Utilization of medical services for the treatment of acute low back pain: conformance with clinical guidelines

Sacrum magnetic resonance imaging for low back and tail bone pain: A quality initiative to evaluate and improve imaging utility

As quality and cost effectiveness become essential in clinical practice, an evidence-based evaluation of the utility of imaging orders becomes an important consideration for radiology’s value in patient care. We report an institutional quality improvement project including a retrospective review of utility of sacrum magnetic resonance (MR) imaging for low back pain at our institution over a four-year period and follow-up results after physician education intervention. Sacral MR imaging for low back pain and tailbone pain were only positive for major findings in 2/98 (2%) cases, and no major changes in patient management related to imaging findings occurred over this period, resulting in almost $500000 cost without significant patient benefit. We distributed these results to the Family Medicine department and clinics that frequently placed this order. An approximately 83% drop in ordering rate occurred over the ensuing 3 mo follow-up period. Sacrum MR imaging for low back pain and tail bone pain has not been a cost-effective diagnostic tool at our institution. Physician education was a useful tool in reducing overutilization of this study, with a remarkable drop in such studies after sharing these findings with primary care physicians at the institution. In conclusion, sacrum MR imaging rarely elucidates the cause of low back/tail pain diagnosed in a primary care setting and is even less likely to result in major changes in management. The practice can be adopted in other institutions for the benefit of their patients and improve cost efficiency.

What do we really know about the appropriateness of radiation emitting imaging for low back pain in primary and emergency care? A systematic review and meta-analysis of medical record reviews

Background

Since 2000, guidelines have been consistent in recommending when diagnostic imaging for low back pain should be obtained to ensure patient safety and reduce unnecessary tests. This systematic review and meta-analysis was conducted to determine the pooled proportion of CT and x-ray imaging of the lumbar spine that were considered appropriate in primary and emergency care.

Methods

Pubmed, CINAHL, The Cochrane Database of Systematic Reviews and Embase were searched for synonyms of “low back pain”, “guidelines”, and “adherence” that were published after 2000. Titles, abstracts, and full texts were reviewed for inclusion with forward and backward tracking on included studies. Included studies had data extracted and synthesized. Risk of bias was performed on all studies, and GRADE was performed on included studies that provided data on CT and x-ray separately. A random effect, single proportion meta-analysis model was used.

Results

Six studies were included in the descriptive synthesis, and 5 studies included in the meta-analysis. Five of the 6 studies assessed appropriateness of x-rays; two of the six studies assessed appropriateness of CTs. The pooled estimate for appropriateness of x-rays was 43% (95% CI: 30%, 56%) and the pooled estimate for appropriateness of CTs was 54% (95% CI: 51%, 58%). Studies did not report adequate information to fulfill the RECORD checklist (reporting guidelines for research using observational data). Risk of bias was high in 4 studies, moderate in one, and low in one. GRADE for x-ray appropriateness was low-quality and for CT appropriateness was very-low-quality.

Conclusion

While this study determined a pooled proportion of appropriateness for both x-ray and CT imaging for low back pain, there is limited confidence in these numbers due to the downgrading of the evidence using GRADE. Further research on this topic is needed to inform our understanding of x-ray and CT appropriateness in order to improve healthcare systems and decrease patient harms.

Utility of Patient-reported Symptoms and Health Conditions for Predicting Surgical Candidacy and Utilization of Surgery via an Outpatient Spine Clinic Nomogram

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

Identify the nonradiographic predictors of a patient's decision to undergo elective spine surgery.

SUMMARY OF BACKGROUND DATA

Up to 132 million people seek elective evaluation by spine surgeons annually, though 55%-82% of specialty referrals may be inappropriate. We sought to determine which clinical and psychosocial factors are associated with surgical utilization by patients seeking surgical evaluation for degenerative spine pathologies.

MATERIALS AND METHODS

Consecutive elective outpatient visits seen in a single clinic between May 2016 and April 2017 for degenerative spine pathologies were reviewed. Data were collected on presenting symptoms, baseline medical illness, demographics, and previous spine care. Multivariable logistic regressions were performed to determine which factors were associated with surgical candidacy and surgical utilization.

RESULTS

A total of 353 patients were seen during the period reviewed, of which 144 had complete medical records. Our cohort included 90 nonsurgical candidates, 25 surgical candidates who declined surgery, and 29 patients who underwent surgery. In multivariable analysis, factors negatively associated with surgical candidacy were age, a history of smoking, and osteoporosis, where those positively associated with surgical candidacy were reports of spine-specific pain, higher Charlson Comorbidity Index, pain medication use, number of neurological symptoms, and being myelopathic. Factors positively associated with surgical utilization included proportion of all complaints that were neurological in nature, being myelopathic, higher Charlson Comorbidity Index, and report of pain as chronic, whereas being osteoporotic was negatively associated with surgical use. A receiver operating curve constructed for these models produced c-statistics of 0.75 and 0.80, respectively.

CONCLUSIONS

Our results suggest that the results of standard clinic intake questions, such as review of systems, medical history, and chief complaints, may be predictive of surgical candidacy before evaluation by a surgeon. The present pilot study suggests a preliminary algorithm that can be further validated and expanded upon to help decide on optimal patient referrals to spine surgery specialists.

Methods to detect inappropriate use of MRI and CT for musculoskeletal conditions: A scoping review

OBJECTIVE

Identify and evaluate methods suitable for detecting inappropriate use of MRI or CT in the musculoskeletal system.

DESIGN

Systematic review of studies that described methods to measure inappropriate use of MRI or CT in the musculoskeletal system. We used a multi-step strategy to classify identified methods into categories. These categories were then analyzed according to the data needed and their limitations.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

English or German language studies that measured inappropriate use of MRI or CT in the musculoskeletal system. Articles were also included if they reported a general approach to the measurement of inappropriate imaging regardless of body region. Expert opinions, unsystematic reviews, commentaries, articles without abstracts, and studies on cancer were excluded.

RESULTS

47 studies met the inclusion criteria. The categorization of the studies resulted in seven individual approaches to measure inappropriate use: (1) availability of meaningful diagnostic information; (2) predictors associated with imaging use; (3) comparison with guideline recommendations; (4) assessment by experts; (5) comparison or analysis of patients' paths; (6) comparison with surgery findings; (7) geographic variation. All these approaches have specific data requirements and individual advantages and disadvantages regarding risk of bias and needed data.

CONCLUSIONS

We could not find a single method of choice to detect inappropriate use of MRI or CT in the musculoskeletal system. A combination of different approaches is the preferred strategy to deal with the advantages and disadvantages of the individual methods.

A Day in the Life of MRI: The Variety and Appropriateness of Exams Being Performed in Canada

Purpose

This study aimed to determine the volumes and types of magnetic resonance imaging exams being performed across Canada, common indications for the exams, and exam appropriateness using multiple evaluation tools.

