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A Survey of Primary Care Physician Practice Patterns and Adherence to Acute Low Back Problem Guidelines

A Survey of Primary Care Physician Practice Patterns and Adherence to Acute Low Back Problem... ObjectiveThis study evaluated physicians' self-reported management of acute low back problems in adults and adherence with published guidelines.DesignSelf-administered written survey based on the US Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) guideline on acute low back problems in adults.SettingA region of northern Illinois with a population around 250 000 and encompassing a medium-sized city.ParticipantsOne hundred eighty-two primary care physicians (nonpediatric) with medical staff appointments at area hospitals.Main Outcome MeasureAdherence to published recommendations.ResultsEighty-seven surveys were received for a 48% response rate. Overall, survey respondents recognized 5 of 7 red flags representing serious underlying abnormality 50% or less of the time. Forty percent (35/87) of physicians provided patients with written educational material, and only 25%(22/87) indicated they evaluated motor function of the fifth lumbar nerve, the most commonly affected level in intervertebral disk disease disease. About 25% (24/87) reported routine use of plain films; and 16% (14/87), routine use of computed tomography or magnetic resonance imaging. Most oral medication use was consistent with recommendations, but many also used drugs conditionally discouraged by the guideline (muscle relaxants, 91% [79/87]; opioids, 62% [54/87]) or cautioned against (oral steroids, 45% [39/87]; antidepressants, 23% [20/87]; injection therapy, 52% [45/87]). Only 22% (19/87) of respondents used or recommended manipulation.ConclusionsThe management of patients with acute low back problems by primary care physicians differs significantly from Agency for Health Care Policy and Research guideline recommendations in several key areas that include awareness of red flags, use of medication, use of radiographic studies, the need for patient education, and the use of physical modalities. Future research should focus on the impact of guideline compliance on patient outcomes and cost-effectiveness.LOW BACK PAIN is one of the leading symptoms prompting physician visits.An estimated 50% of adults experience back symptoms in any given yearand nearly 20% have frequent back pain.In 1990, estimated direct medical care costs for low back pain exceeded $24 billion. Estimates for disability compensation and lost productivity raise the total annual costs in the United States to approximately $100 billion.Additionally, there have been wide geographic and professional variations in the medical evaluation and treatment of this problem.These variations imply a lack of professional consensus on management strategies for low back pain and suggest that some patients may be receiving less than optimal care.In December 1994, the US Agency for Health Care Policy and Research (AHCPR) issued a clinical practice guideline directed at the primary care management of acute low back problems (ALBPs) in adults.The guideline was developed by an independent, 23-member multidisciplinary panel of private-sector clinicians (including primary care providers), researchers, and a consumer representative. Findings and recommendation statements were based on an exhaustive and systematic review and analysis of the scientific literature. Every recommendation was explicitly linked to the evidence on which it was based (along with rating the strength of that evidence). The principal recommendations describe a form of diagnostic and therapeutic triage with periodic reassessment to guide management decisions (Table 1).Table 1. Principal Conclusions of the AHCPR Guidelines on Acute Low Back Problems in Adults*The initial assessment of patients with acute low back problems focuses on the detection of "red flags" (indicators of potentially serious spinal pathology or other nonspinal pathology).In the absence of red flags, imaging studies and further testing of patients are not usually helpful during the first 4 weeks of low back symptoms.Relief of discomfort can be accomplished most safely with nonprescription medication and/or spinal manipulation.While some activity modification may be necessary during the acute phase, bed rest >4 days is not helpful and may further debilitate the patient.Low-stress aerobic activity can be safely started in the first 2 weeks of symptoms to help avoid debilitation; exercises to condition trunk muscles are commonly delayed at least 2 weeks.Patients recovering from acute low back problems are encouraged to return to work or their normal daily activities as soon as possible.If low back problems persist, further evaluation may be indicated.Patients with sciatica may recover more slowly, but further evaluation can also be safely delayed.Within the first 3 months of low back symptoms, only patients with evidence of serious spinal pathology or severe, debilitating symptoms of sciatica, and physiologic evidence of specific nerve root compromise corroborated on imaging studies can be expected to benefit from surgery.With or without surgery, 80% of patients with sciatica recover eventually.Nonphysical factors (such as psychological or socioeconomic problems) may be addressed in the context of discussing reasonable expectations for recovery.*AHCPR indicates Agency for Healthcare Research and Policy. From Bigos et al.It was originally assumed that providing credible, scientific information in a succinct form would stimulate practitioners and consumers to voluntarily adopt and use guideline information.The implementation of guideline recommendations would then remedy the apparent clinical uncertainty and reduce variation involving the care of patients presenting with acute low back pain. These expectations, however, rely on the critical concept of "effective dissemination," defined as the diffusion, distribution, awareness, acceptance, adoption, and use of information.Despite the laudable effort to develop this guideline, there are only limited descriptions of the degree to which these recommendations have influenced routine primary care management of ALBPs in the United States.Cherkin et alinvestigated the use of medications by primary care physicians for patients making a first visit for an episode of back pain. The results demonstrated that medication use for back pain in the staff model health maintenance organization under study was generally concordant with the national guideline. Several researchers have recently investigated the use of imaging studies for patients with low back pain.Findings from these studies have been mixed, with examples of both overutilization and underutilization of plain films. Disparities were attributed to characteristics of the providers, impreciseness of the guideline, and patient-centered features. A British studyused their available national guidelines to construct a survey instrument eliciting general practitioner responses to questions on specific assessment and patient education activities. The authors did not seek to obtain information regarding physician-dependent treatment modalities (eg, prescription drugs, physical therapy referral) and did not examine the effect of physician characteristics.The goal of the present study was to more fully describe primary care physicians' self-reported management of patients with ALBPs by comparing physician behavior with the AHCPR guideline recommendations and by identifying individual physician characteristics associated with overall guideline adherence.POPULATION SAMPLE AND METHODSThis study of family practice and internal medicine physicians was accomplished via an anonymous self-administered mail survey that involved physicians in 3 counties in northern Illinois. The project received institutional review board approval. A questionnaire was developed to elicit physician practice preferences and allow direct comparison to the AHCPR guideline on ALBPs. The questionnaire was prefaced by the definition of ALBPs as adopted by the AHCPR panel: "any adult patient with activity intolerance due to lower back or back-related leg symptoms of less than 3 