Unaware of Best Practices for Low Back Pain Management? You're Not Alone
Abstract & Commentary
By Rahul Gupta, MD, MPH, FACP, Clinical Assistant Professor, West Virginia University School of Medicine, Charleston, WV. Dr. Gupta reports no financial relationship to this field of study.
Synopsis: For low back pain management, the usual care recommended by general practitioners does not follow evidence-based guidelines and does not provide best outcomes; this has not improved over time.
Source: Williams CM, et al. Low back pain and best practice care: A survey of general practice physicians. Arch Intern Med 2010;170:271-277.
Low back pain (LBP) is one of the most common reasons for a visit to the general practitioner (GP) or primary care physician in the United States. At any one time, about 15% of adults have LBP. Most episodes of LBP improve after a couple of weeks and most individuals will return to work within 1 week, with 90% returning within 2 months. Initial imaging is usually not recommended. However, with increasing duration of pain and disability, the outcome gets worse. After 6 months sick leave, fewer than 50% will return to work, and after 2 years of absence, there is little chance of returning to work at all.1 Of those improved, many patients have a recurrent course. It is vital that evidence-based practice guidelines be available and properly utilized by GPs and other primary care physicians since they are the first to be called upon in a majority of such instances.
Williams et al evaluated the usual care provided by GPs in Australia for patients presenting with LBP. Australia has a government-funded medical insurance scheme that covers most direct costs of GP visits who in turn act as gatekeepers. Therefore, the effect of insurance is eliminated. They analyzed 3533 patient visits to Australian GPs during the 3 years before and the 3 years after the publication of a clinical practice guideline for the treatment of LBP. The authors found that the introduction of a local, evidence-based clinical practice guideline had no effect on physician treatment of LBP as measured by the frequency of patient counseling, prescription of analgesics, and use of imaging. For example, GPs recommended NSAIDs or opioids in preference to the safer and equally effective acetaminophen, and when acetaminophen was recommended, the dose was typically suboptimal. Contrary to the recommendations, more patients were referred for imaging (which is not routinely recommended) than those who received advice. The authors concluded that passive release of treatment guidelines and brief workshops are insufficient to change clinical practice. They concluded that additional strategies seem necessary to educate GPs about the use of the guidelines and how to provide guideline-based care.
Commentary
Could it be that simple just disseminate information more widely? If so, why hasn't it been done? Similar data on the lack of adherence to LBP management guidelines exist for other nations and should be of significant concern since the problem is common and we know that adherence to such guidelines improves quality of care and contains costs. In fact, the results of this study are remarkably similar to those of a study analyzing a U.S. national health survey.2 There was a minimum impact of the Agency for Health Research and Quality's (AHRQ) clinical practice guidelines on the management of acute LBP in primary care settings. While the use of acetaminophen increased, so did the use of NSAIDs and referrals for radiographs.
I don't think the answer is so simple. While all stakeholders can be faulted (payment structure, patients, pharmaceutical industry, professional organizations, medical education), according to researchers, the majority of the responsibility still remains with the physician.3 It is unfortunate that often there are as many guidelines on a topic as there are professional medical societies and most of them find creative ways to state the same facts. I hope that as we progress toward comparative effectiveness research, there is a concerted effort to reduce the redundancy in the medical field in this area as well. This should start by the development of a unified guideline and recommendation system, which would then become the standard of care for some of the most common medical conditions. So, when a patient visits a primary care practice for a common medical condition (headaches, LBP, hypertension, diabetes, URI, sinusitis, asthma, etc.), the condition should dictate the management, not the type of physician (DO or MD; family or internal medicine). This would eventually not only improve the quality of care and contain costs, but also reduce the practice of defensive medicine. However, this would require both primary care physicians and subspecialists to develop consensus, and not issue their separate guidelines as if they were treating a different set of human beings.
References
1. Krismer M, van Tulder M; Low Back Pain Group of the Bone and Joint Health Strategies for Europe Project. Strategies for prevention and management of musculoskeletal conditions. Low back pain (non-specific). Best Pract Res Clin Rheumatol 2007;21:77-91.
2. Jackson JL, Browning R. Impact of national low back pain guidelines on clinical practice. South Med J 2005;98:139-143.
3. Cabana MD, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282:1458-1465.
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