Methods

Thirteen academic medical institutions across Canada participated. Data were obtained relating to a single common day, October 1, 2014. Patient demographics, type by anatomic region and indication for imaging were analysed. Each exam was assessed for appropriateness via the Canadian Association of Radiologists Referral Guidelines and the American College of Radiology Appropriateness Criteria. The Alberta and Saskatchewan spine screening forms and the Alberta knee screening form were also used where applicable. The proportion of exams that were unscorable, appropriate, and inappropriate was determined. Exam-level results were compared between the 2 main evaluation tools.

Results

Data were obtained for 1087 relevant exams. There were 591 women and 460 men. 36 requisitions did not indicate the patient's sex. Brain exams were the most common, comprising 32.5% of the sample. Cancer was the most common indication. Overall, 87.0%–87.4% of the MR exams performed were appropriate; 6.6%–12.6% were inappropriate, based on the 2 main evaluation tools. Results differed by anatomic region; spine exams had the highest proportion, with nearly one-third of exams deemed inappropriate.

Conclusion

Variations by anatomic region indicate that focused exam request evaluation or screening methods could substantially reduce inappropriate imaging.

Back Pain in a Pediatric Emergency Department: Etiology and Evaluation

OBJECTIVES

Back pain is an uncommon chief complaint in the pediatric emergency department (ED). However, there are serious underlying conditions requiring prompt diagnosis and treatment. While the etiology is usually benign, variation exists in the evaluation. The study purpose was to describe pediatric patients who presented to the ED with back pain and evaluate for associations with laboratory and radiologic abnormalities indicative of underlying musculoskeletal pathology.

METHODS

A retrospective review was conducted of patients aged birth to 18 years who presented to a pediatric ED with a chief complaint of back pain during a 1-year period. Primary outcome was discharge diagnosis, categorized as nonpathologic back pain, pathologic back pain, and other etiologies. Descriptive statistics were used.

RESULTS

Two-hundred thirty-two patient encounters were reviewed, with 177 included in data analysis. A nonpathologic diagnosis of back pain was found in 76.8% of visits. Back pain and back or muscle strain were the most common diagnoses. Pathologic back pain diagnoses represented 2.3% of visits. Radiologic imaging was performed in 37.9%. Positive findings were noted in 16.9% of radiographs; no abnormalities were noted on computed tomography scan or magnetic resonance imaging. Laboratory studies were conducted in 35%. Abnormal plain radiographs were associated with a pathologic diagnosis of back pain (P < 0.001).

CONCLUSIONS

Most pediatric patients presenting to the ED with back pain were found to have a nonpathologic etiology and were discharged. Among those with a pathologic back pain diagnosis, abnormal radiograph findings were the only statistically significant factor, whereas laboratory studies, computed tomography scans, and magnetic resonance imaging scans were less indicative.

Reuse and reduce: abdominal CT, lumbar spine MRI, and a potential 1.2 to 3.4 billion dollars in cost savings

PURPOSE

To determine how much money could potentially be saved by re-evaluating a patient's prior recent abdominal CT for lumbar spine pathology instead of ordering a lumbar spine MRI.

METHODS

Abdominal CT studies, from all consecutive patients who had an abdominal CT within 12 months prior to a lumbar spine MRI obtained between 11/1/15 and 5/30/16, were retrospectively reviewed in a blinded fashion for the presence of any significant lumbar spine abnormalities. CT studies that accurately reflected all normal and abnormal findings when compared to the standard of reference, the prospectively interpreted lumbar spine MR imaging reports, were used to indicate which lumbar spine MRI studies potentially could have been avoided and to calculate the potential cost savings.

RESULTS

Of the 81 abdominal CT studies that met the inclusion criteria of this study, 62% (50/81) were TP, 28% (23/81) were TN, 5% (4/81) were FP, and 5% (4/81) were FN studies. 90% (73/81) of the lumbar spine MRI studies could potentially have been avoided during the 7 months of this study. The predicted savings by reviewing the abdominal CT for lumbar spine abnormalities prior to ordering a lumbar spine MRI are an estimated 1.2-3.4 billion dollars per year.

CONCLUSION

Recent abdominal CT studies should be reviewed for lumbar spine pathology prior to a patient undergoing lumbar spine MRI. Avoiding unnecessary lumbar spine MRI studies could potentially save the U.S. healthcare system an estimated 1.2-3.4 billion dollars per year.

The assessment and treatment of back and neck pain: an initial investigation in a primary care practice-based research network

AIM

The purpose of this study was to conduct an exploratory examination of the current state of non-malignant acute and chronic back and neck pain assessment and management among primary care providers in a multi-site, practice-based research network.

BACKGROUND

Acute and chronic pain are distinct conditions that often require different assessment and management approaches, however, little research has examined assessment and management of acute and chronic pain as separate conditions. The large majority of patients with acute and chronic back and neck pain are managed in primary care settings. Given the differences between acute and chronic pain, it is necessary to identify differences in patient characteristics, practitioner evaluation, treatment and management in primary care settings.

METHODS

Over a two-week period, 24 practitioners in a multi-site practice-based research network completed 196 data cards about 39 patients experiencing acute back and neck pain and 157 patients suffering from chronic back and neck pain. Findings There were significant differences between the patients experiencing acute and chronic pain in regards to practitioner evaluation, current medication management and current treatment for depression. In addition, diagnostics differed between patients experiencing acute versus chronic back and neck pain. Further, primary care providers' review of online drug monitoring program reports during the current visit was associated with current medication management using short term opioids, long-term opioids or tramadol. Most research examining acute and chronic pain focuses on the low back. Additional research needs to be conducted to explore and compare acute and chronic pain across the whole spine.

A systematic review of diagnostic imaging use for low back pain in the United States

BACKGROUND CONTEXT

Various studies have reported on the increasing use and costs of diagnostic imaging for low back pain (LBP) in the United States. However, it is unclear whether the methods used in these studies allowed for meaningful comparisons or whether the reported use data can be used to develop evidence-based use benchmarks.

PURPOSE

The primary purpose of this study was to review previous estimates of the use of diagnostic imaging for LBP in the United States.

STUDY DESIGN/SETTING

The study design is a systematic review of published literature.

METHODS

A search through May 2012 was conducted using keywords and free text terms related to health services and LBP in Medline and Health Policy Reference; results were screened for relevance independently, and full-text studies were assessed for eligibility. Only studies published in English since the year 2000 reporting on use of diagnostic imaging for LBP using claims data from the United States were included. Reporting quality was assessed using a modified Downs and Black tool for observational studies.

RESULTS

The search strategy yielded 1,102 citations, seven of which met the criteria for eligibility. Studies reported use from commercial health plans (N=4) and Medicare (N=3), with sample sizes ranging from 13,760 to 740,467 members with LBP from specific states or across the United States. The number of diagnostic codes used to identify nonspecific LBP ranged from 2 to 66; other heterogeneity was noted in the methods used across these studies. In commercial health plans, use of radiography occurred in 12.0% to 32.2% of patients with LBP, magnetic resonance imaging (MRI) was used in 16.0% to 21.0%, computed tomography (CT) was used in 1.4% to 3.0%, and MRI and/or CT was used in 10.9% to 16.1%. Findings in Medicare populations were 22.9% to 48.2% for radiography, 11.6% for MRI, and 10.4% to 16.3% for MRI and/or CT.