months' duration."QUESTIONNAIRE DEVELOPMENT AND CONTENTThe questionnaire was structured to closely parallel the AHCPR guideline recommendations. An existing, validated survey instrument was made available by Little et aland served as a model. The questionnaire concentrated on the 3 core elements of the guideline: (1) initial assessment methods, (2) clinical care methods, and (3) special studies and diagnostic considerations. A section pertaining to physician demographics was added. The questionnaire was revised after review by 2 family physicians (one was E.H.), 2 internists, and an epidemiologist (A.D.). The final questionnaire included mostly closed-end questions and several with an open format.Initial assessment methods were evaluated in 3 broad areas. First, physicians were asked to identify which of 14 historic characteristics and/or physical signs associated with acute low back pain they would consider red flags that would raise suspicion of a serious underlying abnormality. The items were evenly split between red flags and benign distracters. The red flags were selected from the guideline and included those that may indicate the presence of tumor, infection, spinal fracture, or cauda equina syndrome (Table 2). Second, physicians were queried about instruments used to document a patient's pain distribution, intensity of symptoms, or level of disability (5 choices). Finally, respondents indicated which of the following items they evaluated during a physical examination: straight-leg raising, muscle-strength grading, circumferential measurements of the thigh and calf, palpation of the spine, neurologic reflexes, and sensation. Muscle-strength grading required specification by the respondent of the muscle group(s) being tested. Clinical care methods were also evaluated in 3 areas: patient education, symptom control methods, and activity modification. Physicians were asked if they supplied educational booklets to their patients. Symptom control methods evaluated included oral medications (7 options), physical treatments (9 options), and injection therapy (3 options). Physicians were asked if they routinely recommended bed rest for their patients with ALBPs and, if they did, for how long. Diagnostic strategies were evaluated by asking about any laboratory tests and imaging studies ordered routinely in the first month of symptoms.Table 2. Number and Percentage of Physicians Who Recognized the Following Symptoms as "Red Flags," Raising Suspicion of a Serious Underlying Spinal Disorder (Fracture, Infection, Tumor) or Nonspinal Pathology*Medical History Confirmed "Red Flags"Family PracticeInternal MedicineTotalPain when recumbent21 (43.8)19 (48.7)40 (46.0)Saddle anesthesia43 (89.6)35 (89.7)78 (89.7)Pseudoclaudication19 (39.6)16 (41.0)35 (40.2)Age >50 y21 (43.8)20 (51.3)41 (47.1)Recent bacterial infection (urinary tract)15 (31.3)9 (23.1)24 (27.6)Trauma34 (70.8)31 (79.5)65 (74.7)Pain persisting >1 mo26 (54.2)19 (48.7)45 (51.7)*Values are given as number (percentage).Demographic information was collected regarding physicians' years in practice, primary care specialty, subspecialty, practice environment, satisfaction with management of patients with ALBPs, percentage of total patient encounters devoted to patients with ALBPs, and the most common diagnosis. Physicians were also asked to estimate the age distribution of their patient population and describe their practice's payer mix.PHYSICIAN SAMPLEAddresses of primary care physicians were obtained from the 3 main hospitals serving Winnebago County and the greater northern Illinois region. Computer records identified 191 physicians in the adult primary care specialties of general internal medicine and family practice. Of these, 114 (59.7%) were family physicians (FPs) and 77 (40.3%) were general internists (IMs); 41 (24%) were women. Most (90.8%) of the respondents were from Winnebago County, which has a population around 250 000 and includes a medium-sized city.SURVEY PROCESSThe 4-page questionnaire and a cover letter were sent to all 191 physicians in April 1998. Nonresponders were sent a second mailing 3 weeks later. A prepaid, addressed return envelope was included.STATISTICAL ANALYSISData were entered and analyzed using SPSS 8.0 (SPSS Inc, Chicago, Ill). The χ2and ttests were used to evaluate whether there was significant variation between the two specialties. A standard value of type I error (α≤.05) was adopted. Additional analyses included correlation and 1-way analysis of variance with post hoc tests.RESULTSRESPONSE RATEOf the 191 physicians mailed surveys, 9 were returned because the physician no longer practiced (3 FPs, 2 IMs) or the questionnaire was not deliverable (3 FPs, 1 IM). After 2 mailings, 47.8% (87/182) (48 FPs, 39 IMs) of the remaining eligible sample responded (Table 3). Participation was greater among the IMs (52.7% [39/74]) than the FPs (44.4% [48/108]). Respondents had been practicing primary care medicine for a mean of 14.2 years (nocode for FPs = 15.1 years, nocodefor IMs = 13.1 years). Internists were more likely to have a clinical subspecialty interest (geriatrics, 6; occupational medicine, 2; endocrinology, 2; and oncology, 2). These physicians were included in the study because they reported practicing primarily as generalists. Internists had a greater likelihood of practicing in a multispecialty group (P= .05). Patients with ALBPs accounted for an average of 7.0% (range, 2%-30%) of the total patient encounters in this sample. Managed care penetration into this market was reported at 29.0% (range, 2%-70%). Family physicians expressed significantly greater satisfaction with their management of ALBPs on a 5-point scale than did IMs (P= .007, &mean;for FPs = 3.83, nocode for IMs = 3.28).Table 3. Demographic Characteristics of the Study RespondentsDemographic VariableFamily Practice, No. (%)Internal Medicine, No. (%)Total, No. (%)SexF9 (18.8)8 (20.5)17 (19.5)M39 (81.2)31 (79.5)70 (80.5)No. of years in practice<6 y11 (22.9)13 (33.3)24 (27.6)6-1310 (20.8)11 (28.2)21 (24.1)14-2015 (31.3)6 (15.4)21 (24.1)>2112 (25.0)9 (23.1)21 (24.1)SubspecialtyYes2 (4.2)10 (25.6)12 (13.8)No46 (95.8)29 (74.4)75 (86.2)Practice environmentSolo practitioner8 (16.7)4 (10.3)12 (13.8)Primary care group35 (72.9)23 (59.0)58 (66.7)Multispecialty group5 (10.4)12 (30.2)17 (19.5)Average percentage of age (age range) of patient population, y<2020.2 (2-50)6.4 (0-30)14.7 (0-50)20-4528.0 (10-60)23.6 (5-60)26.1 (5-60)46-6427.9 (10-60)34.1 (15-50)30.6 (10-60)>6525.9 (5-100)40.2 (10-100)32.0 (5-100)Average percentage (range) of population with ALBP†Average6.6 (2-25)7.6 (1-30)7.0 (1-30)Satisfaction with ALBP management‡Least satisfied000Less satisfied4 (8.3)7 (17.9)11 (12.6)Neither satisfied or dissatisfied8 (16.7)17 (43.6)25 (28.7)More satisfied28 (58.3)12 (30.8)40 (46.0)Most satisfied8 (16.7)3 (7.7)11 (12.6)*Physicians in internal medicine are significantly more likely than physicians in family practice to have a subspecialty while practicing primary care medicine (P= .005).†ALBP indicates acute low back problem.‡Family practitioners report a significantly greater level of satisfaction with their management of patients with ALBP than do physicians in internal medicine (P= .007).INITIAL ASSESSMENT METHODSAt least three quarters of physicians routinely asked about only 2 of the 7 historic factors considered red flags in the AHCPR guideline— saddle anesthesia and trauma (Table 2). There was no significant difference between FPs and IMs. Physicians usually checked for 4 of the 6 physical examination findings considered red flags— light touch, Achilles reflex, straight-leg raising, and spinal palpation (Table 4).Table 4. Number and Percentage of Physicians Who Reported Routinely Performing the Following Physical Examination Tests*Initial Assessment Method: Physical ExaminationFamily PracticeInternal MedicineTotalStraight-leg raise47 (97.9)38 (97.4)85 (97.7)Muscle strength gradingAnkle dorsiflexion and extensor hallucis longus13 (27.1)9 (22.0)22 (25.3)Palpation of the spine46 (95.8)39 (100)85 (97.7)Circumferential measurements4 (8.3)1 (2.6)5 (5.7)Neurologic reflexesPatellar45 (93.8)39 (100)84 (96.6)Achilles†42 (87.5)39 (100)81 (93.0)Babinski‡8 (16.7)15 (38.5)23 (26.4)Sensory examinationLight touch38 (79.2)33 (84.6)71 (81.6)*Values are provided as number (percentage).