Our findings suggest that gaining information from focus groups prior to designing physician behavior change interventions may aid the design of more effective interventions.

OBJECTIVE:To reduce variability in primary care physicians' use of procedures for imaging the lumbar spine. DESIGN:Controlled intervention using clinical practice guideline and practice pattern feedback.STUDY SAMPLE: Sixty-seven internists and 28 family practitioners in a large, group-model HMO. MEASUREMENTS AND MAIN RESULTS:Intervention group physicians received the clinical practice guideline for low back pain, followed after 4 months by three bimonthly feedback reports on their current use rates for lumber spine x-rays and computed tomography and magnetic resonance imaging scans of the lumbar spine. Control group physicians received neither the guideline nor the feedback reports. Automated radiology utilization data were used to compare intervention and control group physicians' changes in use rates and variability in use rates over the course of the study period. Neither the guideline alone nor the guideline plus feedback was associated with a significant decrease in use rates or in the variability in use rates for the lumbar spine imaging procedures under study. ow back pain affects about half the adults in the United States in a given year, 1 and is second only to colds as a reason for visits to primary care physicians. 2 In 1990, estimated direct medical care costs for low back pain were over $24 billion. Estimates for disability compensation and lost productivity brought the total costs associated with low back pain to approximately $100 billion. 3 The cause of low back pain is often unclear, the correspondence between symptoms and anatomic findings is low, and up to 85% of patients with low back pain cannot be given a definitive diagnosis. 4 Recent trends toward increasing use of expensive imaging procedures such as computed tomography (CT) scans and magnetic resonance imaging (MRI) may be driven in part by physician uncertainty about the diagnosis of low back pain. 5 But lumbar spine imaging tests frequently reveal clinically irrelevant pathologic findings even in asymptomatic patients and thus may lead to unnecessary, expensive, and potentially harmful medical interventions. [6][7][8] The majority of low back pain episodes can be treated conservatively in the primary care setting. Experts recommend early mobilization and nonprescription pain killers as the only necessary treatment for most patients, with lumbar spine imaging tests reserved for patients who are still limited by symptoms after a number of weeks of conservative treatment. 9,10 Yet despite this increasing consensus regarding the appropriate treatment of low back pain, wide geographic variations in diagnostic and treatment patterns have been found in the United States and other countries. These variations cannot be explained by differences in the patient populations studied. 7,[11][12][13][14][15] Variations in physicians' patterns of care for patients with low back pain are an example of a well-recognized broader phenomenon of unexplained practice pattern variations, [16][17][18][19] for which diagnostic uncertainty is one among a number ...

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