:   (-) Decrease the text size for the main body of this article    (+) Increase the text size for the main body of this article
Share this:  Add to TwitterAdd to DiggAdd to del.icio.usAdd to FacebookAdd to GoogleAdd to LinkedInAdd to MixxAdd to MySpaceAdd to NewsvineAdd to RedditAdd to StumbleUponAdd to Yahoo

A February 2010 study of 3,533 general practice low back pain patients found that many providers are not following their own evidence based guidelines.A February 2010 study of 3,533 general practice low back pain patients found that many providers are not following their own evidence based guidelines.  Guidelines do provide the overall best evidence but are not meant to be a cookbook approach to care.  There is also a need for flexibility so the physician can deviate from guidelines when the specific needs and desires of the patient dictate.  In addition, the clinical judgment of the physician may override the guidelines when in a particular patient’s case they are inappropriate.  There is, however, reason for concern when risky and or expensive unneeded procedures are used.  The medical guideline for acute low back pain call for advice and analgesics, but 80% of the 3,533 patients in this study were not given advice and 82% were not given analgesics.  More harmful medications that are not recommended in the guidelines were prescribed, with 37% getting anti-inflammatory drugs and ~20% opioids.

Other research suggests similar problems with medical care for chronic low back pain. “Current treatment patterns are consistent with overutilization of some medications and treatments, and underutilization of exercise and depression treatment.”  A brief review of the contemporary research documenting the inadequacy of overall medical training for musculoskeletal conditions was published earlier.

Medical Training Related to Musculoskeletal Conditions is Inadequate.


Low back pain and best practice care: a survey of general practice physicians.

Arch Intern Med. 2010 Feb 8;170(3):271-7.

Williams CM, Maher CG, Hancock MJ, McAuley JH, McLachlan AJ, Britt H, Fahridin S, Harrison C, Latimer J.
MAppSc, Musculoskeletal Division, The George Institute for International Health, PO Box M201, Missenden Road, Camperdown, NSW 2000, Australia. cwilliams@george.org.au.

BACKGROUND: Acute low back pain (LBP) is primarily managed in general practice. We aimed to describe the usual care provided by general practitioners (GPs) and to compare this with recommendations of best practice in international evidence-based guidelines for the management of acute LBP.

METHODS: Care provided in 3533 patient visits to GPs for a new episode of LBP was mapped to key recommendations in treatment guidelines. The proportion of patient encounters in which care arranged by a GP aligned with these key recommendations was determined for the period 2005 through 2008 and separately for the period before the release of the local guideline in 2004 (2001-2004).

RESULTS: Although guidelines discourage the use of imaging, over one-quarter of patients were referred for imaging. Guidelines recommend that initial care should focus on advice and simple analgesics, yet only 20.5% and 17.7% of patients received these treatments, respectively. Instead, the analgesics provided were typically nonsteroidal anti-inflammatory drugs (37.4%) and opioids (19.6%). This pattern of care was the same in the periods before and after the release of the local guideline.

CONCLUSIONS: The usual care provided by GPs for LBP does not match the care endorsed in international evidence-based guidelines and may not provide the best outcomes for patients. This situation has not improved over time. The unendorsed care may contribute to the high costs of managing LBP, and some aspects of the care provided carry a higher risk of adverse effects.

A long way to go: practice patterns and evidence in chronic low back pain care.

Spine (Phila Pa 1976). 2009 Apr 1;34(7):718-24.

Carey TS, Freburger JK, Holmes GM, Castel L, Darter J, Agans R, Kalsbeek W, Jackman A.
Cecil G. Sheps Center for Health Services Research, University of North Carolina, 725 Airport Road, Chapel Hill, NC 27599-7590, USA. carey@mail.schsr.unc.edu

STUDY DESIGN: A cross-sectional, telephone survey of a representative sample of North Carolina households in 2006.

OBJECTIVE: The primary objectives of these analyses were to describe health care use (providers, medications, treatments, diagnostic tests) for chronic low back pain (LBP) and relate current patterns of use to current best evidence for care of the condition.

SUMMARY OF BACKGROUND DATA: Chronic LBP is common and expensive. Prior research on care utilization often was derived from medical claims databases, reflecting reimbursed health care use, often by one payer.

METHODS: Five thousand three hundred fifty-seven households were contacted in 2006 to identify 732 noninstitutionalized adults 21 years and older with chronic LBP. Five hundred ninety individuals sought care. Patient reported health care utilization, comparison with efficacy was demonstrated by current systematic reviews.

RESULTS: Individuals with chronic back pain were middle-aged (mean age 53 years), and the majority were women (62%). Provider and treatment use was common and varied. Sixty percent used narcotics in the previous month. The mean number of provider visits was 21, and over one-third had an advanced imaging procedure in the past year. Physical treatments were common, and often not supported by evidence. Only 3% had engaged in a formal spine rehabilitation program. Half of patients not taking antidepressants were positive on a 2-item depression screen. Although this study was population-based, it was conducted in only one state.

CONCLUSION: Provider and treatment use for chronic LBP are both very common and varied. Current treatment patterns are consistent with overutilization of some medications and treatments, and underutilization of exercise and depression treatment.

Understanding primary care physicians' treatment of chronic low back pain: the role of physician and practice factors.

Pain Med. 2009 Oct;10(7):1270-9.

Phelan SM, van Ryn M, Wall M, Burgess D.
Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center, Minneapolis, MN 55417, USA. phel0085@umn.edu

BACKGROUND: An increasing number of Operation Iraqi Freedom/Operation Enduring Freedom veterans experience chronic pain. Despite treatment guidelines, there is wide variation in physicians' approaches to pain treatment, and many physicians are unsure of the best treatment approach. Research has examined factors associated with opioid prescribing, but there is little information on physician characteristics that predict patterns of clinical responses to pain.