†Achilles reflex was significantly more likely to be tested routinely by physicians in internal medicine vs family practice (P= .031).‡A Babinski reflex is tested on a routine basis significantly more often by physicians in internal medicine when compared with those in family practice (P = .029).CLINICAL CARE METHODSAbout 40% of physicians said they supplied patients with written information explaining ALBPs (31% [15/48] of FPs and 51% [20/39] of IMs). Most used oral medications deemed appropriate by the guideline (97.7% [85/87] used nonsteroidal anti-inflammatory drugs; 72.4% [63/87], acetaminophen). A majority of physicians also used oral medications that were deemed appropriate only in limited situations by the guideline (90.8% [79/87] used muscle relaxants; 62.1% [54/87], opioid analgesics). A minority of physicians used oral medications the guideline specifically cautioned against (44.8% [49/87] used oral steroids; 23.0% [20/87], antidepressants) (Table 5). For physical treatments, the application of heat or ice, therapeutic ultrasound, and massage therapy were used by most of the physicians (88.5% [77/87], 55.2% [48/87], and 65.5% [57/87], respectively). Physicians prescribed, performed, or recommended spinal manipulation only 21.8% (19/87) of the time although the guideline recognized manipulation as the only physical treatment with proven efficacy. About half of the physicians (45/87) used some form of injection therapy despite evidence demonstrating equivocal results. Importantly, the majority of physicians (65.5% [57/87]) did not routinely recommend bed rest for their patients with ALBPs. Of those who did, only 9.2% (8/87) would routinely recommend a duration greater than 48 hours.Table 5. Number and Percentage of Physicians Who Reported Prescribing the Following Medication to Achieve Symptom Relief for Patients With Acute Low Back Problems*Oral MedicationsFamily PracticeInternal MedicineTotalAcetaminophen34 (70.8)29 (74.4)63 (72.4)Nonsteroidal anti-inflammatory drugs46 (95.8)39 (100)85 (97.7)Muscle relaxants44 (91.7)35 (89.7)79 (90.8)Opioid analgesics27 (56.3)27 (69.2)54 (62.1)Oral steroids19 (39.6)20 (51.3)39 (44.8)Colchicine000Antidepressants11 (22.9)9 (23.1)20 (23.0)*Values are given as number (percentage).SPECIAL STUDIES AND DIAGNOSTIC CONSIDERATIONSThe guideline emphasizes a conservative approach to diagnostic testing in the first month and recommends that any imaging study be reserved for patients with symptoms and signs of serious illness. However, 24 (27.6%) of 87 respondents reported using a diagnostic aid in the routine evaluation of patients with ALBPs (Table 6). Plain films were the most frequently used and FPs were significantly more likely than IMs to routinely employ these studies (P= .008). Urinalysis was routinely used by only 9 (10.3%) of 87 respondents, although again, FPs demonstrated a significantly greater use (P= .038). About 1 in 6 primary care physicians (16.1% in 14 of our 87 respondents) reported routinely ordering advanced imaging (computed tomography or magnetic resonance imaging) for patients with ALBPs.Table 6. Number and Percentage of Physicians Who Reported Use of Diagnostic Aids for Patients With Acute Low Back Problems in the First Month of Symptoms*Special Studies and DiagnosticsFamily PracticeInternal MedicineTotalDo you routinely use diagnostic aids?Yes*19 (39.6)5 (12.8)24 (27.6)No29 (60.4)34 (87.2)63 (72.4)Tests of physiologic functionElectrophysiologic tests1 (2.1)1 (2.6)2 (2.3)Bone scan000Thermography000Urinalysis†8 (16.7)1 (2.6)9 (10.3)Complete blood count2 (4.2)2 (5.1)4 (4.6)Chemistry panel1 (2.1)2 (5.1)3 (3.4)Sedimentation rate1 (2.1)3 (7.7)4 (4.6)Tests providing anatomic definitionPlain x-ray films‡19 (39.6)5 (12.8)24 (27.6)Computed tomography, magnetic resonance imaging10 (20.8)4 (10.3)14 (16.1)*Physicians in family practice are significantly more likely than those in internal medicine to routinely order diagnostic aids in the evaluation of patients with acute low back problems (P= .008). It is noteworthy that more than 25% of primary care physicians routinely order some tests.†Physicians in family practice routinely use urinalysis as a diagnostic aid significantly more frequently than those in internal medicine (P= .04). However, overall, urinalysis is used routinely only 10.3% of the time.‡Of the routinely ordered diagnostic aids, plain x-ray films were the most commonly used (100% of those that ordered routine tests). Also, physicians in family practice are significantly more likely to order them routinely as compared with those in internal medicine (P= .008).SUMMARY VARIABLEA summary variable was created using only those items for which there was at least moderate research evidence—a "B-level" or better rating by the AHCPR panel (Table 7). The summary variable consisted of 16 items with a total score ranging from 0 to 16. Using the summary variable as a measure of overall guideline adherence, we found compliance to be 68.1% (&mean;score = 10.9). Only 5 (5.7%) of 87 physicians achieved a 90% or better compliance level. No relationship was found between physician sex, specialty or subspecialty interest, and overall guideline adherence. Similarly, physician satisfaction with the management of ALBPs and the percentage of patient encounters devoted to this problem both failed to demonstrate any correlation to guideline adherence. Those physicians practicing in a primary care group practice demonstrated significantly higher levels of overall guideline adherence than their counterparts in solo practices and marginally superior adherence than those practicing in multispecialty practices (F = 4.91, P= .009, &mean;scores = 11.2, 9.7, and 10.5, respectively). In addition, there was a negative correlation (ie, inverse relationship) between years in practice and guideline adherence (Pearson r= −0.21, P= .05).Table 7. Variables Meeting the Requirement of "B-Level" Evidence or Better for Inclusion Into the Cumulative Summary VariablePositive Variables (Evidence to Support)Negative Variables (Evidence to Rebut)Pain on recumbencyTaking colchicineAge >50 yTractionPain >1 moRoutine x-ray filmsRecent bacterial infection (urinary tract)Spinal manipulationMotor examinationFoot dorsiflexion and extensor hallucis longusReflexes, patellarReflexes, AchillesSensation to light touchStraight-leg raiseBed rest, none or <48 hEducational bookletCOMMENTThis study reflects primary care physicians' self-reported management of patients with ALBPs in northern Illinois. The results suggest that for many primary care practitioners, the management of these conditions does not follow the AHCPR guideline. Physicians complied more often with recommendations involving the physical examination, use of preferred drug therapies, and avoidance of bed rest. They were less compliant in recognizing red flags, providing patients with written educational material, using equivocal drug therapies and proven physical treatments, and diminishing their overreliance on imaging studies. With the exception of increased ordering of radiographs by family physicians, little measurable difference was noted between the specialties. Overall compliance, as measured through a summary variable, was moderate. Being part of a primary care group practice or more recently entering clinical practice was positively associated with guideline compliance.This study has some limitations. The answers are of self-reported behavior. Although the physicians were assured of anonymity and asked for their routine management practices, the answers may reflect a more idealized version than actually takes place. In addition, responding physicians may have a greater interest in back problems than nonresponders. Thus the results may underestimate the true discrepancy with guidelines. The response rate and the regional nature of the survey may limit its generalizability. Our sample population was not queried as to the frequency, duration, or combination of oral medications they prescribe. We should therefore be cautious when interpreting the reported use of muscle relaxants and opioids in the management of ALBPs.The observed variability described in this study is not what the AHCPR guideline panel envisioned. Furthermore, it is