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A Survey of Primary Care Physician Practice Patterns and Adherence to Acute Low Back Problem Guidelines
Daniel Di Iorio, MD, DC;
Eric Henley, MD, MPH;
Andrea Doughty, PhD
Arch Fam Med. 2000;9:1015-1021.
ABSTRACT
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Objective This study evaluated physicians' self-reported management of acute low back problems in adults and adherence with published guidelines.
Design Self-administered written survey based on the US Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) guideline on acute low back problems in adults.
Setting A region of northern Illinois with a population around 250 000 and encompassing a medium-sized city.
Participants One hundred eighty-two primary care physicians (nonpediatric) with medical staff appointments at area hospitals.
Main Outcome Measure Adherence to published recommendations.
Results Eighty-seven surveys were received for a 48% response rate. Overall, survey respondents recognized 5 of 7 red flags representing serious underlying abnormality 50% or less of the time. Forty percent (35/87) of physicians provided patients with written educational material, and only 25%(22/87) indicated they evaluated motor function of the fifth lumbar nerve, the most commonly affected level in intervertebral disk disease disease. About 25% (24/87) reported routine use of plain films; and 16% (14/87), routine use of computed tomography or magnetic resonance imaging. Most oral medication use was consistent with recommendations, but many also used drugs conditionally discouraged by the guideline (muscle relaxants, 91% [79/87]; opioids, 62% [54/87]) or cautioned against (oral steroids, 45% [39/87]; antidepressants, 23% [20/87]; injection therapy, 52% [45/87]). Only 22% (19/87) of respondents used or recommended manipulation.
Conclusions The management of patients with acute low back problems by primary care physicians differs significantly from Agency for Health Care Policy and Research guideline recommendations in several key areas that include awareness of red flags, use of medication, use of radiographic studies, the need for patient education, and the use of physical modalities. Future research should focus on the impact of guideline compliance on patient outcomes and cost-effectiveness.
INTRODUCTION
LOW BACK PAIN is one of the leading symptoms prompting physician visits.1 An estimated 50% of adults experience back symptoms in any given year2 and nearly 20% have frequent back pain.3 In 1990, estimated direct medical care costs for low back pain exceeded $24 billion. Estimates for disability compensation and lost productivity raise the total annual costs in the United States to approximately $100 billion.4 Additionally, there have been wide geographic and professional variations in the medical evaluation and treatment of this problem.5-8 These variations imply a lack of professional consensus on management strategies for low back pain and suggest that some patients may be receiving less than optimal care.
In December 1994, the US Agency for Health Care Policy and Research (AHCPR) issued a clinical practice guideline directed at the primary care management of acute low back problems (ALBPs) in adults.9 The guideline was developed by an independent, 23-member multidisciplinary panel of private-sector clinicians (including primary care providers), researchers, and a consumer representative. Findings and recommendation statements were based on an exhaustive and systematic review and analysis of the scientific literature. Every recommendation was explicitly linked to the evidence on which it was based (along with rating the strength of that evidence). The principal recommendations describe a form of diagnostic and therapeutic triage with periodic reassessment to guide management decisions (Table 1 ).9-10
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Table 1. Principal Conclusions of the AHCPR Guidelines on Acute Low Back Problems in Adults*
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It was originally assumed that providing credible, scientific information in a succinct form would stimulate practitioners and consumers to voluntarily adopt and use guideline information.11 The implementation of guideline recommendations would then remedy the apparent clinical uncertainty and reduce variation involving the care of patients presenting with acute low back pain. These expectations, however, rely on the critical concept of "effective dissemination," defined as the diffusion, distribution, awareness, acceptance, adoption, and use of information.11 Despite the laudable effort to develop this guideline, there are only limited descriptions of the degree to which these recommendations have influenced routine primary care management of ALBPs in the United States.
Cherkin et al12 investigated the use of medications by primary care physicians for patients making a first visit for an episode of back pain. The results demonstrated that medication use for back pain in the staff model health maintenance organization under study was generally concordant with the national guideline. Several researchers have recently investigated the use of imaging studies for patients with low back pain.8, 13-15 Findings from these studies have been mixed, with examples of both overutilization and underutilization of plain films. Disparities were attributed to characteristics of the providers, impreciseness of the guideline, and patient-centered features. A British study16 used their available national guidelines to construct a survey instrument eliciting general practitioner responses to questions on specific assessment and patient education activities. The authors did not seek to obtain information regarding physician-dependent treatment modalities (eg, prescription drugs, physical therapy referral) and did not examine the effect of physician characteristics.
The goal of the present study was to more fully describe primary care physicians' self-reported management of patients with ALBPs by comparing physician behavior with the AHCPR guideline recommendations and by identifying individual physician characteristics associated with overall guideline adherence.