CONCLUSIONS

The reported use of diagnostic imaging for LBP varied across the studies reviewed; differences in methodology made meaningful comparisons difficult. Standardizing methods for performing and reporting analyses of claims data related to use could facilitate efforts by third-party payers, health care providers, and researchers to identify and address the perceived overuse of diagnostic imaging for LBP.

Diagnostic imaging for spinal disorders in the elderly: a narrative review

The high prevalence of neck and low back pain in the rapidly aging population is associated with significant increases in health care expenditure. While spinal imaging can be useful to identify less common causes of neck and back pain, overuse and misuse of imaging services has been widely reported. This narrative review aims to provide primary care providers with an overview of available imaging studies with associated potential benefits, adverse effects, and costs for the evaluation of neck and back pain disorders in the elderly population. While the prevalence of arthritis and degenerative disc disease increase with age, fracture, infection, and tumor remain uncommon. Prevalence of other conditions such as spinal stenosis and abdominal aortic aneurysm (AAA) also increase with age and demand special considerations. Radiography of the lumbar spine is not recommended for the early management of non-specific low back pain in adults under the age of 65. Aside from conventional radiography for suspected fracture or arthritis, magnetic resonance imaging (MRI) and computed tomography (CT) offer better characterization of most musculoskeletal diseases. If available, MRI is usually preferred over CT because it involves less radiation exposure and has better soft-tissue visualization. Use of subspecialty radiologists to interpret diagnostic imaging studies is recommended.

Ten-year survey reveals differences in GP management of neck and back pain

PURPOSE

Clinical guidelines provide similar recommendations for the management of new neck pain and low back pain (LBP) but it is unclear if general practitioner's (GP) care is similar. While GP's management of LBP is well documented, little is known about GP's management of neck pain. We aimed to describe GP's management of new neck pain and compare this to GP's management of new LBP in Australia between April 2000 and March 2010.

METHODS

All GP-patient encounters for a new (i.e. first visit to any medical practitioner) neck pain or LBP problem were compared in terms of treatment delivered, referral patterns and requests for laboratory and imaging investigations.

RESULTS

General practitioners in Australia have managed new neck pain and LBP problems at a rate of 3.1 and 5.8 per 1,000 GP-patient encounters, respectively. GP's primarily utilised medications, in particular non-steroidal anti-inflammatory drugs, to manage new neck and LBP problems and referred approximately 25% of all patients for imaging. Patients with new neck pain are more frequently managed using physical treatments and were referred more often to allied health professionals and specialists. In comparison, patients with new LBP were managed more frequently with medication, advice, provision of a sickness certificate and ordering of pathology tests.

CONCLUSIONS

This is the first time GP management of a new episode of neck pain has been documented using a nationally representative sample and it is also the first time that the management of back and neck pain has been compared. Despite guidelines endorsing a similar approach for the management of new neck pain and LBP, in actual clinical practice Australian GPs manage these two conditions differently.

Primary care clinician adherence to guidelines for the management of chronic musculoskeletal pain: results from the study of the effectiveness of a collaborative approach to pain

OBJECTIVE

We assessed primary care clinician-provided guideline-concordant care as documented in patients' medical records, predictors of documented guideline-concordant care, and its association with pain-related functioning. Patients were participants in a randomized trial of collaborative care for chronic musculoskeletal pain. The intervention featured patient and primary care clinician education, symptom monitoring and feedback to clinicians by the intervention team.

METHODS

To assess concordance with the evidence-based treatment guidelines upon which our intervention was based, we developed an 8-item chart review tool, the Pain Process Checklist (PPC). We then reviewed electronic medical records for 365 veteran patients treated by 42 primary care clinicians over 12 months. Intervention status, demographic, and clinical variables were tested as predictors of PPC scores using generalized estimating equations (GEE). GEE was also used to test whether PPC scores predicted treatment response (≥30% decrease in Roland-Morris Disability Questionnaire score).

RESULTS

Rates of documented guideline-concordant care varied widely among PPC items, from 94% of patients having pain addressed to 17% of patients on opioids having side effects addressed. Intervention status was unrelated to item scores, and PPC-7 totals did not differ significantly between intervention and treatment-as-usual patients (61.2%, standard error [SE] = 3.3% vs 55.2%, SE = 2.6%, P = 0.15). In a multivariate model, higher PPC-7 scores were associated with receiving a prescription for opioids (odds ratio [OR] = 1.07, P = 0.007) and lower PPC-7 scores with patient age (10-year difference OR = 0.97, P = 0.004). Finally, intervention patients who received quantitative pain and depression assessments were less likely to respond to treatment (assessed vs not: 18% vs 33%, P = 0.008, and 13% vs 28%, P = 0.001, respectively).

CONCLUSIONS

As measured by medical record review, additional training and clinician feedback did not increase provision of documented guideline-concordant pain care, and adherence to guidelines by primary care clinicians did not improve clinical outcomes for patients with chronic musculoskeletal pain.

[Quality indicators for managing patients with low back pain]

INTRODUCTION

Low back pain (LBP) is an epidemiologically and economically relevant health care problem appropriate for quality assurance approaches. Therefore an expert panel (AQUIK) of the National Association of Statutory Health Insurance Physicians has proposed three quality indicators (QI) for monitoring the quality of ambulatory care for LBP. The aim of this article is to present and evaluate the proposed QIs.

MATERIAL AND METHODS

The three proposed QIs relating to red flags, imaging and sick leave certificates were evaluated with regard to the underpinning evidence, epidemiology and feasibility. Guidelines and original research as well results from surveys and observational studies evaluating adherence to LBP guidelines were used for assessment.

RESULTS

The expert panel concluded that only the recording of red flags is a relevant and feasible QI. Despite a two-stage expert method the epidemiology of LBP, feasibility and existing routine health care data were not sufficiently taken into account. The author's conclusion differs in two instances. The red flag concept is not sufficiently clinically validated and recordable to be used as a QI. Otherwise imaging is considered a suitable QI given the observed overuse and the availability of billing data.

CONCLUSION

Deriving valid and pragmatic QI from LBP guidelines for evaluating care for LBP is difficult. The core messages of guidelines are only recommendations with limited precision and transferability to individual patients. For pragmatic reasons definition of an upper or lower proportion of patients receiving a given health care service is recommended instead of tedious individual evaluation. Reasonable estimates can be based on data from research on health care services. Because of this uncertainty QIs should be evaluated before they are used as a steering instrument.

In the eye of the beholder: preferences of patients, family physicians, and surgeons for lumbar spinal surgery

STUDY DESIGN

Survey to all orthopedic and neurosurgeons, a random sample of family physicians (FPs) and patients in Ontario, Canada.

OBJECTIVE

To identify the dominant clinical factors influencing patient and physician preferences for lumbar spinal surgery.

SUMMARY OF BACKGROUND DATA

Surgery on the degenerative lumbar spine offers significant benefit for patients with moderate-severe symptoms failing nonoperative treatment. Referring FPs have little appreciation of factors that identify the ideal surgical candidate. Differences in preferences may lead to wide variation in referrals and impedes the shared decision-making process.