not certain if the areas recognized as following the guideline recommendations actually represent a change in physician practices due to the availability of guidelines or if they were standard practice prior to the guideline's release. Systematic review of interventions designed to promote the implementation of research findings have consistently demonstrated the inadequacies of passive distribution and didactic education when attempting to change physician behavior.Interventions with proven efficacy have also failed to improve physician diagnosis and treatment of ALBPs.Schrothtested a model in a health maintenance organization using active education, audit, feedback intervention supported by peer group opinion leaders, and a patient educational tool; it was unsuccessful in changing the appropriateness of clinical care. He attempted to measure important patient outcomesand suggested that implementation strategies such as administrative controls or financial incentives or disincentives may be necessary to alter primary care physicians' behavior. These methods, however, would be difficult to implement with physicians enjoying a more diverse reimbursement base as found in northern Illinois.While recognizing the potential benefits of practice guidelines, FPs and IMs have expressed substantial concerns about possible effects on clinical autonomy and regulatory intrusion into practice.The AHCPR attempted to address concerns regarding quality, validity, and applicability by using an explicit and evidence-based method in guideline development and by targeting primary care physicians as the principal audience. Statements and recommendations were directly linked to the evidence along with ratings of the quality of supporting evidence. However, a few studies have reported unpredictable beliefs and behaviors on the part of primary care physicians about the value of diagnostic and therapeutic interventions for ALBP. These clinical opinions were not founded on sound scientific evidence and frequently clashed with guideline recommendations.This suggests physician characteristics may disproportionately influence the adoption and implementation of the guideline. Other studies have emphasized the impact of patient-centered factors as an often underestimated element of guideline compliance.These studies suggest that variations in individual practice styles and patient demands may be sufficient to overwhelm the efforts of guideline implementation at times.In the case of this AHCPR guideline, another explanation may be the lack of clear evidence that divergence from guideline recommendations leads to adverse events or that conformity to the guideline improves patient outcomes. As described earlier, the guideline reviewed a variety of individually supportable statements and constructed an algorithm outlining the "ideal" management of a patient presenting with an ALBP. We do not know, however, if the guideline can acheive its stated goals. Does strict adherence reduce the number of patients becoming chronically disabled? Does strict adherence reduce the personal and societal costs associated with ALBPs? Or can selective adherence based on a combination of physician experience and patient-centered factors (ie, preferences, expectations, financial concerns, or quality of life) yield better compliance and similar results? Future research will need to compare and contrast the impact of strict or selective adherence on patient outcomes. The largely unknown influence of patient-centered factors requires further study. When data on patient outcomes are incomplete, physicians may be justified in not wanting to change their practices. Our findings that primary care specialty peer interaction and recent entry into clinical practice were positively associated with guideline adherence may be important. Lastly, medical education should continue to emphasize life-long learning and evidence-based medicine to train physicians capable of accessing and interpreting the expansive medical literature.LGHartRADeyoDCCherkinPhysician office visits for low back pain.Spine.1995;20:11-19.RASternbachSurvey of pain in the United States: the Nuprin pain report.Clin J Pain.1986;2:49-53.LSReisbordSGreenlandFactors associated with self-reported back pain prevalence: a population based study.J Chronic Dis.1985;38:691-702.JWFrymoyerWLCats-BarilAn overview of the incidences and costs of low back pain.Orthop Clin North Am.1991;22:263-271.DCCherkinRADeyoKWheelerMACiolPhysician variation in diagnostic testing for low back pain: who you see is what you get.Arthritis Rheum.1994;37:15-22.DCCherkinRADeyoKWheelerMACiolPhysicians' views about treating low back pain: the results of a national survey.Spine.1995;20:1-10.VMTaylorRADeyoDCCherkinWKreuterLow back pain hospitalization: recent United States trends and regional variations.Spine.1994;19:1207-1213.TSCareyJGarrettPatterns of ordering diagnostic tests for patients with acute low back pain: the North Carolina Back Pain Project.Ann Intern Med.1996;125:807-814.SJBigosORBowyerGRBraenAcute Low Back Problems in Adults: Clinical Practice Guideline.No. 14.Rockville, Md: US Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; December 1994. Publication 95-0642.AKBurtonGWaddellClinical guidelines in the management of low back pain.Baillieres Clin Rheumatol.1998;12:17-35.MVanAmringeTShannonAwareness, Assimilation, and Adoption: The Challenge of Effective Dissemination and the First AHCPR-Sponsored Guidelines.Rockville, Md: US Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; January 1993. Publication 93-0028.DCCherkinKJWheelerWBarlowRADeyoMedication use for low back pain in primary care.Spine.1998;23:607-614.DKFreebornDShyeJPMulloolySErakerJRomeoPrimary care physicians' use of lumbar spine imaging tests: effects of guidelines and practice pattern feedback.J Gen Intern Med.1997;12:619-625.MESuarez-AlmazorEBelseckARussellJMackelUse of lumbar radiographs for the early diagnosis of low back pain: proposed guidelines would increase utilization.JAMA.1997;277:1782-1786.PLittleTCantrellLRobertsJChapmanJLangridgeRPickeringWhy do GP's perform investigations? the medical and social agendas in arranging back x-rays.Fam Pract.1998;15:264-265.PLittleLSmithTCantrellJChapmanJLangridgeRPickeringGeneral practitioners' management of acute back pain: a survey of reported practice compared with clinical guidelines.BMJ.1996;312:485-488.DADavisMAThomsonADOxmanRBHaynesChanging physician performance: a systematic review of the effect of continuing medical education strategies.JAMA.1995;274:700-05.DADavisATTaylor-VaiseyTranslating guidelines into practice: A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines.CMAJ.1997;157:408-416.LABeroRGrilliJMGrimshawEHarveyADOxmanMAThomsonClosing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings.BMJ.1998;317:465-468.WSSchrothPractice Guidelines in Primary Care: Abstract, Executive Summary and Final Report.Rockville, Md: US Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; August 1996. Publication 97-22, National Technical Information Service accession PB97-127328.SRTunisRSHaywardMCWilsonInternist' attitudes about clinical practice guidelines.Ann Intern Med.1994;120:956-963.PAJamesTMCowanRPGrahamBAMajeroniFamily physicians' attitudes about and use of clinical practice guidelines.J Fam Pract.1997;45:341-347.PAJamesTMCowanRPGrahamPatient-centered clinical decisions and their impact on physician adherence to clinical guidelines.J Fam Pract.1998;46:311-318.Accepted for publication September 14, 2000.The authors wish to acknowledge the contributions of Michael Glasser, PhD; the Department of Family and Community Medicine, University of Illinois College of Medicine at Rockford; Rockford Health System; OSF (Order of Saint Francis) Saint Anthony Medical Center; and Swedish American Health System in supporting the completion of this study.Corresponding author: Daniel R. Di Iorio, MD, DC, 1 S 570 Nimitz Rd, Oakbrook Terrace, IL 60181 (e-mail: dr.dan.diiorio@att.net). http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Family Medicine American Medical Association

A Survey of Primary Care Physician Practice Patterns and Adherence to Acute Low Back Problem Guidelines

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American Medical Association
