As many as 80% of adults will experience acute low back pain (LBP) once in their lifetime, and many of them will first seek treatment from a primary care physician. According to a new study recently published by the University of Pittsburgh in The Lancet, despite the prevalence of acute low back pain and lack of evidence for effective interventions, few PCP follow existing clinical guidelines to prevent patients from developing chronic low back pain .
“Many primary care physicians prescribe expensive imaging tests for patients with acute LBP and often turn to medications, including unnecessary opioids,” said Dr. Tony Delitto, dean and researcher of the Pitt School of Health and Rehabilitation Sciences. Therefore, in order to change this situation, Delitto and his team tested the implementation of a simple screening tool-a patient survey with nine questions to assess someone’s risk of becoming a chronic LBP patient.
Delitto said: “We are trying to promote doctors to provide better options for high-risk groups by bringing these patients to non-drug treatment to help them enter chronic LBP.”
Acute LBP cases may be improved or resolved with little or no intervention; however, those who do not improve tend to become chronic diseases and extremely difficult to manage. Previous studies have shown that only one-third of acute LBP patients treated with PCP recover after three months. Approximately 65% of patients still feel pain one year after the first back pain.
In this study, providers used the STarTBack tool to classify adults with acute LBP as low, medium, or high risk. Risk is based on a person’s behavior or psychological characteristics. For example, people who think the worst will happen are classified as high-risk groups of chronic pain. Patients who were screened as high-risk intervened through the use of “best practice alerts,” which triggered referrals for Psychologically Informed Physical Therapy (PIPT).
In previous studies in Europe, the screening tool approach resulted in fewer people becoming chronic LBP. Delitto’s research data comes from Pitt’s TARGET trial, which included 76 clinics in four health care systems in the United States, with 1,300 patients, from May 2016 to June 2018. 38 primary care institutions used screening tools, while 37 clinics did not use screening tools.
After analyzing the data, the researchers found that primary care practices that use screening tools have the same rate of conversion to chronic LBP as patients who do not use screening tools.
Despite the automated process used to identify high-risk patients, only half of the patients in the STARTBack group received PIPT referrals, while one-third of the patients in the control group received physical therapy.
“We believe that the doctors participating in this study did not consistently provide their patients with the best options-they never fully implemented best practices,” Delitto said. “Based on our review, the number of opioid prescriptions, X-ray and advanced imaging orders, and referrals to specialists, in many cases, doctors did not follow clinical guidelines.”
Delitto acknowledges that the current healthcare system poses a challenge to implement this risk-based approach. He pointed out that primary care doctors usually pay by quantity and there is little financial incentive to change the way they treat patients with acute LBP.
Doctors also described “alarm fatigue”, which causes best practice alerts in their electronic health records to be overwritten and hinders decision support systems such as those in the STARTBack tool.
Delitto said that combining research with patient treatment in a real-world setting often reveals the challenge of effectively translating what we know will help patients’ knowledge into daily practice.
Delitto said: “We plan to explore collaborations between doctors and extended staff such as physician assistants and nurse practitioners to transfer who will manage low back pain.” “It is clear that primary care practice is very busy and it is unrealistic to require doctors to do more.”