Clinical StudyActivities performed and treatments conducted before consultation with a spine surgeon: are patients and clinicians following evidence-based clinical practice guidelines?
Introduction
Clinical practice guidelines (CPGs) are important tools in the management of common medical conditions. The use of CPGs ensures that a consistent and evidence-based standard of care is available to all parties involved within the health care system. Several different CPGs are available in Canada to help guide treatment for individuals suffering from low back pain (LBP). One of the most predominant and highly recognized CPGs for LBP is the “Guideline for the Evidence-Informed Primary Care Management of LBP,” produced by the Toward Optimized Practice program of Alberta, Canada (TOP CPG) [1].
For CPGs to be truly useful, they must first be put into practice. Whether or not primary care physicians and allied health providers (eg, physiotherapists and chiropractors) actually heed the recommendations and provide treatment as directed is unclear [2], [3]. This is especially true when considering the volume of patients requiring treatment for LBP. Canadian spine surgeons receive a significant amount of LBP referrals, creating undesirable wait times in excess of what has been deemed to be clinically acceptable [4]. Many of these referrals are from primary care physicians for patients who are unlikely to be surgical candidates, and thereby will require only medical interventional treatment to manage their condition [5], [6].
The use of CPGs to dictate appropriate medical interventional treatment could reduce the number of unnecessary referrals to spine surgeons and decrease wait times for patients who would benefit from surgery [7]. CPG implementation may also reduce direct and indirect health care costs as patients may receive appropriate conservative care sooner and avoid clinical deterioration while waiting to see a spine specialist [8].
The aim of the present study was to investigate whether patients complaining of LBP received evidence-based medical interventional treatment, as per recommendations outlined in the TOP CPG, at the time of their referral by their primary care physician to a spine surgeon for consultation.
Section snippets
Methods
Consecutive adult patients (aged >18–80 years old) referred by primary care physicians over a 2-year period to one of two spine surgeons at a regional academic health center in Ontario, Canada, for consultation for an elective lumbar spinal condition were considered eligible for the study. Of note, this center is the only tertiary care hospital performing spinal surgery in the geographic region. Patients with cervical pathologies or adult spinal deformities (eg, scoliosis), or those with urgent
Results
A total of 229 eligible patients returned the informed consent form and completed questionnaires (equivalent to a 45% response rate) and were included in the study (Figure). Table 1 outlines the patient demographics and questionnaire results. In comparing the 229 included patients against 155 excluded patients who did not consent to the study nor complete the questionnaires (but were still eventually seen by one of two spine surgeons and hence for whom we could obtain basic data upon), we found
Discussion
In our study population, the most commonly followed medical interventional treatment recommendation was the use of medications, with opioid use representing the highest proportion of use. This is concerning, given that the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain states that opioid initiation requires very careful consideration and implementation [11]. Patients who reach a certain dosage of opioid per day can actually become more sensitive to certain
Acknowledgments
The authors would like to thank Nora McRae and Courtney Wilson for their assistance with data collection and data entry.
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Author disclosures: EIL: Nothing to disclose. DMR: Consulting: Palladian Health, LLC (C), Pacira Pharmaceuticals, Inc. (C), outside the submitted work. MJC: Nothing to disclose. PP: Nothing to disclose. SPK: Nothing to disclose. EKW: Grant: The Ottawa Hospital Academic Medical Organization (TOHAMO) (D, Paid directly to institution), pertaining to the submitted manuscript.
The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.