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Copyright 2000 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
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1063-3987
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10-1001/pubs.Arch Fam Med.-ISSN-1063-3987-9-10-foc0005
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Abstract

ObjectiveThis study evaluated physicians' self-reported management of acute low back problems in adults and adherence with published guidelines.DesignSelf-administered written survey based on the US Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) guideline on acute low back problems in adults.SettingA region of northern Illinois with a population around 250 000 and encompassing a medium-sized city.ParticipantsOne hundred eighty-two primary care physicians (nonpediatric) with medical staff appointments at area hospitals.Main Outcome MeasureAdherence to published recommendations.ResultsEighty-seven surveys were received for a 48% response rate. Overall, survey respondents recognized 5 of 7 red flags representing serious underlying abnormality 50% or less of the time. Forty percent (35/87) of physicians provided patients with written educational material, and only 25%(22/87) indicated they evaluated motor function of the fifth lumbar nerve, the most commonly affected level in intervertebral disk disease disease. About 25% (24/87) reported routine use of plain films; and 16% (14/87), routine use of computed tomography or magnetic resonance imaging. Most oral medication use was consistent with recommendations, but many also used drugs conditionally discouraged by the guideline (muscle relaxants, 91% [79/87]; opioids, 62% [54/87]) or cautioned against (oral steroids, 45% [39/87]; antidepressants, 23% [20/87]; injection therapy, 52% [45/87]). Only 22% (19/87) of respondents used or recommended manipulation.ConclusionsThe management of patients with acute low back problems by primary care physicians differs significantly from Agency for Health Care Policy and Research guideline recommendations in several key areas that include awareness of red flags, use of medication, use of radiographic studies, the need for patient education, and the use of physical modalities. Future research should focus on the impact of guideline compliance on patient outcomes and cost-effectiveness.LOW BACK PAIN is one of the leading symptoms prompting physician visits.An estimated 50% of adults experience back symptoms in any given yearand nearly 20% have frequent back pain.In 1990, estimated direct medical care costs for low back pain exceeded $24 billion. Estimates for disability compensation and lost productivity raise the total annual costs in the United States to approximately $100 billion.Additionally, there have been wide geographic and professional variations in the medical evaluation and treatment of this problem.These variations imply a lack of professional consensus on management strategies for low back pain and suggest that some patients may be receiving less than optimal care.In December 1994, the US Agency for Health Care Policy and Research (AHCPR) issued a clinical practice guideline directed at the primary care management of acute low back problems (ALBPs) in adults.The guideline was developed by an independent, 23-member multidisciplinary panel of private-sector clinicians (including primary care providers), researchers, and a consumer representative. Findings and recommendation statements were based on an exhaustive and systematic review and analysis of the scientific literature. Every recommendation was explicitly linked to the evidence on which it was based (along with rating the strength of that evidence). The principal recommendations describe a form of diagnostic and therapeutic triage with periodic reassessment to guide management decisions (Table 1).Table 1. Principal Conclusions of the AHCPR Guidelines on Acute Low Back Problems in Adults*The initial assessment of patients with acute low back problems focuses on the detection of "red flags" (indicators of potentially serious spinal pathology or other nonspinal pathology).In the absence of red flags, imaging studies and further testing of patients are not usually helpful during the first 4 weeks of low back symptoms.Relief of discomfort can be accomplished most safely with nonprescription medication and/or spinal manipulation.While some activity modification may be necessary during the acute phase, bed rest >4 days is not helpful and may further debilitate the patient.Low-stress aerobic activity can be safely started in the first 2 weeks of symptoms to help avoid debilitation; exercises to condition trunk muscles are commonly delayed at least 2 weeks.Patients recovering from acute low back problems are encouraged to return to work or their normal daily activities as soon as possible.If low back problems persist, further evaluation may be indicated.Patients with sciatica may recover more slowly, but further evaluation can also be safely delayed.Within the first 3 months of low back symptoms, only patients with evidence of serious spinal pathology or severe, debilitating symptoms of sciatica, and physiologic evidence of specific nerve root compromise corroborated on imaging studies can be expected to benefit from surgery.With or without surgery, 80% of patients with sciatica recover eventually.Nonphysical factors (such as psychological or socioeconomic problems) may be addressed in the context of discussing reasonable expectations for recovery.*AHCPR indicates Agency for Healthcare Research and Policy. From Bigos et al.It was originally assumed that providing credible, scientific information in a succinct form would stimulate practitioners and consumers to voluntarily adopt and use guideline information.The implementation of guideline recommendations would then remedy the apparent clinical uncertainty and reduce variation involving the care of patients presenting with acute low back pain. These expectations, however, rely on the critical concept of "effective dissemination," defined as the diffusion, distribution, awareness, acceptance, adoption, and use of information.Despite the laudable effort to develop this guideline, there are only limited descriptions of the degree to which these recommendations have influenced routine primary care management of ALBPs in the United States.Cherkin et alinvestigated the use of medications by primary care physicians for patients making a first visit for an episode of back pain. The results demonstrated that medication use for back pain in the staff model health maintenance organization under study was generally concordant with the national guideline. Several researchers have recently investigated the use of imaging studies for patients with low back pain.Findings from these studies have been mixed, with examples of both overutilization and underutilization of plain films. Disparities were attributed to characteristics of the providers, impreciseness of the guideline, and patient-centered features. A British studyused their available national guidelines to construct a survey instrument eliciting general practitioner responses to questions on specific assessment and patient education activities. The authors did not seek to obtain information regarding physician-dependent treatment modalities (eg, prescription drugs, physical therapy referral) and did not examine the effect of physician characteristics.The goal of the present study was to more fully describe primary care physicians' self-reported management of patients with ALBPs by comparing physician behavior with the AHCPR guideline recommendations and by identifying individual physician characteristics associated with overall guideline adherence.POPULATION SAMPLE AND METHODSThis study of family practice and internal medicine physicians was accomplished via an anonymous self-administered mail survey that involved physicians in 3 counties in northern Illinois. The project received institutional review board approval. A questionnaire was developed to elicit physician practice preferences and allow direct comparison to the AHCPR guideline on ALBPs. The questionnaire was prefaced by the definition of ALBPs as adopted by the AHCPR panel: "any