Wednesday, July 31, 2013

Treating Back Pain in a “Do Something” Society
Don’t do nothing, do something.

David Coombes,  Healthcare Consultant

I used to work with David Coombes, a consultant trained in hospital administration.  We sought to put together hospital-physician organizations featuring bundled-bills in which the hospital, primary care physicians and specialists,  submitted fees they considered acceptable for a variety of hospital evaluations and treatments,  In his stump speech, David, sensing the economic crunch ahead for hospitals and doctors, would say, “Don’t do nothing, do something,”  another way of saying, “Nothing ventured, nothing gained.”
I thought of David’s  advice when I read the following abstract of an online article in the JAMA Internal Medicine.
Worsening Trends in the Management and Treatment of Back Pain,
John N. Mafi, MD1; Ellen P. McCarthy, PhD, MPH1; Roger B. Davis, ScD1; Bruce E. Landon, MD, MBA, MSc
I"mportance Back pain treatment is costly and frequently includes overuse of treatments that are unsupported by clinical guidelines. Few studies have evaluated recent national trends in guideline adherence of spine-related care.
Objective To characterize the treatment of back pain from January 1, 1999, through December 26, 2010.
Design, Setting, and Patients Using nationally representative data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, we studied outpatient visits with a chief symptom and/or primary diagnosis of back or neck pain, as well as those with secondary symptoms and diagnoses of back or neck pain. We excluded visits with concomitant “red flags,” including fever, neurologic symptoms, or cancer. Results were analyzed using logistic regression adjusted for patient and health care professional characteristics and weighted to reflect national estimates. We also present adjusted results stratified by symptom duration and whether the health care professional was the primary care physician (PCP).
Main Outcomes and Measures We assessed imaging, narcotics, and referrals to physicians (guideline discordant indicators). In addition, we evaluated use of nonsteroidal anti-inflammatory drugs or acetaminophen and referrals to physical therapy (guideline concordant indicators).
Results We identified 23 918 visits for spine problems, representing an estimated 440 million visits. Approximately 58% of patients were female. Mean age increased from 49 to 53 years (P < .001) during the study period. Nonsteroidal anti-inflammatory drug or acetaminophen use per visit decreased from 36.9% in 1999-2000 to 24.5% in 2009-2010 (unadjusted P < .001). In contrast, narcotic use increased from 19.3% to 29.1% (P < .001). Although physical therapy referrals remained unchanged at approximately 20%, physician referrals increased from 6.8% to 14.0% (P < .001). The number of radiographs remained stable at approximately 17%, whereas the number of computed tomograms or magnetic resonance images increased from 7.2% to 11.3% during the study period (P < .001). These trends were similar after stratifying by short-term vs long-term presentations, visits to PCPs vs non-PCPs, and adjustment for age, sex, race/ethnicity, PCP status, symptom duration, region, and metropolitan location.
Conclusions and Relevance Despite numerous published clinical guidelines, management of back pain has relied increasingly on guideline discordant care. Improvements in the management of spine-related disease represent an area of potential cost savings for the health care system with the potential for improving the quality of care."

This seems straightforward enough.  If only doctors would treat low back pain conservatively  with ibuprofen and physical therapy, patience, and watchful waiting,  and stop using pain-killing narcotics, unnecessary referrals to back surgeons,  CT and EMR imaging, and surgery could be avoided.  Conservative therapy is what evidence-based guidelines call for.  Evidence indicates patient due just as well with conservative treatment as with more aggressive approaches.
Give this evidence, why do doctors defy evidence-based guidelines.
I  offer these reasons: 
1)      When you’re suffering from low-back pain, which can be excruciating and debilitating, you go to the doctor because you want him/her to “do something.”  We are an impatient, activist society, and we tend to be leery of doctors who do nothing in the short term.
2)      When we go to a specialists, we have high expectations that they “will do something” to relieve our pain.
3)      Specialists tend to do what they are trained to do rather than “do nothing.”
4)      Because of the malpractice environment, specialists do what they are expected to do to impress patients.
5)      Guidelines are 20/20 in retrospect,  but tend not to impress patients who are looking for immediate prospective relief.

I am not justifying physician treatment of back pain .  I am explaining  it

As Don Marquis of Archy and Mehitabel fame, said;

I suppose the human race

is doing the best it can

but hells bells thats

only an explanation

its not an excuse

Tweet:   Physicians overuse narcotics, imaging, and surgery rather than evidence-based guidelines recommending ibuprofen and physical therapy.



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