Decreasing Adherence to Evidence-Based Guidelines for Low Back Pain

Thomas L. Schwenk, MD

Narcotic prescriptions, physician referrals, and complex imaging all increased from 1999 to 2010.

Despite the availability of evidence-based guidelines (e.g., Ann Intern Med 2007; 147:478) for conservative management of uncomplicated low back pain (LBP), many patients receive inappropriate imaging and treatments. Researchers used a U.S. national ambulatory care database to identify nearly 24,000 visits for spine problems from 1999 through 2010. Patients with “red flags” for complicated LBP — fever, weight loss, known cancer, or adverse neurological findings — or with a wide range of comorbid diagnoses were excluded.

Prescriptions for nonsteroidal anti-inflammatory drugs (NSAIDs) decreased from 1999 to 2010 (from 37% to 24% of patients), whereas prescriptions for narcotics increased (from 19% to 29%). Referrals to physical therapy remained constant at about 20%, but referrals to specialists doubled (from 7% to 14%). Use of plain radiography also held constant at about 17% of visits, whereas use of computed tomography or magnetic resonance imaging increased from 7% to 11%. Analyses adjusted for demographic, insurance-coverage, and healthcare variables (e.g., care delivered in metropolitan vs. rural areas) yielded similar results.

Citation(s):

Mafi JN et al. Worsening trends in the management and treatment of back pain. JAMA Intern Med 2013 Sep 23; 173:1573.