adult patient with activity intolerance due to lower back or back-related leg symptoms of less than 3 months' duration."QUESTIONNAIRE DEVELOPMENT AND CONTENTThe questionnaire was structured to closely parallel the AHCPR guideline recommendations. An existing, validated survey instrument was made available by Little et aland served as a model. The questionnaire concentrated on the 3 core elements of the guideline: (1) initial assessment methods, (2) clinical care methods, and (3) special studies and diagnostic considerations. A section pertaining to physician demographics was added. The questionnaire was revised after review by 2 family physicians (one was E.H.), 2 internists, and an epidemiologist (A.D.). The final questionnaire included mostly closed-end questions and several with an open format.Initial assessment methods were evaluated in 3 broad areas. First, physicians were asked to identify which of 14 historic characteristics and/or physical signs associated with acute low back pain they would consider red flags that would raise suspicion of a serious underlying abnormality. The items were evenly split between red flags and benign distracters. The red flags were selected from the guideline and included those that may indicate the presence of tumor, infection, spinal fracture, or cauda equina syndrome (Table 2). Second, physicians were queried about instruments used to document a patient's pain distribution, intensity of symptoms, or level of disability (5 choices). Finally, respondents indicated which of the following items they evaluated during a physical examination: straight-leg raising, muscle-strength grading, circumferential measurements of the thigh and calf, palpation of the spine, neurologic reflexes, and sensation. Muscle-strength grading required specification by the respondent of the muscle group(s) being tested. Clinical care methods were also evaluated in 3 areas: patient education, symptom control methods, and activity modification. Physicians were asked if they supplied educational booklets to their patients. Symptom control methods evaluated included oral medications (7 options), physical treatments (9 options), and injection therapy (3 options). Physicians were asked if they routinely recommended bed rest for their patients with ALBPs and, if they did, for how long. Diagnostic strategies were evaluated by asking about any laboratory tests and imaging studies ordered routinely in the first month of symptoms.Table 2. Number and Percentage of Physicians Who Recognized the Following Symptoms as "Red Flags," Raising Suspicion of a Serious Underlying Spinal Disorder (Fracture, Infection, Tumor) or Nonspinal Pathology*Medical History Confirmed "Red Flags"Family PracticeInternal MedicineTotalPain when recumbent21 (43.8)19 (48.7)40 (46.0)Saddle anesthesia43 (89.6)35 (89.7)78 (89.7)Pseudoclaudication19 (39.6)16 (41.0)35 (40.2)Age >50 y21 (43.8)20 (51.3)41 (47.1)Recent bacterial infection (urinary tract)15 (31.3)9 (23.1)24 (27.6)Trauma34 (70.8)31 (79.5)65 (74.7)Pain persisting >1 mo26 (54.2)19 (48.7)45 (51.7)*Values are given as number (percentage).Demographic information was collected regarding physicians' years in practice, primary care specialty, subspecialty, practice environment, satisfaction with management of patients with ALBPs, percentage of total patient encounters devoted to patients with ALBPs, and the most common diagnosis. Physicians were also asked to estimate the age distribution of their patient population and describe their practice's payer mix.PHYSICIAN SAMPLEAddresses of primary care physicians were obtained from the 3 main hospitals serving Winnebago County and the greater northern Illinois region. Computer records identified 191 physicians in the adult primary care specialties of general internal medicine and family practice. Of these, 114 (59.7%) were family physicians (FPs) and 77 (40.3%) were general internists (IMs); 41 (24%) were women. Most (90.8%) of the respondents were from Winnebago County, which has a population around 250 000 and includes a medium-sized city.SURVEY PROCESSThe 4-page questionnaire and a cover letter were sent to all 191 physicians in April 1998. Nonresponders were sent a second mailing 3 weeks later. A prepaid, addressed return envelope was included.STATISTICAL ANALYSISData were entered and analyzed using SPSS 8.0 (SPSS Inc, Chicago, Ill). The χ2and ttests were used to evaluate whether there was significant variation between the two specialties. A standard value of type I error (α≤.05) was adopted. Additional analyses included correlation and 1-way analysis of variance with post hoc tests.RESULTSRESPONSE RATEOf the 191 physicians mailed surveys, 9 were returned because the physician no longer practiced (3 FPs, 2 IMs) or the questionnaire was not deliverable (3 FPs, 1 IM). After 2 mailings, 47.8% (87/182) (48 FPs, 39 IMs) of the remaining eligible sample responded (Table 3). Participation was greater among the IMs (52.7% [39/74]) than the FPs (44.4% [48/108]). Respondents had been practicing primary care medicine for a mean of 14.2 years (nocode for FPs = 15.1 years, nocodefor IMs = 13.1 years). Internists were more likely to have a clinical subspecialty interest (geriatrics, 6; occupational medicine, 2; endocrinology, 2; and oncology, 2). These physicians were included in the study because they reported practicing primarily as generalists. Internists had a greater likelihood of practicing in a multispecialty group (P= .05). Patients with ALBPs accounted for an average of 7.0% (range, 2%-30%) of the total patient encounters in this sample. Managed care penetration into this market was reported at 29.0% (range, 2%-70%). Family physicians expressed significantly greater satisfaction with their management of ALBPs on a 5-point scale than did IMs (P= .007, &mean;for FPs = 3.83, nocode for IMs = 3.28).Table 3. Demographic Characteristics of the Study RespondentsDemographic VariableFamily Practice, No. (%)Internal Medicine, No. (%)Total, No. (%)SexF9 (18.8)8 (20.5)17 (19.5)M39 (81.2)31 (79.5)70 (80.5)No. of years in practice<6 y11 (22.9)13 (33.3)24 (27.6)6-1310 (20.8)11 (28.2)21 (24.1)14-2015 (31.3)6 (15.4)21 (24.1)>2112 (25.0)9 (23.1)21 (24.1)SubspecialtyYes2 (4.2)10 (25.6)12 (13.8)No46 (95.8)29 (74.4)75 (86.2)Practice environmentSolo practitioner8 (16.7)4 (10.3)12 (13.8)Primary care group35 (72.9)23 (59.0)58 (66.7)Multispecialty group5 (10.4)12 (30.2)17 (19.5)Average percentage of age (age range) of patient population, y<2020.2 (2-50)6.4 (0-30)14.7 (0-50)20-4528.0 (10-60)23.6 (5-60)26.1 (5-60)46-6427.9 (10-60)34.1 (15-50)30.6 (10-60)>6525.9 (5-100)40.2 (10-100)32.0 (5-100)Average percentage (range) of population with ALBP†Average6.6 (2-25)7.6 (1-30)7.0 (1-30)Satisfaction with ALBP management‡Least satisfied000Less satisfied4 (8.3)7 (17.9)11 (12.6)Neither satisfied or dissatisfied8 (16.7)17 (43.6)25 (28.7)More satisfied28 (58.3)12 (30.8)40 (46.0)Most satisfied8 (16.7)3 (7.7)11 (12.6)*Physicians in internal medicine are significantly more likely than physicians in family practice to have a subspecialty while practicing primary care medicine (P= .005).†ALBP indicates acute low back problem.‡Family practitioners report a significantly greater level of satisfaction with their management of patients with ALBP than do physicians in internal medicine (P= .007).INITIAL ASSESSMENT METHODSAt least three quarters of physicians routinely asked about only 2 of the 7 historic factors considered red flags in the AHCPR guideline— saddle anesthesia and trauma (Table 2). There was no significant difference between FPs and IMs. Physicians usually checked for 4 of the 6 physical examination findings considered red flags— light touch, Achilles reflex, straight-leg raising, and spinal palpation (Table 4).Table 4. Number and Percentage of Physicians Who Reported Routinely Performing the Following Physical Examination Tests*Initial Assessment Method: Physical ExaminationFamily PracticeInternal MedicineTotalStraight-leg raise47 (97.9)38 (97.4)85 (97.7)Muscle strength gradingAnkle dorsiflexion and extensor hallucis longus13 (27.1)9 (22.0)22 (25.3)Palpation of the spine46 (95.8)39 (100)85 (97.7)Circumferential measurements4 (8.3)1 (2.6)5 (5.7)Neurologic reflexesPatellar45 (93.8)39 (100)84 (96.6)Achilles†42 (87.5)39 (100)81 (93.0)Babinski‡8 (16.7)15 (38.5)23 (26.4)Sensory examinationLight touch38 (79.2)33 (84.6)71 (81.6)*Values are provided as number (percentage).