POPULATION SAMPLE AND METHODS
This study of family practice and internal medicine physicians was accomplished via an anonymous self-administered mail survey that involved physicians in 3 counties in northern Illinois. The project received institutional review board approval. A questionnaire was developed to elicit physician practice preferences and allow direct comparison to the AHCPR guideline on ALBPs. The questionnaire was prefaced by the definition of ALBPs as adopted by the AHCPR panel: "any adult patient with activity intolerance due to lower back or back-related leg symptoms of less than 3 months' duration."9
QUESTIONNAIRE DEVELOPMENT AND CONTENT
The questionnaire was structured to closely parallel the AHCPR guideline recommendations. An existing, validated survey instrument was made available by Little et al16 and served as a model. The questionnaire concentrated on the 3 core elements of the guideline: (1) initial assessment methods, (2) clinical care methods, and (3) special studies and diagnostic considerations. A section pertaining to physician demographics was added. The questionnaire was revised after review by 2 family physicians (one was E.H.), 2 internists, and an epidemiologist (A.D.). The final questionnaire included mostly closed-end questions and several with an open format.
Initial assessment methods were evaluated in 3 broad areas. First, physicians were asked to identify which of 14 historic characteristics and/or physical signs associated with acute low back pain they would consider red flags that would raise suspicion of a serious underlying abnormality. The items were evenly split between red flags and benign distracters. The red flags were selected from the guideline and included those that may indicate the presence of tumor, infection, spinal fracture, or cauda equina syndrome (Table 2). Second, physicians were queried about instruments used to document a patient's pain distribution, intensity of symptoms, or level of disability (5 choices). Finally, respondents indicated which of the following items they evaluated during a physical examination: straight-leg raising, muscle-strength grading, circumferential measurements of the thigh and calf, palpation of the spine, neurologic reflexes, and sensation. Muscle-strength grading required specification by the respondent of the muscle group(s) being tested. Clinical care methods were also evaluated in 3 areas: patient education, symptom control methods, and activity modification. Physicians were asked if they supplied educational booklets to their patients. Symptom control methods evaluated included oral medications (7 options), physical treatments (9 options), and injection therapy (3 options). Physicians were asked if they routinely recommended bed rest for their patients with ALBPs and, if they did, for how long. Diagnostic strategies were evaluated by asking about any laboratory tests and imaging studies ordered routinely in the first month of symptoms.
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Table 2. Number and Percentage of Physicians Who Recognized the Following Symptoms as "Red Flags," Raising Suspicion of a Serious Underlying Spinal Disorder (Fracture, Infection, Tumor) or Nonspinal Pathology*
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Demographic information was collected regarding physicians' years in practice, primary care specialty, subspecialty, practice environment, satisfaction with management of patients with ALBPs, percentage of total patient encounters devoted to patients with ALBPs, and the most common diagnosis. Physicians were also asked to estimate the age distribution of their patient population and describe their practice's payer mix.
PHYSICIAN SAMPLE
Addresses of primary care physicians were obtained from the 3 main hospitals serving Winnebago County and the greater northern Illinois region. Computer records identified 191 physicians in the adult primary care specialties of general internal medicine and family practice. Of these, 114 (59.7%) were family physicians (FPs) and 77 (40.3%) were general internists (IMs); 41 (24%) were women. Most (90.8%) of the respondents were from Winnebago County, which has a population around 250 000 and includes a medium-sized city.
SURVEY PROCESS
The 4-page questionnaire and a cover letter were sent to all 191 physicians in April 1998. Nonresponders were sent a second mailing 3 weeks later. A prepaid, addressed return envelope was included.
STATISTICAL ANALYSIS
Data were entered and analyzed using SPSS 8.0 (SPSS Inc, Chicago, Ill). The  2 and t tests were used to evaluate whether there was significant variation between the two specialties. A standard value of type I error (  .05) was adopted. Additional analyses included correlation and 1-way analysis of variance with post hoc tests.
RESULTS
RESPONSE RATE
Of the 191 physicians mailed surveys, 9 were returned because the physician no longer practiced (3 FPs, 2 IMs) or the questionnaire was not deliverable (3 FPs, 1 IM). After 2 mailings, 47.8% (87/182) (48 FPs, 39 IMs) of the remaining eligible sample responded (Table 3). Participation was greater among the IMs (52.7% [39/74]) than the FPs (44.4% [48/108]). Respondents had been practicing primary care medicine for a mean of 14.2 years (nocode for FPs = 15.1 years, nocodefor IMs = 13.1 years). Internists were more likely to have a clinical subspecialty interest (geriatrics, 6; occupational medicine, 2; endocrinology, 2; and oncology, 2). These physicians were included in the study because they reported practicing primarily as generalists. Internists had a greater likelihood of practicing in a multispecialty group (P = .05). Patients with ALBPs accounted for an average of 7.0% (range, 2%-30%) of the total patient encounters in this sample. Managed care penetration into this market was reported at 29.0% (range, 2%-70%). Family physicians expressed significantly greater satisfaction with their management of ALBPs on a 5-point scale than did IMs (P = .007,  for FPs = 3.83, nocode for IMs = 3.28).
