Treatment for Lower Back Pain in a Primary Care Setting – Risky Business?
Around four out of five people experience lower back pain (LBP) at some point in their lives—making it highly prevalent and one of the most common reasons people visit a healthcare provider.1 Lower back distress can be caused by various injuries, muscle or tendon strain, structural problems, and other conditions, but it’s rarely related to underlying disease. While LBP typically resolves on its own with rest and over-the-counter medication, when the pain persists more than three months, it’s considered chronic, and can become a disabling and expensive condition.
Overall, 13% of adults suffer from chronic LBP, with one-third experiencing moderate- to high-impact chronic pain.2,3 In the United States, treatment for LBP and related spine disorders now represents the most expensive medical problem, with most costs accrued in ambulatory care settings, including primary care.4,5 Like with many common ailments, when most people seek medical care for LBP, they visit their primary care physician as a first point of entry. While this may seem like a sensible choice, a study published in the Journal of the American Medical Association (JAMA) revealed that it might not be the best path to follow—and it can actually be risky.
Snapshot of the Study
The cohort study was conducted to determine if the transition from acute to chronic LBP was associated with risk stratification, defined by a standardized prognostic tool, and/or with early exposure to non-concordant care guidelines. Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances. While they can identify and describe generally recommended courses of intervention, the guidelines are not fixed protocols, and therefore, are not meant to be a substitute for the advice of a physician.6 Ultimately, the physician uses their education and experience to make diagnostic and treatment decisions.
The authors of “Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care,” an article later published in JAMA, investigated the study and presented the proportion of patients who transitioned from acute to chronic LBP in primary care settings across four geographically dispersed health systems.
The article explains, “acute to chronic LBP transition rates vary widely, owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool can estimate this transition or whether early non–guideline concordant treatment is associated with the transition to chronic LBP.” As a result, the National Institute of Health (NIH) Task Force Pain Consortium developed a standardized definition and research standards for chronic LBP.
The inception study, overseen by four institutional review boards, was conducted alongside a multisite, pragmatic cluster randomized trial. The participants were adult patients with acute LBP enrolled in 77 primary care practices in four regions across the United States (Pittsburgh, Pennsylvania; Boston, Massachusetts; Salt Lake City, Utah; and Baltimore, Maryland) between May 2016 and June 2018, and followed up for six months, with the final follow-up completed by March 2019.
According to the article, data analysis was conducted from January to March 2020 and all study data, except the 6-month surveys, were sourced from existing data fields in the electronic medical records (EMRs). LBP-related processes of care provided by primary care clinicians within 21 days of a patient’s first visit were taken from the EMR. The study used international LBP guidelines and classified the processes of care into three categories: pharmacologic therapies, diagnostic imaging, and medical subspecialty referral; then, categorized each process of care as concordant or nonconcordant with these guidelines.7
The risk for developing chronic LBP was determined at the first visit using the 9-item version of the Subgroups for Targeted Treatment (STarT) Back tool (SBT). The total score ranges from zero to nine and includes a psychological subscale score ranging from zero to five. Patients were stratified as low-risk (total score ≤3), medium-risk (total score ≥4 and subscale score ≤3), or high risk (total score ≥4 and subscale score ≥4).8 The SBT was administered in primary care clinics using the same process as the acute/chronic LBP questionnaire.
Overview of the Outcomes
The final cohort of patients with acute LBP were mostly white (83%) women (58%) who were overweight or obese. Risk stratification showed 34% were low risk, 41% medium risk, and 25% high risk for developing chronic LBP. The overall unadjusted acute to chronic LBP transition rate at 6 months was 32%.
Of the 5,233 study participants, nearly half the patients were exposed to at least one guideline non-concordant recommendation within the first 21 days after the first visit. Across risk levels, 30% received prescriptions for non-recommended medications (65% were opioids), 24% received a radiography or CT/MRI order, and 6% were referred to a medical specialist (62% were surgeons).
There were two main findings from the study: the transition from acute to chronic LBP is substantial and the SBT is a robust prognostic tool. The authors confirmed that patients who were treated for LBP by a primary care physician were more likely to develop chronic LBP due to risk stratification and early exposure to guideline non-concordant care recommendations.
The authors suggest that an emphasis should be placed on discovering strategies to successfully implement guideline concordant care in the primary care setting to reduce the development of chronic LBP. The study outcomes raise a question: if patients were diagnosed and treated in accordance with guidelines from the start, would they be put on the correct care path to recover from acute LBP and have a better chance at avoiding the transition to chronic LBP? As the lead author of the JAMA article, Joel M. Stevans, DC, PhD, states: “there is increasing evidence that getting low back pain patients on the right pathway early in their care is key to improving outcomes and controlling costs.”
Dr. Stevans is one of the clinical experts at TurningPoint Healthcare Solutions and was directly involved in developing the new TurningPoint Digital Joint and Spine program, a comprehensive musculoskeletal (MSK) management platform moving care management upstream, deepening patient access and support. TurningPoint is committed to helping patients avoid risk factors, like the ones found in the LBP study, and improving the safety, quality, and affordability of care across the entire patient journey.
To learn more about TurningPoint’s suite of services, contact us today.
- Von Korff M, Scher AI, Helmick C, et al. United States National Pain Strategy for population research: concepts, definitions, and pilot data. J Pain. 2016;17(10):1068-1080. doi:1016/j.jpain.2016.06.009
- Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of chronic pain and high-impact chronic pain among adults—United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67(36):1001-1006. doi:15585/mmwr.mm6736a2
- Dieleman JL, Cao J, Chapin A, et al. US health care spending by payer and health condition, 1996-2016. JAMA. 2020;323(9):863-884. doi:1001/jama.2020.0734
- Kim LH, Vail D, Azad TD, et al. Expenditures and health care utilization among adults with newly diagnosed low back and lower extremity pain. JAMA Netw Open. 2019;2(5):e193676. doi:1001/jamanetworkopen.2019.3676
- Oliveira CB, Maher CG, Pinto RZ, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018;27(11):2791-2803. doi:1007/s00586-018-5673-2
- Hill JC, Dunn KM, Lewis M, et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum. 2008;59(5):632-641. doi:1002/art.23563