Evidence-based practice for acute low back pain in primary care: Patient outcomes and cost of care

Abstract

Provider adherence with clinical practice guidelines (CPGs) for acute low back pain (LBP) and its impact on clinical outcomes and cost are controversial. A panel and cross-sectional design was used to determine the rate of provider adherence to the Department of Defense/Veteran's Administration CPG for Acute LBP which included ergonomic and psychosocial intervention. The relationship among adherent care, patient satisfaction, general health, functional outcome, and cost was examined. Direct health services and patient survey data 1 year before and 3 years following guideline implementation were analyzed. The sample consisted of 15,789 LBP cases (CPG) and 14,409 upper extremity cases used as controls (no CPG). Ten to 40% of LBP cases received CPG-adherent care across the 4 years. No differences were found between LBP and upper extremity diagnoses groups in the rates of change in the four outcomes over years. Multivariable regression analyses controlling for demographic variables and perceived health indicated that CPG adherence was related to better functional outcomes, Odds ratio (OR)=1.45 [95% CI=1.31-1.60] and lower healthcare costs (beta=-230.15, p<0.001). Cases receiving more adherent care also reported higher levels of patient satisfaction (beta=0.09, p<0.05) and general health, OR=1.44 [95% CI=1.29-1.60]. Higher levels of adherent care which included efforts to address both ergonomic and psychosocial factors in the course of acute back pain were related to better clinical outcomes and lower costs.

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“…Growing evidence exists to support a multidisciplinary therapeutic approach, and physicians should follow clinical practice guidelines in their daily management of LBP 2,3,20 . The integral role played by psychological and social factors in LBP is still largely ignored; attention to it is reserved for patients who do not respond to cheaper treatment options.…”

“…Low back pain (LBP) is a common public health problem world-wide [1][2][3] . For quite a number of patients affected by the development of chronic back pain, the disease is extremely disabling; it is likely to show co-morbidity with mood disorders and is associated with serious risk of ending in early retirement or an inability to cope with activities of daily living.…”

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“…41,42 Yet there is a strong body of evidence suggesting a low level of adherence to guidelines in daily clinical practice. 43,44 Overall adherence to guideline-based care by PCPs has been recorded at 65%, a rate that has remained unchanged despite attempts to increase implementation of evidence-based care.…”

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“…This situation appears to be widespread and common to other health care professionals; unfortunately, studies have found that many guidelines are not used after their development and dissemination, [15][16][17] despite the fact that adherent care has been shown to produce better clinical outcomes and lower costs. 18,19 Research on implementation strategies to improve adherence to guidelines has shown the value of education, discussion, role-playing, feedback, and reminders. 20,21 However, these implementation strategies frequently produce only moderate improvement.…”