What is Usual Care for Low Back Pain?
A Systematic Review of Health Care Provided
to Patients with Low Back Pain in Family
Practice and Emergency DepartmentsThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Pain. 2020 (Apr); 161 (4): 694–702 ~ FULL TEXT
Steven J Kamper, Gabrielle Logan, Bethan Copsey, Jacqueline Thompson3, Gustavo C Machado1 et al,
Institute for Musculoskeletal Health,
Faculty of Medicine and Health,
University of Sydney, Australia.
International clinical practice guidelines for low back pain (LBP) contain consistent recommendations including universal provision of information and advice to remain active, discouraging routine referral for imaging, and limited prescription of opioids. This systematic review describes usual care provided by first-contact physicians to patients with LBP. Studies that reported the assessments and care provided to people with LBP in family practice and emergency departments (EDs) from January 2000 to May 2019 were identified by searches of PubMed, EMBASE, and CINAHL. Study quality was assessed with reference to representativeness of samples, potential misclassification of patients, potential misclassification of outcomes, inconsistent data and precision of the estimate, and the findings of high-quality studies were prioritized in the data synthesis.
We included 26 studies that reported data from almost 195,000 patients: 18 from family practice, and 8 from EDs.
Less than 20% of patients with LBP received evidence-based information and advice from their family practitioner. Around 1 in 4 patients with LBP received referral for imaging in family practice and 1 in 3 in EDs. Up to 30% of patients with LBP were prescribed opioids in family practice and up to 60% in EDs.
Large numbers of patients who saw a physician for LBP received care that is inconsistent with evidence-based clinical practice guidelines. Usual care included overuse of imaging and opioid prescription and underuse of advice and information. Suboptimal care may contribute to the massive burden of the condition worldwide.
PROSPERO Registration CRD42018070241
Keywords: low back pain; usual care; Family Medicine; emergency department; imaging; Opioids
From the FULL TEXT Article:
Introduction
Low back pain (LBP) is an extremely common condition with a mean lifetime prevalence of around 40% [22] and is the leading cause of disability globally. [53] At an individual level, LBP causes limitations to day to day function, impacts mental health, can result in financial hardship and reduces quality of life. [18] The condition also has considerable implications for society as a whole due to the costs of healthcare, reduced work productivity, early retirement and strains on the welfare system. [19, 49]
Recently updated clinical practice guidelines for LBP from Canada, the United States and the United Kingdom (UK) provide some consistent recommendations for how to assess and treat patients with LBP. [2, 30] Reviews of international guidelines show that these recommendations have been largely unchanged since 2000, the only major change being removal of paracetamol as first line care [2, 27] following a large RCT and subsequent systematic review published in 2015. [32, 55] These guidelines are based on high quality evidence and widely endorsed by professional organisations. Recommended assessment involves diagnostic triage [3, 52] based on patient history and physical examination to exclude patients with a problem beyond the lumbar spine (e.g. renal colic) and then categorise patients into one of three groups. A) non-specific LBP, B) lumbar radicular syndromes (sciatica and canal stenosis), or C) a serious pathology affecting the lumbar spine (e.g. infection, fracture, cancer). In family practice and emergency departments, more than 90% of lumbar spine problems fall into categories A or B. [20, 51]
There is a perception that people with back pain who present to ED have on average more severe symptoms, and are more likely present with serious pathology, [12] however, there are few data available to confirm this suspicion. Recommended first line treatment for patients with LBP includes; advice to remain active, and education and reassurance. Adjunctive options include application of heat, manual therapy, non-steroidal anti-inflammatory drugs, and structured exercise and cognitive behavioural therapy for patients with persistent symptoms. [40] Guidelines recommend against imaging unless serious spinal pathology is suspected, and strong analgesics such as opioids should only be prescribed with caution in selected patients.
While these recommendations are well established over several years, and health providers report being aware of them, [42, 54] there are concerns about substantial gaps between guideline recommendations and the care delivered in usual practice. [15] Individual studies report high rates of imaging [11], opioid prescription [9], and inconsistent provision of appropriate advice. However, to date there has been no synthesis of studies that comprehensively report the nature of usual care as delivered by primary contact physicians for this condition.