METHODS

We used conjoint analysis, a rigorous method for eliciting preferences, to determine the importance that respondents place on decisions for lumbar spinal surgery. We identified 6 clinical factors (walking tolerance, pain duration, severity, neurologic symptoms, typical onset, and dominant location of pain) and presented hypothetical vignettes to participants who rated their preference for surgery. Data were analyzed using random-effects ordered probit regression models and the importance of each clinical factor relative to the others was determined.

RESULTS

We obtained responses from 131 surgeons, 202 FPs, and 164 patients. We found that FPs had the highest overall preferences for surgery and surgeons had the lowest. Surgeons placed the highest importance on the location of pain. FPs considered neurologic symptoms, walking tolerance, and severity to be of similar importance. Pain severity, walking tolerance, and duration of pain were the most important factors for patients in deciding for surgery. Orthopedic (over neurosurgical) surgeons had a lower preference for surgery (P < 0.05). Older patients (P < 0.03) and previous surgical consultation (P < 0.03) had greater patient preferences for surgery.

CONCLUSION

Different preferences for surgery exist between surgeons, FPs, and patients. FPs may reduce over- and under-referrals by appreciating surgeons' importance on location of pain (leg vs. back). Surgeons and FPs may improve the shared decision-making process by understanding that patients place high importance on quality of life symptoms.

Overtreating chronic back pain: time to back off?

Chronic back pain is among the most common patient complaints. Its prevalence and impact have spawned a rapidly expanding range of tests and treatments. Some of these have become widely used for indications that are not well validated, leading to uncertainty about efficacy and safety, increasing complication rates, and marketing abuses. Recent studies document a 629% increase in Medicare expenditures for epidural steroid injections; a 423% increase in expenditures for opioids for back pain; a 307% increase in the number of lumbar magnetic resonance images among Medicare beneficiaries; and a 220% increase in spinal fusion surgery rates. The limited studies available suggest that these increases have not been accompanied by population-level improvements in patient outcomes or disability rates. We suggest a need for a better understanding of the basic science of pain mechanisms, more rigorous and independent trials of many treatments, a stronger regulatory stance toward approval and post-marketing surveillance of new drugs and devices for chronic pain, and a chronic disease model for managing chronic back pain.

Low Back Pain in Older Adults: Are We Utilizing Healthcare Resources Wisely?

OBJECTIVES

1) To examine recent change in prevalence and Medicare-associated charges for non-invasive/minimally invasive evaluation and treatment of nonspecific low back pain (LBP); and 2) to examine magnetic resonance imaging (MRI) utilization appropriateness in older adults with chronic low back pain (CLBP).

DESIGN

Two cross-sectional surveys of 1) national (1991-2002) and Pennsylvania (2000-2002) Medicare data; and 2) patients aged >or= 65 years with CLBP.

SETTING

Outpatient data.

PARTICIPANTS

Patients aged >or= 65 years with LBP.

MEASUREMENTS

Study 1: Outpatient national and Pennsylvania Part A Medicare data were examined for number of patients and charges for all patients, and for those with nonspecific LBP. Total number of visits and charges for imaging studies, physical therapy (PT), and spinal injections was also examined for Pennsylvania. Study 2: 111 older adults with CLBP were interviewed regarding presence of red flags necessitating imaging and history of having a lumbar MRI, neurogenic claudication (NC), and back surgery.

RESULTS

Study 1: Between 1991 and 2002, there was a 42.5% increase in total Medicare patients, 131.7% increase in LBP patients, 310% increase in total charges, and 387.2% increase in LBP charges. In Pennsylvania (2000-2002), there was a 5.5% increase in LBP patients and 33.2% increase in charges (0.2% for PT, 59.4% for injections, 41.9% for MRI/CT, and 19.3% for X rays). Study 2: None of the 111 participants had red flags and 61% had undergone MRIs (29% with NC, 24% with failed back surgery syndrome).

CONCLUSION

LBP documentation and diagnostic studies are increasing in Medicare beneficiaries, and evidence suggests that MRIs may often be ordered unnecessarily. Injection procedures appear to account for a significant proportion of LBP-associated costs. More studies are needed to examine the appropriateness with which imaging procedures and non-invasive/minimally invasive treatments are utilized, and their effect on patient outcomes.

Routine primary care management of acute low back pain: adherence to clinical guidelines

One of the major challenges for general practitioners is to manage individuals with acute low back pain appropriately to reduce the risk of chronicity. A prospective study was designed to assess the actual management of acute low back pain in one primary care setting and to determine whether existing practice patterns conform to published guidelines. Twenty-four family physicians from public primary care centers of the Basque Health Service in Bizkaia, Basque Country (Spain), participated in the study. A total of 105 patients aged 18-65 years presenting with acute low back pain over a 6-month period were included. Immediately after consultation, a research assistant performed a structured clinical interview. The patients' care provided by the general practitioner was compared with the Agency for Health Care Policy and Research (AHCPR) guidelines and guidelines issued by the Royal College of General Practitioners. The diagnostic process showed a low rate of appropriate use of history (27%), physical examination (32%), lumbar radiographs (31%), and referral to specialized care (33%). Although the therapeutic process showed a relatively high rate of appropriateness in earlier mobilization (77%) and educational advice (65%), only 23% of patients were taught about the benign course of back pain. The study revealed that management of acute low back pain in the primary care setting is far from being in conformance with published clinical guidelines.

Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain

OBJECTIVE

The effect of clinical guidelines on resource utilization for complex conditions with substantial barriers to clinician behavior change has not been well studied. We report the impact of a multifaceted guideline implementation intervention on primary care clinician utilization of radiologic and specialty services for the care of acute low back pain.

DESIGN

Physician groups were randomized to receive guideline education and individual feedback, supporting patient education materials, both, or neither. The impact on guideline adherence and resource utilization was evaluated during the 12-month period before and after implementation.

PARTICIPANTS

Fourteen physician groups with 120 primary care physician and associate practitioners from 2 group model HMO practices.

INTERVENTIONS

Guideline implementation utilized an education/audit/feedback model with local peer opinion leaders. The patient education component included written and videotaped materials on the care of low back pain.

MAIN RESULTS

The clinician intervention was associated with an absolute increase in guideline-consistent behavior of 5.4% in the intervention group versus a decline of 2.7% in the control group (P =.04). The patient education intervention produced no significant change in guideline-consistent behavior, but was poorly adopted. Patient characteristics including duration of pain, prior history of low back pain, and number of visits during the illness episode were strong predictors of service utilization and guideline-consistent behavior.

CONCLUSIONS

Implementation of an education and feedback-supported acute low back pain care guideline for primary care clinicians was associated with an increase in guideline-consistent behavior. Patient education materials did not enhance guideline effectiveness. Implementation barriers could limit the utility of this approach in usual care settings.

