Elsevier

The Spine Journal

Volume 3, Issue 6, November–December 2003, Pages 442-450
The Spine Journal

Clinical Study
Compliance with clinical practice guidelines in family physicians managing worker's compensation board patients with acute lower back pain

https://doi.org/10.1016/S1529-9430(03)00152-9Get rights and content

Abstract

Background context

Family physician compliance with acute lower back pain clinical practice guidelines remains uncertain.

Purpose

To determine the degree of guideline compliance of family physicians managing patients with workers' compensation claims and acute mechanical lower back pain.

Study design

Observational study.

Patient sample

One hundred thirty-nine family physicians in British Columbia.

Outcome measures

Compliance with guideline recommendations for history, examination procedures, diagnostic testing and treatments.

Methods

Physician workers' compensation board patient reports for acute lower back pain without leg symptoms and not greater than 2 to 3 weeks duration were scored for guideline adherence up until 12 weeks after onset.

Results

Physicians demonstrated a high degree of compliance with the guideline-recommended history, examination procedures and medications, but low compliance with recommended imaging and many treatment recommendations.

Conclusions

Recently published clinical practice guidelines regarding the management of patients with acute mechanical lower back pain have not been fully implemented into the patterns of practice of the family physicians.

Introduction

Approximately 40% of all worker's compensation board (WCB) claims concern back injuries. The majority of these claims involve acute injury to the soft tissues of the lower back or acute mechanical lower back pain. The WCB in the Province of British Columbia recently compiled, published and distributed clinical practice guidelines for the management of acute mechanical lower back pain to all family physicians in this province [1]. These guidelines were based primarily on extensive and critical reviews of the literature carried out by a number of expert panels, which included the Agency on Health Care Policy and Research (US National Institutes of Health) [2], the Industrial Medicine Council of California [3] and the Quebec Task Force on Spinal Disorders [4]. Since that time, several other countries have convened multidisciplinary expert panels and have published similar guidelines [5], [6], [7], [8], [9]. As such, these guidelines are derived exclusively from the best available scientific evidence or expert panel consensus and are independent of any bias associated with worker/employer special interest issues.

Family physicians are the most common portal of entry into the health-care system for injured workers and are therefore in a unique position to significantly influence the clinical management of this group of patients. It has been demonstrated that the patterns of practice of family physicians managing patients with lower back pain varies widely [10] and is resistant to change [11], [12]. Furthermore, patients who receive compensation benefits are at increased risk for treatment failure, overuse of narcotics and for delayed return to preinjury activities [13], [14]. Thus, family physician adherence to a patient management strategy that has the greatest potential for enhancing recovery by emphasizing evidence-based treatments and lessening the influence of interventions that have no long-term value or may prolong recovery from injury would seem to be of particular importance in these patients. This study investigated the degree to which the patterns of practice of a group of British Columbia family physicians was in compliance with the current clinical practice guidelines for managing patients with acute mechanical lower back pain who have an accepted WCB claim.

Section snippets

Methods

The research design was an observational study. It involved a consecutive sample of 139 different family physicians identified through the WCB database who submitted First Report forms identifying a patient with acute lower back pain without lower extremity involvement (i.e., Quebec Task Force Categories I and II) of 2 to 3 weeks duration. Each physician in the study managed one patient. The subsequent Progress Reports of the physicians whose patients went on to have approved WCB claims were

Results

As shown in Fig. 3, 89% of attending family physicians in the study group reported information relating to the history of the initiating event of the acute episode, and 24% also reported information regarding prior episodes of similar symptoms. In addition, recorded physical examination information showed that 63% of physicians reported carrying out a neurological examination that was consistent with guideline recommendations. However, only 5% of physicians reported assessing patients for “red

Discussion

Evidence-based clinical practice guidelines are now being developed and introduced to many areas of medical practice. These guidelines currently represent the “gold standard” of health care. They are derived mainly from research studies that, using sound methodology, have clearly demonstrated that a particular therapy/treatment has proven efficacy/effectiveness and that other treatments are either ineffective or actually increase morbidity. As such, clinical practice guidelines have the

References (18)

  • Campin C, et al. Clinical practice guidelines for the diagnosis and treatment of low back pain. Worker's Compensation...
  • S Bigos et al.

    Clinical practice guideline number 4: acute low back problems in adults

    (December 1994)
  • Industrial Medical Council

    Practice parameter: low back problems (draft April 27, 1994)

    (1994)
  • W.O Spitzer et al.

    Scientific approach to the assessment and management of activity-related spinal disorders. A monograph for clinicians. Report of the Quebec Task Force on Spinal Disorders

    Spine

    (1987)
  • B.W Koes et al.

    Clinical guidelines for the management of low back pain in primary care: an international comparison

    Spine

    (2001)
  • L Abenhaim et al.

    Report of the International Paris Task Force on Back Pain: the role of activity in the therapeutic management of back pain

    Spine

    (2000)
  • N.A Kendall et al.

    Guide to assessing psychosocial yellow flags in acute low back pain: risk factors for long-term disability and work loss

    (1997)
  • Royal College of General Practitioners. Clinical guidelines for the management of acute low back pain. Available at:...
  • A.K Burton et al.

    Clinical guidelines in the management of low back pain

    Baillieres Clin Rheumatol

    (1998)
There are more references available in the full text version of this article.

Cited by (80)

  • Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis

    2018, Spine Journal
    Citation Excerpt :

    In 19 studies (58%), the target population was not representative of a typical LBP population presenting to primary care [6,20,21,23,25,26,28–30,33,36,38–40,43–45,48,49]. The proportion of patients deemed as inappropriate for imaging of the sample that had been previously referred for imaging was assessed in 23 studies [7,21,22,25–29,31–37,39–43,45,46,50] (Supplementary Table S2), with pooled results in Fig. 2. The absence of red flag clinical features was the criterion in 15 studies [22,26,29,31,32,34,35,37,39–43,46,50] (N=1,805), providing low quality evidence that the proportion of inappropriate referral was 34.8% (95% confidence interval [CI]: 27.1, 43.3).

View all citing articles on Scopus

FDA device/drug status: not applicable.

Nothing of value received from a commercial entity related to this research.

View full text