Understanding the nature of usual care in various settings is necessary to identify what aspects of care are most commonly divergent from recommendations, and hence direct efforts to increase provision of evidence-based care. To address this gap we conducted a systematic review of studies that report usual care provided by first contact physicians, the extent to which generalizable data are available will determine how well this review documents usual care for low back pain.
The aim was to synthesize evidence about current management of LBP in family practice and emergency departments (ED). The specific objective was to describe the assessments, treatment advice, imaging, medication and referrals provided in family practice or EDs to patients with LBP.
Methods
Prospectively registered systematic review, PROSPERO 2018 CRD42018070241.
Data sources and Searches
An electronic search was conducted in three databases (EMBASE, PubMed-Medline, and CINAHL) using search terms related to “back pain”, “guideline recommendations”, and “medical records” from inception to May 2019 (eTable 1, available as supplemental digital content at http://links.lww.com/PAIN/A913). Further potentially relevant studies were identified via consultation with experts and citation tracking on the included studies.
Study Selection
Studies were included if they: (1) reported family practice or ED physicians’ assessment and/or treatment of adult patients (aged >18 years) with LBP of any duration and, (2) had a quantitative design assessing actual treatment records. Qualitative studies and studies that measured usual care via recall or hypothetical scenarios/vignettes were not included. Studies that analysed data from prior to 2000 were excluded as we were not interested in historical patterns of practice. Grey literature including non-peer-reviewed literature, theses and letters to the editor were not included. Non-English language studies were included and translated as necessary. A full list of the eligibility criteria appears in eTable 2 (available as supplemental digital content at http://links.lww.com/PAIN/A913). Two reviewers independently screened all titles and abstracts, and then potentially eligible full texts. Disagreements were resolved by discussion, arbitrated by a third reviewer as needed.
Data Extraction
Two reviewers independently extracted study characteristics and outcomes data into an Excel spreadsheet. Study characteristics included; healthcare setting, LBP duration, period of data collection, data source, and sample size. Family practice was defined as primary-contact outpatient/ambulatory care that was not in ED. For each outcome, data were extracted on collection method, metric used to assess utilisation (e.g. proportion or rate), and the denominator used (e.g. episodes of care, number of patients). Studies most commonly reported the proportion of patients that received a particular aspect of care, which could have been at a single appointment or over a number of visits, we categorised this as ‘per patient’. Fewer studies reported the proportion of visits that involved that aspect of care, we categorised this as ‘per episode’ of care. One study reported the proportion of physicians that delivered that aspect of care; ‘per physician’.
Reporting and Methodological Quality
The STROBE (STrength of Reporting in OBservational Studies in Epidemiology) Statement and its extension statement entitled RECORD (REporting of studies Conducted using Observational Routinely-collected health Data) were used to assess the transparency of reporting. We used items from key domains for assessing susceptibility to bias in observational studies as recommended in Sanderson et al. [46] This includes items in 4 domains; representativeness of the sample, potential misclassification of patients, potential misclassification of outcomes, and inconsistent data. Because we used methodological quality to prioritise interpretation of findings, we also considered precision as an indicator of study quality. Included studies were considered high quality if they met criteria for ≥4 of 5 items.
Data Synthesis
Findings from included studies were divided by healthcare setting (family practice or ED) and organised according to outcome category: assessments, treatment advice, imaging, medication, referrals. Within each outcome category (e.g. Imaging) individual types are described separately (e.g. x-ray, CT, MRI, any image). We planned meta-analysis of single proportions, however clinical heterogeneity prevented meta-analysis for any outcome. We present all available estimates in the tables and focus our interpretation on the range of estimates that came from the high quality studies. A narrow range of high quality estimates from several studies provided greater confidence in the findings, and vice-versa.