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Table 3. Demographic Characteristics of the Study Respondents
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INITIAL ASSESSMENT METHODS
At least three quarters of physicians routinely asked about only 2 of the 7 historic factors considered red flags in the AHCPR guideline— saddle anesthesia and trauma (Table 2). There was no significant difference between FPs and IMs. Physicians usually checked for 4 of the 6 physical examination findings considered red flags— light touch, Achilles reflex, straight-leg raising, and spinal palpation (Table 4).
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Table 4. Number and Percentage of Physicians Who Reported Routinely Performing the Following Physical Examination Tests*
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CLINICAL CARE METHODS
About 40% of physicians said they supplied patients with written information explaining ALBPs (31% [15/48] of FPs and 51% [20/39] of IMs). Most used oral medications deemed appropriate by the guideline (97.7% [85/87] used nonsteroidal anti-inflammatory drugs; 72.4% [63/87], acetaminophen). A majority of physicians also used oral medications that were deemed appropriate only in limited situations by the guideline (90.8% [79/87] used muscle relaxants; 62.1% [54/87], opioid analgesics). A minority of physicians used oral medications the guideline specifically cautioned against (44.8% [49/87] used oral steroids; 23.0% [20/87], antidepressants) (Table 5). For physical treatments, the application of heat or ice, therapeutic ultrasound, and massage therapy were used by most of the physicians (88.5% [77/87], 55.2% [48/87], and 65.5% [57/87], respectively). Physicians prescribed, performed, or recommended spinal manipulation only 21.8% (19/87) of the time although the guideline recognized manipulation as the only physical treatment with proven efficacy. About half of the physicians (45/87) used some form of injection therapy despite evidence demonstrating equivocal results. Importantly, the majority of physicians (65.5% [57/87]) did not routinely recommend bed rest for their patients with ALBPs. Of those who did, only 9.2% (8/87) would routinely recommend a duration greater than 48 hours.
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Table 5. Number and Percentage of Physicians Who Reported Prescribing the Following Medication to Achieve Symptom Relief for Patients With Acute Low Back Problems*
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SPECIAL STUDIES AND DIAGNOSTIC CONSIDERATIONS
The guideline emphasizes a conservative approach to diagnostic testing in the first month and recommends that any imaging study be reserved for patients with symptoms and signs of serious illness. However, 24 (27.6%) of 87 respondents reported using a diagnostic aid in the routine evaluation of patients with ALBPs (Table 6). Plain films were the most frequently used and FPs were significantly more likely than IMs to routinely employ these studies (P = .008). Urinalysis was routinely used by only 9 (10.3%) of 87 respondents, although again, FPs demonstrated a significantly greater use (P = .038). About 1 in 6 primary care physicians (16.1% in 14 of our 87 respondents) reported routinely ordering advanced imaging (computed tomography or magnetic resonance imaging) for patients with ALBPs.
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Table 6. Number and Percentage of Physicians Who Reported Use of Diagnostic Aids for Patients With Acute Low Back Problems in the First Month of Symptoms*
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SUMMARY VARIABLE
A summary variable was created using only those items for which there was at least moderate research evidence—a "B-level" or better rating by the AHCPR panel (Table 7). The summary variable consisted of 16 items with a total score ranging from 0 to 16. Using the summary variable as a measure of overall guideline adherence, we found compliance to be 68.1% ( score = 10.9). Only 5 (5.7%) of 87 physicians achieved a 90% or better compliance level. No relationship was found between physician sex, specialty or subspecialty interest, and overall guideline adherence. Similarly, physician satisfaction with the management of ALBPs and the percentage of patient encounters devoted to this problem both failed to demonstrate any correlation to guideline adherence. Those physicians practicing in a primary care group practice demonstrated significantly higher levels of overall guideline adherence than their counterparts in solo practices and marginally superior adherence than those practicing in multispecialty practices (F = 4.91, P = .009, scores = 11.2, 9.7, and 10.5, respectively). In addition, there was a negative correlation (ie, inverse relationship) between years in practice and guideline adherence (Pearson r = -0.21, P = .05).
