Usual care often not consistent with clinical guidelines for low back pain

Australian general practitioners often treat patients with low back pain in a manner that does not appear to match the care endorsed by international clinical guidelines, according to a report in the February 8 issue of Archives of Internal Medicine.

Low back pain is estimated to be the seventh most common reason for a general practitioner visit in Australia and the fifth most common in the United States, according to background information in the article. An overwhelming body of literature on the management of low back pain—more than 1,200 published trials and systematic reviews—makes practice guidelines an efficient way for clinicians to base their care on the best evidence. A previous review concluded that guidelines in 11 countries around the world provide similar recommendations for assessment and management of low back pain.

"Given the proliferation of clinical practice guidelines outlining best practice, it is timely to consider how closely usual care aligns with guideline recommendations," write Christopher M. Williams, M.App.Sc., of The George Institute for International Health, Camperdown, Australia, and colleagues. The authors assessed the care provided for new episodes of low back pain during 3,533 patient visits to general practitioners in Australia between 2001 and 2008. These visits were mapped to key recommendations in treatment guidelines; in addition, data were compared for two three-year periods before and after the release of Australian national guidelines in 2004.

"Our findings show that key aspects of the usual care provided to patients do not align with the care recommended in international evidence-based guidelines," the authors write. For example, although guidelines discourage the use of imaging, more than one-quarter of patients were referred for radiology, computed tomography or similar tests.

Only 20.5 percent of patients received advice and 17.7 percent received simple pain-relieving medications, both of which are recommended as part of initial care for low back pain. Instead of the safer and equally effective acetaminophen, patients were more often prescribed non-steroidal anti-inflammatory drugs (37.4 percent) and opioids (19.6 percent).

In addition, patterns of care did not change significantly following the release of local guidelines, the authors note.

"Understanding why general practitioners do not follow key treatment recommendations of guidelines is an important prerequisite to improving this situation," they write. Evidence suggests that the views of both patients and clinicians, and potentially miscommunication between the two, contribute to departures from guideline-based care.

"In the back pain field, there has been extensive activity in the past two decades focusing on the evaluation of new and existing therapies within clinical trials and systematic reviews," the authors conclude. "Arguably, we need a parallel line of research that focuses on how best to encourage provision of evidence-based treatments. Educational outreach with broader societal focus may enhance guideline dissemination and reduce the burden of low back pain."