RESULTS
Characteristics of included studies
The database and hand searches yielded 989 titles, of which 26 studies were included (Figure 1). The 26 studies reported data from a total of 194,388 patients, 18 studies were in family practice and 8 from emergency departments (Table 1). A further two studies that collected data from mixed settings were not included in the main analyses but findings are reported in eTable 3 (available as supplemental digital content at http://links.lww.com/PAIN/A913). Studies were published between 2003 and 2018. Most studies included patients with LBP of any duration, however, 6 included patients with acute LBP only. Studies most commonly reported data from routinely collected medical records in hospital administrative databases (n= 20), followed by insurance claims or worker compensation databases (n= 3).
Transparency of Reporting
Most studies met criteria on most items in the STROBE checklist (eTable 4, available as supplemental digital content at http://links.lww.com/PAIN/A913). The main areas of poor reporting related to the extended RECORD checklist items, specifically with respect to data capture from medical records. These included reporting who had access to the database and created the database of the study, what codes were used select participants and outcome variables from the database, if the codes were validated and if data linkages were required to obtain variables and if so, how the linkage was conducted.
Methodological quality
Nearly all included studies met criteria for consistency of data and representativeness of the sample, 12 used methods to limit bias due to patient misclassification, 15 used methods to limit bias due to misclassification of the outcome, and 15 studies reported on sufficiently large samples to provide precise estimates (eTable 5, available as supplemental digital content at http://links.lww.com/PAIN/A913). We considered sufficient precision to be confidence intervals with a width of 5% or less. According to our criteria, 12 studies provided high quality evidence (Table 1).
Components of usual care
There was often considerable variability in the proportions of patients that received assessments, various types of treatment advice, imaging, medication or referrals. This heterogeneity was in part due to differences in measurement between studies, and precluded meta-analysis. Method of measurement was an important source of heterogeneity, most commonly studies either reported rates (of assessments, images etc) per single patient visit (per patient), or per patient over multiple visits (per episode). To focus on the most reliable estimates of usual care, we only describe results from the high-quality studies in the text of the Results, data from all included studies appears in the Tables.Assessments Assessments were categorised into four types; assessment of red flags, history taking, physical examination, and neurological examination. There were no high-quality estimates of rates for any of the assessments (eTable 6, available as supplemental digital content at http://links.lww.com/PAIN/A913).
Treatment advice Treatment advice was categorised into five types; education and reassurance, exercise, bed rest, return to work and sickness certificates (Table 2). In family practice settings, two highquality studies reported that 21% and 23% of patients received education or reassurance, one study reported that 19% of patients received exercise advice, and 3% a sick certificate. There were no high-quality estimates for advice regarding bed rest or return to work. There were no high-quality estimates for any of these types of advice in ED.
Lumbar imaging Imaging referral was categorised into five types; X-Ray, CT scan, MRI, CT or MRI, any image (Table 3). Four studies reported that between 16 and 20% of patients received referral for X-Ray from family practice, in ED the proportion was 30%. Three studies in family practice reported rates of 2 to 6% for CT scans, and one study in ED reported 6%. Three studies estimated that <1 and 5% of family practice patients were referred for MRI, two ED studies reported 3% and 25%. Ten percent of family practice patients, and 7 to 18% of ED patients received an MRI or CT. Three studies reported that 11 to 26% of family practice patients received referral for an image of any type, and two studies in ED reported 29 and 37%.
Medication Medication recommendations were divided into four categories; paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and opioids (including in combination with other analgesics) (Table 4). Where specified in the included studies, the data for EDs relate to medications provided in ED, as opposed to recommended after discharge. In family practice, three studies reported that paracetamol was recommended to 6 to 18% of patients, in ED, the proportion was 4%. NSAIDs were recommended to 36 to 37% of family practice patients, and 50% of ED patients. Muscle relaxants were recommended to 1 to 8% of family practice patients, and 42% of ED patients. Opioids, including in combination with other analgesics were prescribed to 5 to 31% of family practice patients, and two studies in ED reported rates of 17 and 61%.
