A survey of primary care physician practice patterns and adherence to acute low back problem guidelines

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 250000 and encompassing a medium-sized city. Participants: One hundred eighty-two primary care physicians (nonpediatric) with medical staff appointments at area hospitals. Main Outcome Measurer 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.