Evaluation and treatment of low back pain: an evidence-based approach to clinical care

Low back pain is a common reason for patient visits to a health care provider. For most patients, low back symptoms are nonspecific, meaning that the pain is localized to the back or buttocks and is due to a presumed musculoligamentous process. For patients with radicular leg symptoms, a precise etiology is more commonly identified. The history and physical examination usually provide clues to the uncommon but potentially serious causes of low back pain, as well as to those patients at risk for prolonged recovery. Diagnostic testing should not be a routine part of the initial evaluation, but used selectively based upon the history, examination, and initial treatment response. For patients without significant neurological impairment, initial treatments should include activity modification, nonnarcotic analgesics, and education. For patients whose symptoms are not improving over 2 to 4 weeks, referral for physical treatments is appropriate. A variety of therapeutic options of limited or unproven benefit are available for patients with radicular leg symptoms or chronic low back pain. Patients with radicular pain and little or no neurological findings should receive conservative treatment, but elective surgery is appropriate for those with nerve root compression who are unresponsive to conservative therapy.

Patients' views on importance and usefulness of plain radiography for low back pain

STUDY DESIGN

Quantitative and qualitative cross-sectional interview study.

OBJECTIVES

To investigate how patients who are referred for plain radiography because of low back pain perceive the importance and usefulness of the examination.

SUMMARY OF BACKGROUND DATA

Up to 50% of plain radiography examinations for low back pain may be unnecessary based on clinical criteria. However, many patients have great confidence in these examinations. A further exploration of the patients' views may indicate how their needs can be met without unnecessary use of radiography.

METHODS

Ninety-nine patients (65 women, 34 men) 14-91 years of age who were referred from Norwegian general practitioners for plain radiography of the lumbosacral spine were asked to rate the examination as slightly/fairly or very important (93 responded). Chi-squared tests were used to evaluate differences in rating according to age, gender, clinical history, and clinical appropriateness of the examination, as determined by comparing information in the referral form with Norwegian (NR) and British (BR) recommendations for use of radiography. Each of the 99 patients also underwent a semistructured interview that was based on questions about importance, usefulness, and reasons for the radiography referral. Answers were categorized and described using a qualitative method (template analysis).

RESULTS

Seventy-two percent (68 of 93) of patients rated radiography as very important. The proportion was higher for men than women (85% vs. 65%, P = 0.04), higher for those with worsening than those with improving/unchanged symptoms (86% vs. 65%, P = 0.03), and higher for inappropriately than appropriately referred patients (NR: 76% vs. 61%, P = 0.17; BR: 81% vs. 56%, P = 0.01). The qualitative analysis showed that the patients related their views on the importance and usefulness of receiving radiography to seven different issues: symptoms and clinical history, information and advice (especially from health care providers), need for emotional support from the physician, need for certainty and reassurance, need for symptom explanation and diagnosis, reliability of radiography compared with clinical evaluation, and expected practical consequences of the radiologic examination.

CONCLUSIONS

The finding that inappropriately referred patients tended to rate their radiography referral as more important than appropriately referred patients indicates that the patient's view may be a substantial barrier to appropriate use of radiography. The study identified seven issues underlying the patients' views on importance and usefulness of receiving radiography. Strategies to prevent unnecessary use of plain radiography for low back pain that address these issues are suggested.

Evaluating and managing acute low back pain in the primary care setting

Acute low back pain is a common reason for patient calls or visits to a primary care clinician. Despite a large differential diagnosis, the precise etiology is rarely identified, although musculoligamentous processes are usually suspected. For most patients, back symptoms are nonspecific, meaning that there is no evidence for radicular symptoms or underlying systemic disease. Because episodes of acute, nonspecific low back pain are usually self-limited, many patients treat themselves without contacting their primary care clinician. When patients do call or schedule a visit, evaluation and management by primary care clinicians is appropriate. The history and physical examination usually provide clues to the rare but potentially serious causes of low back pain, as well as to identify patients at risk for prolonged recovery. Diagnostic testing, including plain x-rays, is often unnecessary during the initial evaluation. For patients with acute, nonspecific low back pain, the primary emphasis of treatment should be conservative care, time, reassurance, and education. Current recommendations focus on activity as tolerated (though not active exercise while pain is severe) and minimal if any bed rest. Referral for physical treatments is most appropriate for patients whose symptoms are not improving over 2 to 4 weeks. Specialty referral should be considered for patients with a progressive neurologic deficit, failure of conservative therapy, or an uncertain or serious diagnosis. The prognosis for most patients is good, although recurrence is common. Thus, educating patients about the natural history of acute low back pain and how to prevent future episodes can help ensure reasonable expectations.

Finding cancer in primary care outpatients with low back pain: a comparison of diagnostic strategies

OBJECTIVE

To compare strategies for diagnosing cancer in primary care patients with low back pain. Strategies differed in their use of clinical findings, erythrocyte sedimentation rate (ESR), and plain x-rays prior to imaging and biopsy.

DESIGN

Decision analysis and cost effectiveness analysis with sensitivity analyses. Strategies were compared in terms of sensitivity, specificity, and diagnostic cost effectiveness ratios.

SETTING

Hypothetical

MEASUREMENTS

Estimates of disease prevalence and test characteristics were taken from the literature. Costs were represented by the Medicare reimbursement for the tests and procedures employed.

MAIN RESULTS

In the baseline analysis, using magnetic resonance imaging (MRI) as the imaging procedure prior to a single biopsy, strategies ranged in sensitivity from 0.40 to 0.73, with corresponding diagnostic costs of $14 to $241 per patient and average cost effectiveness ratios of $5,283 to $49,814 per case of cancer found. Incremental cost effectiveness ratios varied from $8,397 to $624,781; 5 strategies were dominant in the baseline analysis. Use of a higher ESR cutoff point (50 mm/hr) improved specificity and cost effectiveness for certain strategies. Imaging with MRI, or bone scan followed in series by MRI, resulted in a fewer unnecessary biopsies than imaging with bone scan alone. Cancer prevalence was an important determinant of cost effectiveness.

CONCLUSIONS

We recommend a strategy of imaging patients who have a clinical finding (history of cancer, age > or = 50 years, weight loss, or failure to improve with conservative therapy) in combination with either an elevated ESR (> 50 mm/hr) or a positive x-ray, or using the same approach but imaging directly those patients with a history of cancer.

General practitioners' willingness to request plain lumbar spine radiographic examinations

OBJECTIVES

To examine general practitioners' attitudes to plain lumbar spine radiographic examinations.

DESIGN

A postal questionnaire consisting of questions on background data and doctors' opinions about plain lumbar spine radiographic examinations, as well as eight vignettes (imaginary patient cases) presenting indications for lumbar radiography, and five vignettes focusing on the doctors' willingness to request lumbar radiography on the basis of patients' age and duration of symptoms. The data were analysed according to the doctor's age, sex, workplace and the medical school of graduation.

SETTING

Finland.

SUBJECTS

Six hundred and fifteen randomly selected physicians working in primary health care (64% of original target group).

RESULTS

The vignettes revealed that the use of plain lumbar radiographic examination varied between 26 and 88%. Patient's age and radiation protection were the most prominent factors influencing doctors' decisions to request lumbar radiographies. Only slight differences were observed between the attitudes of male and female doctors, as well as between young and older doctors. Doctors' willingness to request lumbar radiographies increased with the patient's age in most vignettes. The duration of patients' symptoms had a dramatic effect on the doctor's decision: in all vignettes, doctors were more likely to request lumbar radiography when patient's symptoms had exceeded 4 weeks.

