Up to 80 percent of adults will experience one episode of acute low back pain (LBP) in their lifetime and many of those people will first seek care from their primary care physicians. Despite the prevalence of acute low back pain– and a lack of evidence for effective interventions – few PCPs are following existing clinical guidelines to prevent patients from developing chronic LBP, according to a new University of Pittsburgh study recently published in The Lancet.
“Many primary care doctors prescribe expensive imaging for patients with acute LBP and routinely turn to pharmacological treatment including unnecessary opioids,” said Tony Delitto, Ph.D., dean and researcher at Pitt’s School of Health and Rehabilitation Sciences. So to try to change that, Delitto and his team tested the implementation of a simple screening tool – a nine-question patient survey to assess the risk for someone becoming a chronic LBP sufferer.
“We tried to push doctors to provide better options for people at high risk for moving into chronic LBP by driving those patients to non-pharmacological care,” said Delitto.
Acute LBP cases may improve or resolve with little to no intervention; however, those that do not improve often become chronic and extremely difficult to manage. Previous studies have shown that only a third of patients seen by a PCP for acute LBP recovered after three months. Approximately 65 percent of patients still have pain a year after they first experience low back pain.
In this study, providers used the STarTBack tool to classify adults with acute LBP as low, medium, or high-risk. Risk was based on a person’s behavioral or psychological traits. For example, people who assume the worst will happen were categorized as high-risk for experiencing chronic pain. Patients screened as high-risk were targeted for intervention 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 led to fewer people transitioning into chronic LBP. Data from Delitto’s study came from the TARGET Trial at Pitt, which included 76 clinics in four health care systems across the U.S., with 1,300 patients, from May 2016 through June 2018. Thirty-eight primary care practices used the screening tool, while 37 practices did not.
After analyzing the data, researchers found that primary care practices that used the screening tool approach had the same percentage of patients transition to chronic LBP as the practices that did not.
Despite the automated process to identify high-risk patients, only half of the patients received a PIPT referral in the STarTBack group compared to a third of patients receiving a referral to physical therapy in the control group.
“We don’t think the doctors enrolled in this study consistently offered the best options for their patients – they never fully implemented the best practices,” said Delitto. “Based on our review, the number of opioid prescriptions, orders for x-rays and advanced imaging, and referrals to specialists, the doctors in many cases didn’t follow clinical guidelines.”
Delitto acknowledged that the current health care system poses a challenge to implement this risk-based approach. He noted that primary care doctors are often paid by volume, with little financial incentive to change the way they treat acute LBP patients.
Doctors also describe “alert fatigue,” which leads to overriding best practice alerts in their electronic health records and hindering decision-support systems, like the one in the STarTBack tool.
Combining research with the treatment of patients in real world settings often reveals the challenge of effectively translating what we know will help patients into everyday practice, said Delitto.
“We plan to explore having physicians partner with extenders, such as physician assistants and nurse practitioners, to shift who manages low back pain,” said Delitto. “It is clear that primary care practices are busy and asking doctors to do more is unrealistic.”