Although family physicians from the Basque Country conform to clinical practice guidelines with respect to recommendations for earlier mobilization and provision of educational advice to patients with acute low back pain, there were substantial deviations from published clinical guidelines in other aspects of care, such as history and physical examination, diagnostic testing, lumbar radiography, and referrals to specialized care.
Guidelines emphasize the importance of a careful history and physical examination, concentrating on neurological deficit [5
]. The importance of history taking for a correct diagnosis has been emphasized over skills in interpreting special investigations [14
]. In the present study, however, underutilization rates of history and physical examination were very high (73% and 67%, respectively). Physicians working in primary health care centers in the Basque Health Service on average care for 41 patients per day, with a mean time per visit of less than 10 min [22
]. These poor results may therefore be explained by a shortage of time in which to conduct at least a brief history and physical examination as well as recording the data obtained. It should be noted that patients without previous episodes of low back pain had a higher probability of history and examination, which indicates a more active attitude for assessing danger symptoms or signs in patients presenting to the general practitioner with an initial episode of low back pain.
Plain radiography of the lumbar spine was substantially underutilized relative to suggested guidelines. Appropriate use of lumbar radiography in the index visit was found in 31% of cases—a much higher percentage than the 17–19% reported in other studies [29
]—which is consistent with our criterion of considering it appropriate not to require lumbar radiographs in the absence of “red flags” for spinal fracture, cancer, or infection in subjects aged over 50 years. Of the seven cases in which lumbar radiographs were required (spinal trauma in subjects over 50 years), radiographs were obtained in only one case (underutilization rate of 85.7%). In contradistinction, a 13% overutilization rate indicates that an important percentage of patients is being exposed unnecessarily to potential risks of ionizing radiation (lumbar spine X-rays involve 40 times the dose received during chest radiography) [31
]. Our findings of underutilization and overutilization of plain radiography of the lumbar spine in the management of acute low back pain are consistent with results of other studies [29
]. Furthermore, avoidable costs were adversely affected by inappropriate use of lumbar X-rays.
Overutilization of specialized care referral (8%), although it was lower than that reported in other studies [29
], may have important consequences for the patient as the starting point for unnecessary diagnostic tests (stoking fear beliefs about back trouble) [8
] and unnecessary therapeutic interventions, including surgical treatment, which is carried out in 10% of patients referred to specialized care [38
]. The effectiveness of most of these interventions has not yet been demonstrated beyond doubt [33
]. With regard to cost control, 54.5% of referrals to specialists could have been avoided. This situation is particularly unsatisfactory in our primary health care system, in which there are serious problems with the waiting list for consultations with specialists, with a mean (SD) waiting time of 30 (10) days for orthopedics.
The therapeutic management of low back pain varies widely. Since there is conflicting evidence regarding whether NSAIDs are more effective than analgesics for acute low back pain and strong evidence that various types of NSAIDs are equally effective [17
], drug treatment in primary care was not analyzed in the present study. Appropriate use of earlier mobilization (no prescription of bed rest or bed rest for less than 2 days) and educational advice—the only two factors that have been shown to exert a positive effect on the course of back pain [8
]—were analyzed. Suggested criteria for earlier mobilization and educational advice were met by 77% and 65% of patients, respectively. However, specific information on the favorable evolution of the disease was recorded in only 23% of cases. This is an important finding, because information and advice that health professionals give to patients based on traditional biomechanical concepts of spinal anatomy, adequate postures for activities of daily life, and specific back exercises have shown no significant impact on prognosis of the disorder, whereas it has been shown that clinical effectiveness and cost-effectiveness of nonspecific acute low back pain management can be improved by advice that departs from traditional orthopedic and physiotherapy information and focuses instead on the natural history and benign course of the disease, on patients’ beliefs, and on what they themselves should do about their back pain [8
This study presents a descriptive evaluation of how acute low back pain is managed by physicians working in one primary care setting. The present results provide reliable information on the variability that exists worldwide for appropriateness of existing practice patterns according to recommendations from the medical literature. Our findings, however, should be interpreted taking into account certain characteristics of the study. Firstly, it is well known that observing a process alters the behavior of the people involved in the process. However, general practitioners were not aware of the aims of the study, did not participate in the assessment of eligibility criteria, and were only involved in the referral of patients to an interview after consultation. Therefore, there are no reasons to believe that patients whose management could affect the results were systematically excluded. Secondly, there is always the possibility of a change in the physicians’ approach to the management of acute low back pain, but this seems unlikely, because the study period was relatively short and no interventions related to the problem of low back pain were implemented in the participating practices. In addition, a specific training program for the care of patients with low back pain was not available at any of the participating practices. On the other hand, the study was not designed to determine knowledge of the existence and understanding of the contents of guidelines; however, it may be assumed that practitioners were familiar with US [5
] and UK [17
] clinical guidelines, given that references to these published guidelines are usually included in clinical practice manuals recommended by the most important scientific societies. Thirdly, underutilization of history and physical examination may have occurred, since these data were collected from the patients’ medical records, and it is well known that less is recorded than is actually done [10
]. This method, however, was considered more reliable than self-reported behavior, in which physicians’ clinical practice tends to be presented in a more unrealistic way. The design of our study did not allow for any assessment on whether some general practitioners performed better than others, and whether performance could be related to age, special interest, or other factors. Further studies are needed to address this question and to collect information as to how the situation may be improved.