The Liberty Mutual Research Institute for Safety is owned and operated by the Liberty Mutual Insurance Company. The Institute conducts original scientific investigations into the causes and prevention of job-related injuries and disability. All research is published in peer-reviewed journals in science, engineering, or medicine.
Physicians' Initial Management of Acute Low Back Pain Versus Evidence-Based Guidelines
Influence of Sciatica
Article first published online: 30 AUG 2005
Journal of General Internal Medicine
Volume 20, Issue 12, pages 1132–1135, December 2005
How to Cite
Webster, B. S., Courtney, T. K., Huang, Y.-H., Matz, S. and Christiani, D. C. (2005), Physicians' Initial Management of Acute Low Back Pain Versus Evidence-Based Guidelines. Journal of General Internal Medicine, 20: 1132–1135. doi: 10.1111/j.1525-1497.2005.0230.x
Conference: Presented in part in a poster at the Montreal International Forum V for Primary Care Research on Low-Back Pain, May 2002.
- Issue published online: 22 DEC 2005
- Article first published online: 30 AUG 2005
- Received for publication May 10, 2005 , and in revised form June 13, 2005 , Accepted for publication June 20, 2005
- back pain;
- practice variation;
- clinical vignette;
- decision making
Background: Little information is available on physician characteristics and patient presentations that may influence compliance with evidence-based guidelines for acute low back pain.
Objective: 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.
Design: Cross-sectional study using a mailed survey.
Participants: Participants were randomly selected from internal medicine, family practice, general practice, emergency medicine, and occupational medicine specialties.
Measurements: A questionnaire asked for recommendations for 2 case scenarios, representing patients without and with sciatica, respectively.
Results: 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.
Conclusions: 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.