OBJECTIVES: To identify patterns in primary care physicians' treatment decisions for nonmalignant chronic pain, and identify physician and practice characteristics that predict treatment decision patterns.

METHODS: A national sample of 381 primary care physicians who responded to a mailed vignette involving a veteran with chronic low back pain (LBP) were categorized into latent classes by clinical actions taken to treat the pain. The associations between newly derived treatment patterns and physician and practice characteristics were examined with multivariate models.

RESULTS: Latent class analysis identified three treatment approaches: 1) Multimodal/Aggressive (14%); 2) Low Action (38%); and 3) Psychosocial/Non-Opioid (48%). In a multivariate model, treatment pattern was associated with demographic and personality factors; opioid-related attitudes, beliefs, and concerns; perceptions of the patient; availability of resources; and practice characteristics.

CONCLUSIONS: There may be distinct patterns in primary care physicians' responses to patients with chronic pain. Relatively few physicians use the multimodal approach endorsed by proponents of the biopsychosocial model of pain treatment. Several physician and practice characteristics predict patterns of clinical action.

Doctors with a special interest in back pain have poorer knowledge about how to treat back pain.

Spine (Phila Pa 1976). 2009 May 15;34(11):1218-26; discussion 1227.

Buchbinder R, Staples M, Jolley D.
Department of Clinical Epidemiology, Cabrini Hospital, Melbourne, Australia. rachelle.buchbinder@med.monash.edu.au

STUDY DESIGN: We conducted an observational study using mailed questionnaires to 3 random samples of general practitioners from Victoria and New South Wales, Australia in 1997, 2000, and 2004.

OBJECTIVE: To determine whether general practitioners' beliefs about low back pain (LBP) differ according to whether they have a special interest in back pain, musculoskeletal, or occupational medicine; and whether these beliefs are modified by having had continuing medical education (CME) about back pain in the previous 2 years.

SUMMARY OF BACKGROUND DATA: Physician surveys continue to demonstrate that general practitioners only partially manage LBP in an evidence-based way. Identified barriers to changing physician behavior, in regard to management of back pain, have included patient factors such as their past back pain experiences and preferences for care as well as physician beliefs about the association of pain and activity; although the influence of physician special interests has not been studied.

METHODS: Back pain beliefs of different subsets (special interests vs. no special interests and CME vs. no CME) were compared using relative risks (RRs) adjusted for state and survey. The analysis was then repeated including all special interests and recent back pain CME in the model.

RESULTS: Responses were received from 3831 general practitioners (overall response rate [RR]: 38.2%). Physicians with a special interest in LBP were more likely to believe that complete bed rest and avoidance of work is appropriate for acute low back pain (RR: 1.89 [95% CI: 1.53-2.33] and 1.55 [95% CI: 1.31-1.83], respectively) and lumbar spine radiographs are useful (RR: 1.36 [95% CI: 1.21-1.51]). The disparity between those with and without a special interest in LBP was still evident after adjusting for the presence of other special interests and recent CME. After adjusting for the presence of other special interests and recent CME, there were no important differences in back pain beliefs between those with and without a special interest in musculoskeletal medicine, while those with a special interest in occupational medicine and those who had received recent CME had better beliefs.

CONCLUSION: A special interest in back pain is associated with back pain management beliefs contrary to the best available evidence. This has serious implications for management of back pain in the community.

Patient race and physicians' decisions to prescribe opioids for chronic low back pain.

Soc Sci Med. 2008 Dec;67(11):1852-60. Epub 2008 Oct 15.

Burgess DJ, Crowley-Matoka M, Phelan S, Dovidio JF, Kerns R, Roth C, Saha S, van Ryn M.
Center for Chronic Disease Outcomes Research, VA Medical Center, Minneapolis, MN 55419, USA. diana.burgess@med.va.gov

Nonwhite patients are less likely than white patients to have their pain adequately treated. This study examined the influence of patient race and patient verbal and nonverbal behavior on primary care physicians' treatment decisions for chronic low back pain in men. We randomly assigned physicians to receive a paper-based, clinical vignette of a chronic pain patient that differed in terms of patient race (white vs. black), verbal behavior ("challenging" vs. "non-challenging"), and nonverbal behavior (confident vs. dejected vs. angry). We employed a between-subjects factorial design and surveyed primary care physicians (N=382), randomly selected from the American Medical Association Physician Masterfile. The primary dependent measure was the physician's decision as to whether (s)he would switch the patient to a higher dose or stronger type of opioid. Logistic regression was used to determine the effects of patient characteristics on physicians' prescribing decisions. There was a significant interaction between patient verbal behavior and patient race on physicians' decisions to prescribe opioids. Among black patients, physicians were significantly more likely to state that they would switch to a higher dose or stronger opioid for patients exhibiting "challenging" behaviors (e.g., demanding a specific narcotic, exhibiting anger) compared to those exhibiting "non-challenging" behaviors (55.1%). For white patients there was an opposite pattern of results in which physicians were slightly more likely to escalate treatment for patients exhibiting "non-challenging" (64.3%) vs. "challenging" (54.5%) verbal behaviors. Results point to the need for better understanding of the way a complex interplay of non-clinical characteristics affects physician behavior in order to improve quality of pain management and other clinical decision-making.
Share this:  Add to TwitterAdd to DiggAdd to del.icio.usAdd to FacebookAdd to GoogleAdd to LinkedInAdd to MixxAdd to MySpaceAdd to NewsvineAdd to RedditAdd to StumbleUponAdd to Yahoo