Welcome back to the Spine IQ Back Blog! March is Women’s History Month, so we are going to highlight low back pain studies that feature woman as first author. This week, we will be discussing a paper by Dr. Julie Fritz that has received an incredible 236 citations since publication in 2007!  As you know from reading our previous blogs, we advocate for clinical practice guidelines and care that is concordant with them. This paper titled, “Does adherence to the guideline recommendation for active treatments improve the quality of care for patients with acute low back pain delivered by physical therapists?” is one of the ground-breaking studies for low back pain and guideline adherence.¹

Objective

The burden of low back pain continues to increase with $100+ billion spent by the U.S. healthcare system in 2016 alone.^2,3 To curb the disability and cost burden, clinical practice guidelines have been created and implemented.^4,5 However, the effects of guideline adherent care on clinical outcomes and cost are unknown. Preliminary studies are demonstrating the cost and outcome benefits of guideline integration into practice protocols.

Methods

Dr. Fritz and her team retrospectively looked at a large dataset of 10 outpatient physical therapy clinics over two years. All adults (18-60 years old) with undergoing treatment for low back pain were examined for clinical outcome, cost, and guideline adherent care. Clinical outcome was assessed by the Oswestry Disability Questionnaire and numeric pain rating scale. Cost was assessed by determining the number of visits and charges for care provided by the billing database. Guideline adherence was determined by dividing care of treatment into two phases, treatment received within the first two weeks (phase 1) and treatments received after day 14 (phase 2). The following treatment was considered guideline adherent and non-adherent:

Results

1190 patients met the criteria of which only 481 (40.4%) received guideline-adherent treatment. Guideline adherent care led to:

• Shorter symptom duration by an average of 4.7 days
• Significantly (P = 0.02) fewer visits
• Significantly (P <0.001) shorter episodes of care
• 8% better improvement on Oswestry Disability Scale
• 4% better improvement on numeric pain rating scale
• Significantly (P <0.001) less physical therapy costs
• Significantly (64.7% vs 36.5%) more likely to improve by at least 50% from baseline

As you’ll see, some of these are reported as p-values. What this means is that the smaller the p-value then the more likely the finding is due to the treatment and not random chance. Commonly, a p-value of <0.05 is described as statistically significant and anything above that is believed to be insignificant as it is likely due to random chance and not the intervention.

Conclusion

This rigorous study by Dr. Fritz and her team reports the improved clinical and financial outcomes that guideline adherent care delivers. Unfortunately, less than half the patients in this sample received guideline adherent care. It is important that clinicians self-reflect on their own practice, stay up to date with clinical practice guidelines, and continue to work towards care that is guideline adherent. This will allow clinicians to positively impact the growing burden of low back pain. As well as positively impact the reimbursement in a future value-based model of care.

References

1. Fritz JM, Cleland JA, Brennan GP. Does adherence to the guideline recommendation for active treatments improve the quality of care for patients with acute low back pain delivered by physical therapists? Med Care. 2007;45(10):973-980. doi:10.1097/MLR.0b013e318070c6cd
2. 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:10.1001/jama.2020.0734
3. Buchbinder R, van Tulder M, Öberg B, et al. Low back pain: a call for action. The Lancet. 2018;391(10137):2384-2388. doi:10.1016/S0140-6736(18)30488-4
4. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi:10.7326/M16-2367
5. Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79-86. doi:10.1136/bjsports-2018-099878