As part of my on-going review of the literature which is then used in the case management part of the OPC-DM part of our practice as well as used in the updating of the Carswell Publications Return to Work Compliance Toolkit and the Lower Back and Neck Pain books I come across scientific articles which I think will be of interest to our clients and readers.
This is an important article and study amongst many which still find to this day that General Practitioners in particular, and those with the most experience do not use the Evidence Based Guidelines published extensively for the treatment and management of low back and sciatica.
Could this be the reason why outcomes for treatment of low back pain are so dismal at best and why return to work rates following low back pain and sciatica are so poor in Canadian workplaces?
Have a read and let me know if you think employers need to impact health care standards in Canada.
Should the Canadian Public and employers start to question GP’s more about their standards of care and outcomes?
Jane Sleeth Physiotherapist optimalperformance.ca and Author Carswell.com
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From the Journal of Gen Intern Med. 2005 December; 20(12): 1132–1135.
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PMCID: PMC1490268
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Copyright 2005 by the Society of General Internal Medicine
Physicians’ Initial Management of Acute Low Back Pain Versus Evidence-Based Guidelines Influence of Sciatica
1Center for Disability Research, Liberty Mutual Research Institute for Safety, Hopkinton, MA, USA
4Department of Environmental Health, Occupational Health Program, Harvard School of Public Health, Boston, MA, USA.
The Liberty Mutual Research Institute for Safety is owned and operated by the Liberty Mutual Insurance Company. The Institute conducts original scientific investigations into the causes and prevention of job-related injuries and disability. All research is published in peer-reviewed journals in science, engineering, or medicine.
Background
Little information is available on physician characteristics and patient presentations that may influence compliance with evidence-based guidelines for acute low back pain.
Objective
To assess whether physicians’ management decisions are consistent with the Agency for Health Research Quality’s guideline and whether responses varied with the presentation of sciatica or by physician characteristics.
Design
Cross-sectional study using a mailed survey.
Participants
Participants were randomly selected from internal medicine, family practice, general practice, emergency medicine, and occupational medicine specialties.
Measurements
A questionnaire asked for recommendations for 2 case scenarios, representing patients without and with sciatica, respectively.
Results
Seven hundred and twenty surveys were completed (response rate=25%). In cases 1 (without sciatica) and 2 (with sciatica), 26.9% and 4.3% of physicians fully complied with the guideline, respectively. For each year in practice, the odds of guideline noncompliance increased 1.03 times for case 1. With occupational medicine as the referent specialty, general practice had the greatest odds of noncompliance (3.60, 95%) in case 1, followed by internal medicine and emergency medicine. Results for case 2 reflected the influence of sciatica with internal medicine having substantially higher odds (vs case 1) and the greatest odds of noncompliance of any specialty (6.93, 95%) followed by family practice and emergency medicine.
Conclusions
A majority of primary care physicians continue to be non compliant with evidence-based back pain guidelines. Sciatica dramatically influenced clinical decision-making, increasing the extent of noncompliance, particularly for internal medicine and family practice. Physicians’ misunderstanding of sciatica’s natural history and belief that more intensive initial management is indicated may be factors underlying the observed influence of sciatica.
Keywords: back pain, guidelines, practice variation, clinical vignette, decision making
Low back pain affects up to 80% of the working population during their lifetime and is the second most common reason for physician visits 1 and for work disability.2 Back pain accounts for an estimated $25 billion in annual medical costs in the United States.3
Factors related to the extensive burden of back pain may include variations in physicians’ clinical management as the etiology of back pain is unclear.1,4 Clinical practice guidelines have been systematically developed to improve health care quality and reduce ineffective treatments. A number of evidence-based guidelines for the clinical management of acute back pain in primary care have been published since the first in 1987,5 including the Agency for Healthcare Research and Quality (AHRQ, previously named the Agency for Health Care Policy and Research) guideline in 1994.6 More recent guidelines are based on newer evidence but have similar diagnostic and therapeutic recommendations to the AHRQ guideline.7
All guidelines recommend an initial evaluation to identify the approximately 5% of patients who present with “red flags.” Red flags are those findings that suggest significant pathology (i.e., vertebral fracture, tumor, infection, cauda equina syndrome, or serious nonspinal conditions) that require diagnostic studies and/or specialty referral as part of initial management.6
After ruling out such serious conditions, cases are categorized as nonspecific back pain or sciatica (approximately 85% and 5% of cases, respectively). Disabling symptoms are expected to resolve in up to 90% of patients within the first month, including over 50% of those with sciatica.8 The guideline intent is to change the care focus for both categories of back pain from pain relief to improved activity tolerance, and to limit unnecessary diagnostic and clinical treatment interventions during this period.6
Despite the proliferation of evidence-based back pain guidelines, prior studies, based on chart reviews or physician surveys, found a lack of consensus and compliance with them.9–13 However, these studies were based either on a small sample size, a single specialty group, or were completed more than a decade ago. This study’s purpose was to assess the extent to which the clinical decision-making in a more recent, national sample of primary care physicians was consistent with the guideline, and whether responses varied with the presentation of sciatica or by physician characteristics.6
METHODS
Questionnaire Development
A 2-page questionnaire was developed to assess physicians’ clinical approach to 2 case scenarios of back pain. Scenarios were designed to represent different diagnoses: case 1 representing nonspecific back pain and case 2 representing sciatica with neurological findings. However, neither case presented with “red flags;” therefore, during the first month of care, the guideline recommendations for both require only minimal clinical intervention, and neither requires diagnostic testing. Physicians were asked to indicate the diagnostic and treatment modalities they would order for initial management of each case and whether they would consider specialty or surgical referral. Demographic information (age, gender, years in practice, and frequency treating back pain patients) was also requested.
DISCUSSION
Surveyed physicians departed from the AHRQ guideline to some extent for the case with nonspecific back pain. However, those in general practice and internal medicine and, to a lesser extent, those in emergency medicine, were significantly more likely to choose at least 1 non evidence-based intervention for patients without sciatica.
In case 2, sciatica dramatically influenced clinical decision-making with almost all physicians selecting at least 1 non evidence-based intervention. Increases in noncompliance within internal medicine and family practice were particularly substantial. Between-specialty differences were also pronounced, even when controlling for years in practice and gender. While a diagnosis of sciatica might suggest more intensive clinical intervention, the guidelines for the first month still recommend conservative interventions to allow time for symptom resolution (which occurs in over 50% of patients with sciatica) and for the patient to overcome activity limitations. More intensive management approaches may inhibit activity restoration and have been shown to prolong disability.
The significance of years in practice in noncompliance is consistent with the results of a recent systematic review of empirical studies. More-experienced physicians were found to demonstrate less knowledge, be less likely to follow standards of practice, and have less successful outcomes.
CONCLUSIONS
More than a decade after promulgation of evidence-based guidelines for low back pain, a majority of primary care physicians continued to be non compliant. Sciatica dramatically influenced clinical decision-making, increasing the extent of noncompliance, particularly for internal medicine and family practice. More-experienced physicians were less compliant than their colleagues, irrespective of diagnosis.
Reasons suggested for not following practice guidelines include lack of awareness, familiarity, self-efficacy, or outcome expectancy, and inertia of previous practice or external barriers.