CONCLUSIONS

General practitioners commonly use plain lumbar spine radiographic examinations, despite its limited value in the diagnosis of low back pain. Further consensus and medical education is needed to clarify the indications for plain lumbar radiographic examination.

Disability management of low back injuries by employer-retained physicians: ratings and costs

BACKGROUND

Medico-legal models of disability determination for low back pain lack empirical support. Besides diagnostic and functional parameters, social and situational factors may influence impairment/disability ratings and costs.

METHODS

Archival data from employer-retained occupational medicine physician files and public court records were examined for 184 Workers' Compensation claimants with low back injuries. Regression was used to predict ratings, costs, and settlement duration from medical, functional, social, and situational variables.

RESULTS

Diagnosis, surgery, pain, rating year, and clinic predicted impairment ratings from employer-retained physicians. The clinic effect partially reflected claimant ethnicity. Diagnosis, surgery, tests ordered, legal representation, and impairment rating predicted disability ratings at the administrative law judge level. Diagnosis, tests, and impairment rating predicted costs. For musculoskeletal diagnoses, settlement duration was related negatively to treatment duration and positively to costs.

CONCLUSIONS

Social and situational parameters influence disability management among employer-retained physicians, while functional variables have little impact. For musculoskeletal low back pain, increased disability and cost may result from variation in treatment duration.

Continuous quality improvement for patients with back pain

Recent evidence has changed traditional approaches to low back pain, suggesting minimal bed rest, highly selective imaging, and early return to normal activities. However, there are wide geographical variations in care, and substantial gaps between practice and evidence. This project sought to merge scientific evidence about back pain and knowledge about behavior change to help organizations improve care for back pain. Participating insurance plans, HMOs, and group practices focused on problems they themselves identified. The year-long program included quarterly meetings, coaching for rapid cycles of change, a menu of potential interventions, and recommendations for monitoring outcomes. Participants interacted through meetings, e-mail, and conference calls. Of the 22 participating organizations, 6 (27%) made major progress. Typical changes were reduced imaging, bed rest, and work loss, and increased patient education and satisfaction. Specific examples were a 30% decrease in plain x-rays, a 100% increase in use of patient education materials, and an 81% drop in prescribed bed rest. Despite the complexity of care for back pain, rapid improvements appear feasible. Several organizations had major improvements, and most experienced at least modest improvements. Key elements of successful programs included focus on a small number of clinical goals, frequent measurement of outcomes among small samples of patients, vigilance in maintaining gains; involvement of office staffs as well as physicians, and changes in standard protocols for imaging, physical therapy, and referral.

Internist Judgments of Chronic Low Back Pain

OBJECTIVE

To examine the consistency of internist judgments about low back pain; to examine the influence of different clinical factors on those judgments.

DESIGN

2 x 4 mixed between- and within-subjects analog experiment.

SETTING

Academic health sciences center, school of medicine; department of internal medicine.

PARTICIPANTS

Forty-eight internal medicine physicians.

INTERVENTIONS

Vignettes describing hypothetical chronic low back pain patient varied by patient pain level (low versus high) and clinical information type (history versus physical examination versus functional disability versus medical diagnostics).

OUTCOME MEASURES

Clinical judgments regarding patient medical, psychological, and disability status; referral, treatment, and test ordering options.

RESULTS

Within-physician consistency was very high, while between-physician consistency was very low. Medical diagnostics had the only consistent influence on judgments. Patient pain level had no effect. Physical examination and functional information had little or no effect.

CONCLUSIONS

While there is little agreement among internists regarding judgments of low back pain, individual physicians hold consistently to their opinions. These findings suggest that management of low back pain may be idiosyncratic, potentially compromising patient care.

Socioeconomic aspects of spinal imaging: impact of radiological diagnosis on lumbar spine-related disability

Low back pain presents a difficult problem for patients and their doctors. The symptom affects the majority of people at some point in their lives and usually has a benign natural history. However, as a society, we consume tremendous resources to diagnose and treat painful spinal disorders. Magnetic resonance imaging (MRI) facilitates the "medicalization" of low back pain due to its exquisitely sensitive depiction of pathoanatomy. Unfortunately, many of these findings are present in normal subjects. Radiologists should recognize the poor correlation between MRI findings and significant, treatable disease and support the use of evidence-based guidelines for patient referral. MRI studies should be interpreted stringently, to avoid unnecessary patient labeling and potentially inappropriate treatment.

Back pain in children who present to the emergency department

The purpose of this study was to identify the causes and epidemiology of back pain in children who present to the emergency department. All children who presented to an urban pediatric emergency department (ED) during a 1-year period with the chief complaint of back pain were examined and evaluated with a uniform questionnaire. This was completed at the time of the ED visit in 48%, and within 48 hours in 52%. During a 1-year period, 225 children with a complaint of back pain were evaluated. The mean age was 11.9 +/- 4 years and 60% were female. Onset was acute (< or = 2 days) in 59%, and chronic (> or = 4 weeks) in only 11.6%. Pain awakened children from sleep in 47%, and caused 52% to miss school or work. The most common diagnoses were direct trauma (25%), muscle strain (24%), sickle cell crises (13%), idiopathic (13%), urinary tract infection (5%), and viral syndrome (4%). Radiographs of the back were rarely helpful. About 5% required hospital admission; one half of these were attributed to sickle cell crises. We conclude that back pain is an uncommon reason for children to present to an emergency department. When present, pediatric back pain is most often musculoskeletal, associated with an acute infectious illness or a traumatic event. Although the etiology is rarely serious, back pain often affects the daily activities of symptomatic children.

Capturing health care utilization after occupational low-back pain: development of an interviewer-administered questionnaire

The aim of this study was to develop and test the feasibility and validity of a patient questionnaire to assess health care utilization after occupational low-back pain (LBP). Items generated after a literature search were revised and refined on the basis of their face and content validity (judged by a group of practitioners) and pretested with six lay subjects who had LBP. The 73-item questionnaire was then tested in interviews with subjects with acute, subacute, or chronic LBP. Its validity was judged by comparison with a prospective patient diary and with care-provider reports. Chance-corrected agreement was estimated using the kappa statistic. Response rates were 78%, 70%, and 59% for interview, diary, and provider reports, respectively. Eighty of 102 eligible workers completed the interview in an average of 45 minutes (SD = 17.7). Most LBP subjects (90.1%) found it easy to answer. In the opinion of the interviewer, 94.7% of subjects showed adequate comprehension and ability to recall. With a few exceptions, there was moderate to substantial agreement between the interview and the patient diary (most K values between 0.38 and 0.78). Overall, subjects reported more health care services to the interviewer than they recorded in the diary. Owing to the low response rate from providers, comparison with provider reports had to be restricted to 48 subjects and to physicians' reports only. Agreement between interviews and physicians' reports was substantial in use of plain X-rays (kappa = 0.79) and computed tomography scans (kappa = 0.85), but physicians often reported referrals not volunteered by the subjects. Agreement on prescription medications was fair (kappa = 0.29-0.46) with no systematic over reporting or under reporting. Our interviewer-administered questionnaire had better return rate than the patient diary and provider reports. It was easy to administer and understand. On the basis of our comparison with patient diaries and physicians' reports, we conclude that this questionnaire is a sufficiently valid source of health care utilization data in subjects with LBP.