†Achilles reflex was significantly more likely to be tested routinely by physicians in internal medicine vs family practice (P= .031).‡A Babinski reflex is tested on a routine basis significantly more often by physicians in internal medicine when compared with those in family practice (P = .029).CLINICAL CARE METHODSAbout 40% of physicians said they supplied patients with written information explaining ALBPs (31% [15/48] of FPs and 51% [20/39] of IMs). Most used oral medications deemed appropriate by the guideline (97.7% [85/87] used nonsteroidal anti-inflammatory drugs; 72.4% [63/87], acetaminophen). A majority of physicians also used oral medications that were deemed appropriate only in limited situations by the guideline (90.8% [79/87] used muscle relaxants; 62.1% [54/87], opioid analgesics). A minority of physicians used oral medications the guideline specifically cautioned against (44.8% [49/87] used oral steroids; 23.0% [20/87], antidepressants) (Table 5). For physical treatments, the application of heat or ice, therapeutic ultrasound, and massage therapy were used by most of the physicians (88.5% [77/87], 55.2% [48/87], and 65.5% [57/87], respectively). Physicians prescribed, performed, or recommended spinal manipulation only 21.8% (19/87) of the time although the guideline recognized manipulation as the only physical treatment with proven efficacy. About half of the physicians (45/87) used some form of injection therapy despite evidence demonstrating equivocal results. Importantly, the majority of physicians (65.5% [57/87]) did not routinely recommend bed rest for their patients with ALBPs. Of those who did, only 9.2% (8/87) would routinely recommend a duration greater than 48 hours.Table 5. Number and Percentage of Physicians Who Reported Prescribing the Following Medication to Achieve Symptom Relief for Patients With Acute Low Back Problems*Oral MedicationsFamily PracticeInternal MedicineTotalAcetaminophen34 (70.8)29 (74.4)63 (72.4)Nonsteroidal anti-inflammatory drugs46 (95.8)39 (100)85 (97.7)Muscle relaxants44 (91.7)35 (89.7)79 (90.8)Opioid analgesics27 (56.3)27 (69.2)54 (62.1)Oral steroids19 (39.6)20 (51.3)39 (44.8)Colchicine000Antidepressants11 (22.9)9 (23.1)20 (23.0)*Values are given as number (percentage).SPECIAL STUDIES AND DIAGNOSTIC CONSIDERATIONSThe guideline emphasizes a conservative approach to diagnostic testing in the first month and recommends that any imaging study be reserved for patients with symptoms and signs of serious illness. However, 24 (27.6%) of 87 respondents reported using a diagnostic aid in the routine evaluation of patients with ALBPs (Table 6). Plain films were the most frequently used and FPs were significantly more likely than IMs to routinely employ these studies (P= .008). Urinalysis was routinely used by only 9 (10.3%) of 87 respondents, although again, FPs demonstrated a significantly greater use (P= .038). About 1 in 6 primary care physicians (16.1% in 14 of our 87 respondents) reported routinely ordering advanced imaging (computed tomography or magnetic resonance imaging) for patients with ALBPs.Table 6. Number and Percentage of Physicians Who Reported Use of Diagnostic Aids for Patients With Acute Low Back Problems in the First Month of Symptoms*Special Studies and DiagnosticsFamily PracticeInternal MedicineTotalDo you routinely use diagnostic aids?Yes*19 (39.6)5 (12.8)24 (27.6)No29 (60.4)34 (87.2)63 (72.4)Tests of physiologic functionElectrophysiologic tests1 (2.1)1 (2.6)2 (2.3)Bone scan000Thermography000Urinalysis†8 (16.7)1 (2.6)9 (10.3)Complete blood count2 (4.2)2 (5.1)4 (4.6)Chemistry panel1 (2.1)2 (5.1)3 (3.4)Sedimentation rate1 (2.1)3 (7.7)4 (4.6)Tests providing anatomic definitionPlain x-ray films‡19 (39.6)5 (12.8)24 (27.6)Computed tomography, magnetic resonance imaging10 (20.8)4 (10.3)14 (16.1)*Physicians in family practice are significantly more likely than those in internal medicine to routinely order diagnostic aids in the evaluation of patients with acute low back problems (P= .008). It is noteworthy that more than 25% of primary care physicians routinely order some tests.†Physicians in family practice routinely use urinalysis as a diagnostic aid significantly more frequently than those in internal medicine (P= .04). However, overall, urinalysis is used routinely only 10.3% of the time.‡Of the routinely ordered diagnostic aids, plain x-ray films were the most commonly used (100% of those that ordered routine tests). Also, physicians in family practice are significantly more likely to order them routinely as compared with those in internal medicine (P= .008).SUMMARY VARIABLEA summary variable was created using only those items for which there was at least moderate research evidence—a "B-level" or better rating by the AHCPR panel (Table 7). The summary variable consisted of 16 items with a total score ranging from 0 to 16. Using the summary variable as a measure of overall guideline adherence, we found compliance to be 68.1% (&mean;score = 10.9). Only 5 (5.7%) of 87 physicians achieved a 90% or better compliance level. No relationship was found between physician sex, specialty or subspecialty interest, and overall guideline adherence. Similarly, physician satisfaction with the management of ALBPs and the percentage of patient encounters devoted to this problem both failed to demonstrate any correlation to guideline adherence. Those physicians practicing in a primary care group practice demonstrated significantly higher levels of overall guideline adherence than their counterparts in solo practices and marginally superior adherence than those practicing in multispecialty practices (F = 4.91, P= .009, &mean;scores = 11.2, 9.7, and 10.5, respectively). In addition, there was a negative correlation (ie, inverse relationship) between years in practice and guideline adherence (Pearson r= −0.21, P= .05).Table 7. Variables Meeting the Requirement of "B-Level" Evidence or Better for Inclusion Into the Cumulative Summary VariablePositive Variables (Evidence to Support)Negative Variables (Evidence to Rebut)Pain on recumbencyTaking colchicineAge >50 yTractionPain >1 moRoutine x-ray filmsRecent bacterial infection (urinary tract)Spinal manipulationMotor examinationFoot dorsiflexion and extensor hallucis longusReflexes, patellarReflexes, AchillesSensation to light touchStraight-leg raiseBed rest, none or <48 hEducational bookletCOMMENTThis study reflects primary care physicians' self-reported management of patients with ALBPs in northern Illinois. The results suggest that for many primary care practitioners, the management of these conditions does not follow the AHCPR guideline. Physicians complied more often with recommendations involving the physical examination, use of preferred drug therapies, and avoidance of bed rest. They were less compliant in recognizing red flags, providing patients with written educational material, using equivocal drug therapies and proven physical treatments, and diminishing their overreliance on imaging studies. With the exception of increased ordering of radiographs by family physicians, little measurable difference was noted between the specialties. Overall compliance, as measured through a summary variable, was moderate. Being part of a primary care group practice or more recently entering clinical practice was positively associated with guideline compliance.This study has some limitations. The answers are of self-reported behavior. Although the physicians were assured of anonymity and asked for their routine management practices, the answers may reflect a more idealized version than actually takes place. In addition, responding physicians may have a greater interest in back problems than nonresponders. Thus the results may underestimate the true discrepancy with guidelines. The response rate and the regional nature of the survey may limit its generalizability. Our sample population was not queried as to the frequency, duration, or combination of oral medications they prescribe. We should therefore be cautious when interpreting the reported use of muscle relaxants and opioids in the management of ALBPs.The