General Practitioners Do Not Adhere to Clinical Guidelines when Treating Low Back Pain

General practitioners are not following international evidence-based guidelines when treating patients presenting with new cases of low back pain, according to results of a recent study [Arch Intern Med. 2010;170:271-277].

Evidence has shown that clinical practice guidelines are both cost-effective and time-efficient when physicians base their treatment of low back pain upon them. Researchers recently conducted a study to examine how closely general practitioners in Australia follow guidelines when they treat patients with acute low back pain. They also sought to find any differences in care after guidelines were released by the National Health and Medical Research Council in 2004.

Data on new cases of low back pain were gathered from 2001 to 2008 from the BEACH (Bettering the Evaluation and Care of Health) study, an Australian database that collects survey information from general practitioners each year, such as prescribed or advised medications; clinical treatments, including advice and education; therapeutic procedures; pathology tests; and any referrals made.

The researchers evaluated clinical practice guidelines from Europe, the United States, the United Kingdom, and Australia, as well as a systematic guideline review, and reached a consensus on several key messages. These included the use of a diagnostic triage; avoiding routine ordering of radiologic or ancillary investigations; education of the patient; advising patients to use acetaminophen as a first-choice analgesic, followed by nonsteroidal anti-inflammatory drugs (NSAIDs) if acetaminophen fails; and a review of the patient’s progress.

Results showed there were 6296 patient–general practitioner visits related to low back pain between 2005 and 2008, of which 1706 were new cases. Most visits concerning new cases of low back pain lasted <20 minutes. New cases of low back pain were significantly higher among patients between the ages of 25 and 64 years compared with those younger and older, and slightly higher among men. The researchers found 65.2% of patients received medication for low back pain; 46.7% received a prescription for at least 1 drug, 17.8% were advised to take at least 1 over-the-counter medicine, and 5% received medication from the general practitioner at their visit.

Before the release of the 2004 guidelines, 41.1% of patients were advised to take NSAIDs, followed by opioids (17.2%), and acetaminophen (15.5%). After the release of the guidelines, this pattern did not change: NSAIDs remained the most common medication (37.4%), followed by opioids (19.6%), and acetaminophen (17.7%). When patients were given acetaminophen, 33% were prescribed the recommended dose of 4 g/day.

Although all clinical practice guidelines recommended that general practitioners educate their patients and reassure them of a good prognosis, results showed 20.5% of general practitioners had done so (compared with 24.7% before the 2004 guidelines). About 25% of patients had been advised to undergo imaging, with a significant increase in computed tomography (from 3.7% before the 2004 guidelines to 6.2% after).

All guidelines recommended that low back pain be handled in primary care (with the exception of cases involving serious disease). Researchers found 1.5% of general practitioners referred patients to a specialist. Guidelines were not consistent regarding referrals to allied health practitioners, and results showed 17.2% of general practitioners referred patients to an allied health practitioner (compared with 13.4% before the 2004 guidelines).

The researchers were aware of a few limitations to their study, such as the unavailability of specific data on diagnostic triage and patient review. Furthermore, available data did not allow the researchers to determine the appropriateness of treatment for individual patients. They were also unable to establish why certain aspects of the clinical practice guidelines were or were not followed.—Mary Mihalovic