Webster BS, Courtney TK, Huang YH, et al. Physicians' initial management of acute low back pain versus evidence-based guidelines: influence of sciatica

Department of Environmental Health , Harvard University, Cambridge, Massachusetts, United States
Journal of General Internal Medicine (Impact Factor: 3.42). 01/2006; 20(12):1132-5. DOI: 10.1111/j.1525-1497.2005.0230.x
Source: PubMed


Little information is available on physician characteristics and patient presentations that may influence compliance with evidence-based guidelines for acute low back pain.
To assess whether physicians' management decisions are consistent with the Agency for Health Research Quality's guideline and whether responses varied with the presentation of sciatica or by physician characteristics.
Cross-sectional study using a mailed survey.
Participants were randomly selected from internal medicine, family practice, general practice, emergency medicine, and occupational medicine specialties.
A questionnaire asked for recommendations for 2 case scenarios, representing patients without and with sciatica, respectively.
Seven hundred and twenty surveys were completed (response rate=25%). In cases 1 (without sciatica) and 2 (with sciatica), 26.9% and 4.3% of physicians fully complied with the guideline, respectively. For each year in practice, the odds of guideline noncompliance increased 1.03 times (95% confidence interval [CI]=1.01 to 1.05) for case 1. With occupational medicine as the referent specialty, general practice had the greatest odds of noncompliance (3.60, 95% CI=1.75 to 7.40) in case 1, followed by internal medicine and emergency medicine. Results for case 2 reflected the influence of sciatica with internal medicine having substantially higher odds (vs case 1) and the greatest odds of noncompliance of any specialty (6.93, 95% CI=1.47 to 32.78), followed by family practice and emergency medicine.
A majority of primary care physicians continue to be noncompliant with evidence-based back pain guidelines. Sciatica dramatically influenced clinical decision-making, increasing the extent of noncompliance, particularly for internal medicine and family practice. Physicians' misunderstanding of sciatica's natural history and belief that more intensive initial management is indicated may be factors underlying the observed influence of sciatica.

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    • "The case study refers to an employee with non-specific LBP, a common, costly and complex health problem in welfare states (Airaksinen et al., 2004; Koes et al., 2006; van Tulder et al., 2006; Webster et al., 2005). Occupational rehabilitation was chosen because practitioners face the challenge of how evidence-based practice should and could be used in situations where decision-making often concerns a single patient with comorbidities, complex contexts and high job demands. "
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