Treatment referrals Treatment referrals were divided into four categories; physiotherapy, chiropractic, surgery, medical specialist (Table 5). In family practice, three studies reported that 14 to 27% of patients received physiotherapy referral. Three studies reported that up to 10% of patients were referred from family practice for surgical consult, in ED this figure was 8%. In family practice four studies reported that 1% to 19% of patients received referral to a medical specialist.
DISCUSSION
Statement of main findings
The high-quality estimates for Family Practice suggest around 1 in 4 patients were sent for lumbar imaging, about 20% recommended paracetamol, 35-40% NSAIDs, and up to 30% prescribed opioids. While there were fewer high-quality estimates from ED, the rates of imaging, and medication use were higher (except for paracetamol); around 1 in 3 patients got some type of image, 50% received NSAIDs, and somewhere between 20 and 60% were provided opioids while in ED.
Only around 20% of patients received education, reassurance, and advice regarding exercise from their family practitioner. We found no high-quality data concerning the provision of advice regarding bed rest and return to work, and no high-quality data regarding treatment advice at all for ED settings. Family practitioners referred around 15 to 20% of patients for physiotherapy, 1 to 20% to a medical specialist and up to 6% to a surgeon, approximately 8% of patients in ED were referred for surgical review. We found no high-quality estimates on how many patients received recommended assessments such as red flag assessment, physical, and neurological examination and history taking.
Interpretation in context of other literature
It is important to take a nuanced approach to interpretation of these findings with respect to clinical practice guideline recommendations and epidemiological evidence. For example, guidelines recommend “Do not routinely offer imaging in a non-specialist setting for people with low back pain without alerting features of serious pathology” [36] and robust evidence suggests that prevalence of serious spinal pathology, for which imaging is indicated, in primary care is <5%. [20] In this context, rates in excess of 25% appear to indicate overuse of imaging.
However, these data do not tell us about the reasons for imaging referral, and hence what proportion were inappropriate. A recent systematic review of 33 studies considering appropriateness of imaging for low back pain and estimated that referral was inappropriate in 7 to 28% of the patients referred for imaging that presented for care. The same review also found that 60-65% of patients were not referred for imaging despite the presence of red flags or clinical suspicion of serious pathology. [25] Hence, issues of overuse and underuse may both occur. Overuse of imaging may lead to poorer outcome, [14] which means that efforts to reduce the volume of unnecessary imaging are appropriate. [23] However, understanding the reasons for referral is a pre-requisite to designing these efforts, for example some studies suggest that patient or physician beliefs may drive imaging. [24]
Current guidelines recommend that patients are provided NSAIDs as first line pharmacological treatment, and that use of opioids be limited in those with acute low back pain, and not provided at all for chronic low back pain. [36] Our findings show that less than half of patients were prescribed NSAIDs, up to third received opioids in family practice and up to twice that proportion in ED. Clinical practice guidelines do not offer distinct recommendations for care provided in ED and family practice settings. There is a perception that patients who present to ED have on average more severe symptoms, and are more likely to have a serious spinal pathology such as fracture, cauda equina or acute infection. [12] If this is the case higher rates of diagnostic imaging in ED than family practice may be appropriate, although this is not to suggest that the rates observed in our study are reasonable.
By the same argument, higher rates of prescription of powerful analgesics may also appear warranted, although this is to ignore important questions about the effectiveness of these medications [1] and well-established concerns regarding potential harms including overdose and death. [10] While data regarding the provision of advice are sparse, only approximately 1 in 5 patients visiting family practice were provided education, reassurance and advice regarding exercise.
These findings indicate that evidence-based advice was not routinely delivered to patients with LBP in primary care. High quality estimates come from studies conducted in a small number of countries only. Of the nine high quality family practice studies 3 are from the USA, 3 from Australia and 1 each from Netherlands, Italy and Spain, all of the 4 high quality ED studies come from USA. This raises the question of how well the results from this review represent usual care in other countries. Delivery of the different components of care could be influenced by structural aspects of the healthcare such as access, training of practitioners, and reimbursement processes, legislative constraints operating at the government level, by cultural aspects within a service, region or country, or other factors. We are not able to determine whether variability in the estimates presented in this review are due to any of these factors.