observed variability described in this study is not what the AHCPR guideline panel envisioned. Furthermore, it is not certain if the areas recognized as following the guideline recommendations actually represent a change in physician practices due to the availability of guidelines or if they were standard practice prior to the guideline's release. Systematic review of interventions designed to promote the implementation of research findings have consistently demonstrated the inadequacies of passive distribution and didactic education when attempting to change physician behavior.Interventions with proven efficacy have also failed to improve physician diagnosis and treatment of ALBPs.Schrothtested a model in a health maintenance organization using active education, audit, feedback intervention supported by peer group opinion leaders, and a patient educational tool; it was unsuccessful in changing the appropriateness of clinical care. He attempted to measure important patient outcomesand suggested that implementation strategies such as administrative controls or financial incentives or disincentives may be necessary to alter primary care physicians' behavior. These methods, however, would be difficult to implement with physicians enjoying a more diverse reimbursement base as found in northern Illinois.While recognizing the potential benefits of practice guidelines, FPs and IMs have expressed substantial concerns about possible effects on clinical autonomy and regulatory intrusion into practice.The AHCPR attempted to address concerns regarding quality, validity, and applicability by using an explicit and evidence-based method in guideline development and by targeting primary care physicians as the principal audience. Statements and recommendations were directly linked to the evidence along with ratings of the quality of supporting evidence. However, a few studies have reported unpredictable beliefs and behaviors on the part of primary care physicians about the value of diagnostic and therapeutic interventions for ALBP. These clinical opinions were not founded on sound scientific evidence and frequently clashed with guideline recommendations.This suggests physician characteristics may disproportionately influence the adoption and implementation of the guideline. Other studies have emphasized the impact of patient-centered factors as an often underestimated element of guideline compliance.These studies suggest that variations in individual practice styles and patient demands may be sufficient to overwhelm the efforts of guideline implementation at times.In the case of this AHCPR guideline, another explanation may be the lack of clear evidence that divergence from guideline recommendations leads to adverse events or that conformity to the guideline improves patient outcomes. As described earlier, the guideline reviewed a variety of individually supportable statements and constructed an algorithm outlining the "ideal" management of a patient presenting with an ALBP. We do not know, however, if the guideline can acheive its stated goals. Does strict adherence reduce the number of patients becoming chronically disabled? Does strict adherence reduce the personal and societal costs associated with ALBPs? Or can selective adherence based on a combination of physician experience and patient-centered factors (ie, preferences, expectations, financial concerns, or quality of life) yield better compliance and similar results? Future research will need to compare and contrast the impact of strict or selective adherence on patient outcomes. The largely unknown influence of patient-centered factors requires further study. When data on patient outcomes are incomplete, physicians may be justified in not wanting to change their practices. Our findings that primary care specialty peer interaction and recent entry into clinical practice were positively associated with guideline adherence may be important. Lastly, medical education should continue to emphasize life-long learning and evidence-based medicine to train physicians capable of accessing and interpreting the expansive medical literature.LGHartRADeyoDCCherkinPhysician office visits for low back pain.Spine.1995;20:11-19.RASternbachSurvey of pain in the United States: the Nuprin pain report.Clin J Pain.1986;2:49-53.LSReisbordSGreenlandFactors associated with self-reported back pain prevalence: a population based study.J Chronic Dis.1985;38:691-702.JWFrymoyerWLCats-BarilAn overview of the incidences and costs of low back pain.Orthop Clin North Am.1991;22:263-271.DCCherkinRADeyoKWheelerMACiolPhysician variation in diagnostic testing for low back pain: who you see is what you get.Arthritis Rheum.1994;37:15-22.DCCherkinRADeyoKWheelerMACiolPhysicians' views about treating low back pain: the results of a national survey.Spine.1995;20:1-10.VMTaylorRADeyoDCCherkinWKreuterLow back pain hospitalization: recent United States trends and regional variations.Spine.1994;19:1207-1213.TSCareyJGarrettPatterns of ordering diagnostic tests for patients with acute low back pain: the North Carolina Back Pain Project.Ann Intern Med.1996;125:807-814.SJBigosORBowyerGRBraenAcute Low Back Problems in Adults: Clinical Practice Guideline.No. 14.Rockville, Md: US Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; December 1994. Publication 95-0642.AKBurtonGWaddellClinical guidelines in the management of low back pain.Baillieres Clin Rheumatol.1998;12:17-35.MVanAmringeTShannonAwareness, Assimilation, and Adoption: The Challenge of Effective Dissemination and the First AHCPR-Sponsored Guidelines.Rockville, Md: US Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; January 1993. Publication 93-0028.DCCherkinKJWheelerWBarlowRADeyoMedication use for low back pain in primary care.Spine.1998;23:607-614.DKFreebornDShyeJPMulloolySErakerJRomeoPrimary care physicians' use of lumbar spine imaging tests: effects of guidelines and practice pattern feedback.J Gen Intern Med.1997;12:619-625.MESuarez-AlmazorEBelseckARussellJMackelUse of lumbar radiographs for the early diagnosis of low back pain: proposed guidelines would increase utilization.JAMA.1997;277:1782-1786.PLittleTCantrellLRobertsJChapmanJLangridgeRPickeringWhy do GP's perform investigations? the medical and social agendas in arranging back x-rays.Fam Pract.1998;15:264-265.PLittleLSmithTCantrellJChapmanJLangridgeRPickeringGeneral practitioners' management of acute back pain: a survey of reported practice compared with clinical guidelines.BMJ.1996;312:485-488.DADavisMAThomsonADOxmanRBHaynesChanging physician performance: a systematic review of the effect of continuing medical education strategies.JAMA.1995;274:700-05.DADavisATTaylor-VaiseyTranslating guidelines into practice: A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines.CMAJ.1997;157:408-416.LABeroRGrilliJMGrimshawEHarveyADOxmanMAThomsonClosing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings.BMJ.1998;317:465-468.WSSchrothPractice Guidelines in Primary Care: Abstract, Executive Summary and Final Report.Rockville, Md: US Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; August 1996. Publication 97-22, National Technical Information Service accession PB97-127328.SRTunisRSHaywardMCWilsonInternist' attitudes about clinical practice guidelines.Ann Intern Med.1994;120:956-963.PAJamesTMCowanRPGrahamBAMajeroniFamily physicians' attitudes about and use of clinical practice guidelines.J Fam Pract.1997;45:341-347.PAJamesTMCowanRPGrahamPatient-centered clinical decisions and their impact on physician adherence to clinical guidelines.J Fam Pract.1998;46:311-318.Accepted for publication September 14, 2000.The authors wish to acknowledge the contributions of Michael Glasser, PhD; the Department of Family and Community Medicine, University of Illinois College of Medicine at Rockford; Rockford Health System; OSF (Order of Saint Francis) Saint Anthony Medical Center; and Swedish American Health System in supporting the completion of this study.Corresponding author: Daniel R. Di Iorio, MD, DC, 1 S 570 Nimitz Rd, Oakbrook Terrace, IL 60181 (e-mail: dr.dan.diiorio@att.net).

Journal

Archives of Family Medicine – American Medical Association

Published: Nov 1, 2000

References

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