An intervention based on accepted strategies of physician education, practice audit with performance feedback, and peer opinion leader use produced a modest but significant increase in physician actions consistent with a clinical guideline for the care of acute low back pain. The addition of a patient education intervention did not produce significant changes in the outcome measures of interest, likely a result of failures in implementation and adoption.
There are several potential explanations for our findings. While the randomization process did produce similar groups from a demographic perspective, subsequent utilization data obtained in the baseline year revealed greater procedure and consultant utilization in the intervention group. It is possible that the improvement in clinician utilization behaviors could at least partly be explained by regression to the mean during the intervention year. The fact that the disparity in baseline utilization rates between the groups diminished after adjustment for visit frequency and other clinical covariates suggests a more severe case mix in the intervention group. However, the intervention effect size did not diminish after adjustment for patient clinical covariates.
Since baseline utilization was lower and guideline-consistent behavior higher than expected when compared with other primary care studies of low back pain,9,43,44
as well as preliminary audit data from the study site,39
there was less room for improvement than had been anticipated. We believe that the high control and baseline rates of guideline-consistent behavior are at least in part explained by two factors. First, it may have reflected increased general attention to back pain care in the literature, exemplified by the release of the AHCPR back pain guideline (with similar recommendations to the intervention group's guideline) in the midst of the intervention year.38
It also may indicate greater emphasis on utilization issues by the participating managed care organizations—though there were no specific initiatives in this regard, both organizations studied were under substantial financial duress during this period. Though contamination of control clinician groups by the guideline intervention could have contributed to their low utilization, the physician survey suggests that knowledge of the specific study guideline was not widespread. Furthermore, control group utilization remained stable between baseline and intervention periods.
One concern about clinical guidelines for acute low back pain is that they might prompt increased utilization of services, rather than the generally intended opposite effect.44,45
Contrary to this theoretical concern, we observed no increase in service utilization in our study (). Study clinicians, practicing in a managed care environment, were likely to be more cognizant of utilization concerns and therefore less prone to request services fulfilling “soft” guideline criteria (such as age > 50 for plain films). Additionally, the managed care patient population tended to be relatively young and healthy and thereby less likely to fulfill some of these same criteria. Guideline-driven increased service utilization remains a legitimate concern and may depend on the clinical setting as well as the guideline criteria and language.
Preexisting patient and physician beliefs may have reduced the study guideline's effect. Physicians harbor substantial concerns about the impact of clinical practice guidelines in general on medical practice,46
and many hold beliefs about the value of diagnostic and therapeutic interventions for back pain that conflict with guidelines for its care.47–49
Particularly when confronted with patient expectations for services, it may be harder to convince physicians to do less for patients rather than more,50
and research clearly demonstrates that patient expectations play a significant role in the utilization of services for low back pain.51–55
Most of the patients surveyed in our study had strong beliefs about the need for testing and referral that conflicted directly with the guideline recommendations. Consequently, we felt that a patient education intervention to address this barrier to guideline-consistent actions would complement the physician intervention.
The patient education intervention was designed to support the guideline's evaluation and management strategy by addressing frequent misconceptions about low back pain care. Though we structured the low-intensity pamphlet and videotape-based approach so that it could be practical for wide dissemination, implementation and adoption problems limited any potential effect. Greater attention to integration of the educational materials into the practice structure via use of nurses, office staff, or automated triggers may have led to greater use and impact.56,57
However, though more intensive patient education interventions for low back pain have been successful in altering patient beliefs and satisfaction, they have shown little impact on measures of functional outcome or resource utilization.8,58–60
Patient intervention efforts may need to add cognitive and behavioral approaches to the more traditional educational ones in order to improve, albeit modestly, low back pain outcomes.61
In addition to patient beliefs, individual factors related to the illness episode may be important to the success of guideline implementation strategies. In this study, the frequency of encounters during the back pain episode was strongly associated with utilization of clinical services that was not consistent with the guideline. This finding is concordant with prior studies that have suggested that the chronicity and severity of symptoms may compel physicians to do more in the absence of other firm indications for additional services.4,52,53,62–64
Our results suggest that guideline implementation efforts in this area might benefit from strategies directed specifically at these issues, especially that of return visits for persistent symptoms. Guideline adherence could have been facilitated by offering physicians intermediate strategies for patients suffering with more severe or prolonged pain, but without worrisome neurological features. In retrospect, the recommendation of a strictly conservative approach during the first 4 to 6 weeks of care may have left the clinicians with little defense against the onslaught of patient symptoms and expectations. If the guideline had supported earlier use of physical therapy, for instance, there might have been lower use of other specialty services and advanced imaging in the absence of clear indication. However, such an approach would likely have resulted in more costly overall care without significant improvement in clinical outcomes.65
Alternative “stepped-care” approaches have been suggested but have not been empirically validated.66
Though separate evidence-based systems of care for low back pain appeared to utilize services efficiently in one study,67
their generalizability is questionable.
In this study, clinicians exhibited greater guideline-consistent clinical practice following a multifaceted, moderate-intensity active intervention. Another trial40
utilizing predominantly passive dissemination of guidelines and performance feedback in a similar setting failed to show an effect, suggesting that the threshold of intervention intensity necessary to affect clinician behavior in areas with substantial barriers to change may lie between these two studies. Given the difficulties inherent in translating research into practice, it is reasonable to question whether the interventions we describe are generalizable to other health care settings and conditions. Even a well-organized group might encounter difficulties targeting multiple illnesses for similar active guideline-based interventions. To test and apply implementation strategies such as we studied to other usual care settings might prove to be prohibitively costly or impractical. Alternative strategies to alter systems of primary care practice and reduce dependence on direct clinician interventions may have promise.68–70
As electronic medical record technology matures and is adopted, it will also provide a strong platform for guideline dissemination and implementation strategies.
In summary, this study demonstrates that an intervention based on accepted principles of group education, performance audit and feedback, and use of opinion leaders can result in clinician behavior change in an area with substantial barriers to improvement. It is clear, however, that the challenges to generalizing and extending such success are considerable.