Strengths and limitations
This review was conducted according to contemporary best practice methods including registration of the protocol prior to commencement of data extraction, and double screening and data extraction. Inclusion of studies that made use of routinely-collected data ensured that we gained a true representation of ‘usual care’, and incorporation of study quality into our data synthesis focused our interpretation on the most reliable estimates.
As is the case for all systematic reviews, clinical and methodological heterogeneity between the included studies leads to variation in the estimates. A further limitation is that many aspects of care are typically not well captured and coded in routine clinical data collection systems. This is most likely to influence our findings related to assessments and treatment advice. The issue is reflected in the fact that we found few high-quality estimates of these components, it also means that we have low confidence that the data reported in lower quality studies provide a reliable reflection for these aspects of usual care.
Our study focusses on usual care provided by physicians, and so may not be generalizable to other healthcare professions such as physical therapists and chiropractors who are first-contact providers in some jurisdictions. We found relatively few studies that provided high quality data and these tended to be concentrated in a small number of western countries, this means that the nature of usual care may deviate substantially from our findings in other countries and jurisdictions. The included studies span approximately 15 years, in this time practice patterns may have changed as new evidence has accumulated, our synthesis does not account for any change over this period.
Implications
The findings point to both overuse and underuse of medical services including imaging, medication prescription and provision of advice in the usual care of people with LBP. Commentators have proposed that responses to these problems may come from the top-down, whereby governments, payers and system administrators enact changes, and from the bottom up, where the public and clinicians alter practice to align with best available evidence. [13] Numerous top-down initiatives may serve this purpose including: removal of capacity within the system to provide inappropriate care, financial restrictions, education and support for clinicians, and revision of diagnostic criteria and thresholds. Additionally, stakeholder (clinicians and patients) engagement, support for shared decision-making, and inclusion of (in)appropriate use recommendations in clinical practice guidelines may improve alignment of clinical services with best available evidence.
From a policy perspective, the findings also highlight the need for health systems to invest in and maintain data collection infrastructure. Robust clinical audits are only possible if there is reliable and complete capture of clinical data, such audits being vital to identify problems and inefficiencies in patient care, and evaluate whether remedial strategies are effective. An important barrier to useful audits of practice involves numerous and disconnected data collection and storage systems within institutions, for example imaging, medication prescription, admission and clinical notes may all be located in different databases that are not easily linked. It is noted that this presents a barrier to effective care delivery as well as research.
Dependable information about what constitutes usual medical care for low back pain is also critical for interpreting clinical research, as ‘usual care’ is often used as a comparator (control) in pragmatic trials. If usual care is of poor quality, showing that a new therapy provides better outcome may not provide convincing evidence for the new therapy. At a minimum, it is important to describe the care typically received in the usual care arm [21] so that readers can assess the trial results. These data can also identify system, country and international trends, for example in medication use, or intervention provision. Information such as this can inform research priorities and targets for funding.
Our study also highlights the need for much more fine-grained information about the reasons for decisions made in clinical practice. This might involve a field that links medication or imaging referral specifically to an indication. Machine learning applications may also assist in this regard by generating algorithms to convert clinical notes into categorical fields that enable data users to link indications to treatment or referrals. For example, only by understanding the basis for prescription of opioids can we determine whether action needs to be taken, and if so, what the most promising targets for changing prescribing behaviour might be.
Conclusions
Usual care for patients with low back pain did not align well with recommendations in clinical practice guidelines. Around one in four patients that presented to family practice, and one in three that presented to ED with back pain were referred for imaging. Around 35% and 50% of patients received NSAIDs in family practice and ED respectively. Rates of prescribing of opioids were up to 30% in family practice and up to 60% of patients received an opioid while in ED. Only around 20% of patients received information and advice that aligns with clinical practice guideline recommendations.
Acknowledgements
None of the authors have conflicts of interest to declare. There was no funding for this study.
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