Clinical practices in the management of new-onset, uncomplicated, low back workers' compensation disability claims

Recent consensus guidelines delineate what appears to be the most successful and cost-effective management of low back pain (LBP), and some recent studies have suggested that better outcomes occur with the least aggressive forms of medical intervention. The purpose of this study was to describe how practitioners manage new-onset, uncomplicated low back workers' compensation (WC) disability cases. A sample of cases was randomly selected from a large insurance carrier's national data source. An effort was made to select only uncomplicated cases, which would be expected to have relatively minimal need for medical intervention. There was an apparent overuse of diagnostic and treatment modalities. Diagnostic imaging was overutilized, not only in terms of the number of studies done (65% had plain films, 22% had magnetic resonance imaging scans) but also in the time frame in which they were performed (38% had plain films on the first clinic visit). Ninety percent received at least one medication, and 38% received more than one prescription for opioid analgesics. Expensive non-steroidal anti-inflammatory drugs were prescribed more often than acetaminophen (61% versus 6%, respectively). Sixty-two percent received physical therapy that often included modalities with as yet unproven efficacy. Overutilization of either diagnostic or treatment procedures increases the likelihood of iatrogenic complications, is not cost-effective, and may adversely impact clinical and occupational outcomes.

Imaging studies for acute low back pain. When and when not to order them

Acute low back pain is generally a self-limited condition, and most patients recover within a few weeks without the need for imaging studies. However, physicians need to be on the lookout for red flags that point to more serious conditions, such as infection or malignancy, which require imaging. In this article, the authors identify these warning signs and discuss the appropriate use of imaging studies for a variety of symptoms and conditions.

Utilization of lumbosacral spine radiographs for the evaluation of low back pain in the emergency department

We sought to determine how often Emergency Physicians (EPs) order plain radiographs (XRs) of the lumbosacral spine in evaluating patients with low back pain (LBP). In addition, we sought to determine what history and physical examination findings were statistically associated with the use of an XR. Patients evaluated in our Emergency Department (ED) between April 1, 1995 and September 30, 1995 for LBP were identified retrospectively by their ICD-9 discharge code. The ED record was reviewed, and an odds ratio (OR) was calculated for each of several history and physical examination findings, to determine which of them increased the likelihood of having an XR. Forty of 214 patients (19%) with LBP had an XR done. Patient characteristics associated with the use of an XR were: a positive straight leg examination, age > 50 years, a history of trauma, and vertebral tenderness. In this series, only a small minority of patients with LBP had an XR done as part of their ED evaluation. The choice of which patients to image was determined by history and physical examination findings. We conclude that the EPs we studied are evaluating LBP as conservatively, if not more so, than physicians in other specialties.

Efficacy of lumbar discectomy and percutaneous treatments for lumbar disc herniation

The changing health care environment necessitates careful re-evaluation of all costly elective procedures. Low back surgery is a typical example. This article reviews the current literature addressing the efficacy of surgery and invasive percutaneous treatments for discogenic sciatica. It also discusses the prospects for the continuation of reimbursement for these procedures under a system of managed health care. Relevant articles were identified using the MEDLINE and Current Contents databases, from bibliographies of articles identified from these databases, from recommendations of experts in the field, and from the Canadian Cochrane++ Collaboration. The review includes randomized clinical trials, meta-analyses, published practice guidelines and large case series. The literature is classified and discussed in these quality strata. The review includes 9 randomized trials, 6 meta-analyses or review articles, one evidence-based practice guideline, 38 surgical case series and 35 additional references. Though incomplete, the existing evidence indicates that open discectomy shortens the duration of discogenic sciatica in selected patients. Neurologic outcomes are similar in operated and unoperated patients. Predominant leg pain, evidence of nerve root tension and concordant symptoms and imaging findings, are associated with favorable surgical results. Chemonucleolysis is also associated with more rapid pain relief than conservative treatment, but provides less certain benefit than standard discectomy. Available data on other percutaneous disc treatments do not currently support a statement on efficacy. Various percutaneous techniques are available but there is no solid scientific evidence of efficacy. The benefits of open discectomy, principally reduced duration of pain, appear to justify its use in carefully selected patients when discogenic sciatica fails to improve with conservative measures. Though elective, the procedure will probably continue to be available under managed care, but with increasing scrutiny of operative indications.

Patient characteristics associated with diagnostic imaging evaluation of persistent low back problems

STUDY DESIGN

Post hoc analysis of data from the National Low Back Pain Study, a prospective observational multicenter study of patients referred for the evaluation and treatment of persistent low back problems.

OBJECTIVE

To identify patient characteristics associated with use of particular diagnostic imaging examinations in patients with persistent low back problems.

SUMMARY OF BACKGROUND DATA

The Agency for Health Care Policy and Research clinical practice guidelines on low back problems suggest that the use of particular diagnostic imaging tests for a given patient should be based on specific characteristics of that patient.

METHODS

Use of diagnostic imaging examinations in 2,374 patients with persistent low back problems who were enrolled in the National Low Back Pain Study from 1986 to 1991 was analyzed. Stepwise logistic regression was used to identify patient characteristics that distinguish between enrollees who underwent particular imaging studies.

RESULTS

Characteristics that distinguished patients who had undergone magnetic resonance imaging from those who had received only lumbo-sacral spine radiographs included higher socioeconomic status, greater resource use in the preceding 12 months, more functional impairment, presence of sciatica, and presence of neurologic signs/symptoms suggestive of nerve root compromise. Suspected soft tissue involvement was characteristic of enrollees who had undergone magnetic resonance imaging, whereas suspected structural involvement characterized patients who received noncontrast computed tomography. Only nonclinical factors, such as higher annual household income, disability compensation, and male gender distinguished enrollees who had undergone both magnetic resonance imaging and computed tomography-myelography from those who received only computed tomography-myelography.

CONCLUSION

Particular patient socioeconomic and clinical characteristics are associated with receipt of specific imaging studies in evaluation of persistent low back problems.

Practice variation in Swedish primary care

OBJECTIVE

To study individual practice patterns of physicians working in primary health care for standardized simulated cases on their first visit, and relate them to resource consumption for diagnostic tests, drugs and sick leave from a combined perspective of the health care and social security systems.

DESIGN

Postal questionnaire presenting six hypothetical working-age cases with symptoms of ailments common in primary care asking physicians to order diagnostic tests and procedures, drugs, follow-up appointments and sick pay.

SETTING

Swedish primary health care centres.

SUBJECTS

Two hundred randomly selected physicians.

MAIN OUTCOME MEASURES

Activities taken by the physician-diagnostic and laboratory tests ordered, drugs prescribed, length of sick leave and the cost of these actions.

