Activities performed and treatments conducted prior to consultation with a spine surgeon: Are patients and clinicians following evidence-based clinical practice guidelines?

Publication date: Available online 4 September 2017
Source:The Spine Journal
Author(s): Elliot I. Layne, Darren M. Roffey, Matthew J. Coyle, Philippe Phan, Stephen P. Kingwell, Eugene K. Wai
Background ContextClinical practice guidelines (CPGs) are designed to ensure that evidence-based treatment is easily put into action. Whether patients and clinicians follow these guidelines is equivocal.PurposeTo examine how many patients complaining of low back pain (LBP) underwent evidence-based non-operative treatment in line with CPG recommendations prior to consultation with a spine surgeon, and to evaluate any associations between adherence to CPG recommendations and baseline factors.Study Design/SettingCross-sectional cohort analysis at a tertiary care center.Patient SampleTotal of 229 patients referred for surgical consultation for an elective lumbar spinal condition.Outcome MeasuresNumber of CPG-recommended treatments undertaken by patients at or before the time of referral, validated pain score, EuroQol 5-D (EQ-5D) health status, and Oswestry Disability Index (ODI) score.MethodsQuestionnaires assessing demographic and functional characteristics as well as overall health care utilization were sent to patients immediately after their referral was received by the surgeon's office. Funding for this study was provided via Innovation Funds from The Ottawa Hospital Academic Medical Organization (TOHAMO) ($27,296). DMR reports receiving remuneration for consulting services provided to Palladian Health, LLC. and Pacira Pharmaceuticals, Inc. ($20,000-$30,000 annually), although neither relationship presents a potential conflict of interest with the submitted work. There are no conflict-of-interest associated biases.ResultsMedications were the most common modality prior to consultation (74.2% of patients), of which 46.3% received opioids. Number of medications taken was significantly related to higher ODI score (R = 0.23, p = 0.0004), higher pain score (R = 0.15, p = 0.026), and lower EQ-5D health status (R = -0.15, p = 0.024). In contrast, lower pain score (7.2 vs. 7.7, p = 0.037) and lower ODI score (26.6 vs. 29.9, p = 0.0023) were associated with performing adequate amounts of exercise. There was a significant association between lower number of treatments received and higher numerical pain rating scores (R = -0.14, p = 0.035). The majority (61.1%) of patients received two or less forms of treatment.ConclusionEvidence-based non-operative treatments for patients with LBP are not being taken advantage of prior to spine surgery consultation. If more patients were to undertake CPG-endorsed conservative modalities, it may result in fewer unnecessary referrals from primary care physicians, and patients might not deteriorate as much while lingering on long wait lists. Further studies incorporating knowledge translation or health systems pathway changes are necessary.



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