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Table 7. Variables Meeting the Requirement of "B-Level" Evidence or Better for Inclusion Into the Cumulative Summary Variable
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COMMENT
This study reflects primary care physicians' self-reported management of patients with ALBPs in northern Illinois. The results suggest that for many primary care practitioners, the management of these conditions does not follow the AHCPR guideline. Physicians complied more often with recommendations involving the physical examination, use of preferred drug therapies, and avoidance of bed rest. They were less compliant in recognizing red flags, providing patients with written educational material, using equivocal drug therapies and proven physical treatments, and diminishing their overreliance on imaging studies. With the exception of increased ordering of radiographs by family physicians, little measurable difference was noted between the specialties. Overall compliance, as measured through a summary variable, was moderate. Being part of a primary care group practice or more recently entering clinical practice was positively associated with guideline compliance.
This study has some limitations. The answers are of self-reported behavior. Although the physicians were assured of anonymity and asked for their routine management practices, the answers may reflect a more idealized version than actually takes place. In addition, responding physicians may have a greater interest in back problems than nonresponders. Thus the results may underestimate the true discrepancy with guidelines. The response rate and the regional nature of the survey may limit its generalizability. Our sample population was not queried as to the frequency, duration, or combination of oral medications they prescribe. We should therefore be cautious when interpreting the reported use of muscle relaxants and opioids in the management of ALBPs.
The observed variability described in this study is not what the AHCPR guideline panel envisioned. Furthermore, it is not certain if the areas recognized as following the guideline recommendations actually represent a change in physician practices due to the availability of guidelines or if they were standard practice prior to the guideline's release. Systematic review of interventions designed to promote the implementation of research findings have consistently demonstrated the inadequacies of passive distribution and didactic education when attempting to change physician behavior.17-19 Interventions with proven efficacy have also failed to improve physician diagnosis and treatment of ALBPs.13, 20 Schroth20 tested a model in a health maintenance organization using active education, audit, feedback intervention supported by peer group opinion leaders, and a patient educational tool; it was unsuccessful in changing the appropriateness of clinical care. He attempted to measure important patient outcomes20 and suggested that implementation strategies such as administrative controls or financial incentives or disincentives may be necessary to alter primary care physicians' behavior. These methods, however, would be difficult to implement with physicians enjoying a more diverse reimbursement base as found in northern Illinois.
While recognizing the potential benefits of practice guidelines, FPs and IMs have expressed substantial concerns about possible effects on clinical autonomy and regulatory intrusion into practice.21-22 The AHCPR attempted to address concerns regarding quality, validity, and applicability by using an explicit and evidence-based method in guideline development and by targeting primary care physicians as the principal audience. Statements and recommendations were directly linked to the evidence along with ratings of the quality of supporting evidence. However, a few studies have reported unpredictable beliefs and behaviors on the part of primary care physicians about the value of diagnostic and therapeutic interventions for ALBP. These clinical opinions were not founded on sound scientific evidence and frequently clashed with guideline recommendations.5-6,16 This suggests physician characteristics may disproportionately influence the adoption and implementation of the guideline. Other studies have emphasized the impact of patient-centered factors as an often underestimated element of guideline compliance.15, 23 These studies suggest that variations in individual practice styles and patient demands may be sufficient to overwhelm the efforts of guideline implementation at times.20
In the case of this AHCPR guideline, another explanation may be the lack of clear evidence that divergence from guideline recommendations leads to adverse events or that conformity to the guideline improves patient outcomes. As described earlier, the guideline reviewed a variety of individually supportable statements and constructed an algorithm outlining the "ideal" management of a patient presenting with an ALBP. We do not know, however, if the guideline can acheive its stated goals. Does strict adherence reduce the number of patients becoming chronically disabled? Does strict adherence reduce the personal and societal costs associated with ALBPs? Or can selective adherence based on a combination of physician experience and patient-centered factors (ie, preferences, expectations, financial concerns, or quality of life) yield better compliance and similar results? Future research will need to compare and contrast the impact of strict or selective adherence on patient outcomes. The largely unknown influence of patient-centered factors requires further study. When data on patient outcomes are incomplete, physicians may be justified in not wanting to change their practices. Our findings that primary care specialty peer interaction and recent entry into clinical practice were positively associated with guideline adherence may be important. Lastly, medical education should continue to emphasize life-long learning and evidence-based medicine to train physicians capable of accessing and interpreting the expansive medical literature.
AUTHOR INFORMATION
Accepted for publication September 14, 2000.
The authors wish to acknowledge the contributions of Michael Glasser, PhD; the Department of Family and Community Medicine, University of Illinois College of Medicine at Rockford; Rockford Health System; OSF (Order of Saint Francis) Saint Anthony Medical Center; and Swedish American Health System in supporting the completion of this study.
Corresponding author: Daniel R. Di Iorio, MD, DC, 1 S 570 Nimitz Rd, Oakbrook Terrace, IL 60181 (e-mail: dr.dan.diiorio{at}att.net).
From the Department of Family and Community Medicine, University of Illinois College of Medicine at Rockford.
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