RESULTS

Practice patterns varied considerably, corresponding to a six-fold difference in total cost between the "cheapest" and "most expensive" physician. The largest share was loss of production as estimated by the cost of prescribed sick leave. Physicians who practised further away from hospitals and those who had worked more years tended to prescribe more measures. However, this only explained a small portion of the observed variation, which may be due to different physician attitudes to taking risks.

CONCLUSION

"Paper" cases of common medical ailments presented to primary care physicians revealed considerable differences in practice style, resulting in six-fold differences in cost of measures prescribed at first visits.

Management of chronic nonspecific low back pain in primary care: a descriptive study

STUDY DESIGN

A retrospective, descriptive study.

OBJECTIVES

To describe the diagnostic and therapeutic procedures for patients with chronic low back pain in primary care.

SUMMARY OF BACKGROUND DATA

Most previous studies have described the management of acute low back pain, but little is known about the management of chronic low back pain in primary care.

METHODS

Twenty-six general practitioners involved in the Registration Network of Family Practices of the University of Limburg in The Netherlands participated in this study. All patients and general practitioners were asked to complete a retrospective questionnaire, and there was a 12-month follow-up.

RESULTS

The total study population consisted of 524 patients with chronic low back pain. Twenty-three percent of the patients had had radiographs taken during the previous 12 months, and 5% had been examined by other imaging techniques. Twenty-nine percent of the study population had not received and therapy at all, 46% had received medication, mostly (36%) nonsteroidal anti-inflammatory drugs (NSAIDs), and for 18% (bed)-rest had been advised. Thirty-six percent of the study population had been referred to a physiotherapist.

CONCLUSIONS

The therapeutic management of chronic low back pain seems to lack consistency. Clinical guidelines are needed to improve the management of chronic low back pain in primary care.

Should the gap be filled between guidelines and actual practice for management of low back pain in primary care? The Quebec experience

STUDY DESIGN

A prospective cohort study.

OBJECTIVES

To describe health services utilization for low back pain in the province of Quebec, Canada, and to compare it with North American guidelines.

SUMMARY OF BACKGROUND DATA

The Quebec Task Force and the Agency for Health Care Planning and Research (United States) published guidelines for the management of low back pain in 1987 and 1994, respectively.

METHODS

A cohort of 2147 adults with low back pain identified at the Quebec Worker's Compensation Board were selected randomly and observed over 2 years' time for their health care utilization profile.

RESULTS

During the study period, 57.8% of the workers still under active care 7 weeks after their back injury had not yet been referred to a specialist. Specialized imaging techniques were obtained by 4.5% of the patients, with a delay of 7 weeks or more in 66% of them. Surgery was performed on 1.6% of the patients. The presence of an initial specific diagnosis and proximity to a university hospital significantly increased utilization rate and reduced the delays.

CONCLUSION

Health services utilization for back pain in Quebec was equal or lower to what currently is practiced elsewhere, but access to specialists was not meeting the current recommendations. This would represent a 12% net increase in new specialist contacts and a quicker access in 39% who saw a specialist. Before such an effort can be considered, health care planners will need a better definition of the role of the specialist consultation in the guidelines and scientific evidence specifically addressing their benefit in primary care, especially in the absence of a specific diagnosis.

Piroxicam fast-dissolving dosage form in the treatment of patients with acute low back pain

An open-label, noncomparative study of the efficacy and tolerability of a once-daily piroxicam fast-dissolving dosage form (FDDF) comprised 157 patients aged 15 to 76 years (56.7% men) with acute low back pain of not more than 48 hours' duration. Patients received 40-mg piroxicam FDDF once daily for the first 2 days and 20 mg once daily for up to a total of 14 days of treatment. Fifteen investigators in three countries examined patients at baseline and at follow-up visits on days 4, 8, and 15. All efficacy assessments-including general low back pain; pain on sitting, standing, and walking; overall severity of night pain; duration of morning stiffness; lumbosacral tenderness on moderate pressure; modified Schober test of ability to bend forward; restriction of passive motion; length of time to resumption of an activity impaired by back pain; and overall restriction of back motion-demonstrated statistically significant improvements from baseline at each follow-up visit. Relief of pain, noted 30 minutes after the first dose, was maintained for the 24-hour dosing interval during the first 3 days. At visit 4, after piroxicam FDDF treatment had been completed, the number of patients being assessed had declined by half, principally because the resolution of symptoms had prompted discontinuation of the study drug. At the end of the treatment, 82.9% of patients evaluated the efficacy of piroxicam FDDF as good or excellent and investigators rated efficacy as good or excellent in 85.6% of patients. Tolerability was also rated highly, with 91% of patients characterizing piroxicam FDDF treatment as good or excellent, and investigators rating the treatment as good or excellent in 92% of patients. In all, 12.7% of the patients experienced drug-related adverse events, most frequently involving the gastrointestinal system. Drug-related adverse experiences prompted discontinuation of the study medication in five (3.2%) patients. These results suggest that the newly developed dosage form, piroxicam FDDF, administered in a dosage of 40 mg/d for the first 2 days and 20 mg/d thereafter (for up to 14 days), is effective and well tolerated in the treatment of patients with acute low back pain.

Physician variation in diagnostic testing for low back pain. Who you see is what you get

OBJECTIVE

This study examined patterns of diagnostic test use for patients with low back pain. Three specific questions were addressed: 1) What tests do physicians recommend for patients with 3 common types of low back pain? 2) Do physicians in various specialties differ in the tests they would order? and 3) How appropriate are physicians' choices of tests, based on current medical knowledge and expert recommendations?

METHODS

A stratified national random sample of 2,604 physicians in 8 specialties was mailed questionnaires asking about the tests they would order for hypothetical patients with acute back pain, sciatica, or chronic low back pain. Physicians were also asked which procedures they generally used to evaluate suspected lumbar nerve root compression. These responses were compared with guidelines that have been suggested by the Quebec Task Force on Spinal Disorders, based on comprehensive evaluation of the scientific literature.

RESULTS

Approximately 1,100 physicians responded to the survey (43% response rate). Magnetic resonance imaging was the most frequently used procedure for evaluating suspected lumbar nerve root compression, although a majority of neurosurgeons would still use myelography. Neurosurgeons and neurologists were twice as likely as other specialists to order an imaging study for patients with acute nonradiating pain or chronic back pain. Physiatrists and neurologists were more than 3 times as likely as other specialists to order electromyograms for acute back pain with sciatica or chronic back pain. Rheumatologists were almost twice as likely as other specialists to order laboratory tests for both acute and chronic back pain. The reported use of imaging and electrodiagnostic tests was generally premature and more extensive than that recommended by the Quebec Task Force.

CONCLUSION

There is little consensus, either within or among specialties, on the use of diagnostic tests for patients with back pain. Thus, the diagnostic evaluation depends heavily on the individual physician and his or her specialty, and not just the patient's symptoms and findings. Furthermore, many physicians may be ordering imaging studies too early and for patients who do not have the appropriate clinical indications. These results suggest a need for additional clinical guidelines as well as better adherence to existing guidelines.