Effects of Practice Style in Managing Back Pain

Back pain is the second leading cause for visits to primary care physicians in the United States [1], contributing substantially to total health care costs [2]. Back-related disability costs are a major burden on employers and government insurance programs [3]. Some researchers believe a limited pathophysiologic model of back pain often guides the management of patients with back pain, resulting in medical care that 1) reinforces patient beliefs that the cause of back pain usually can be diagnosed; 2) promises a medical cure for back pain; 3) sanctions bed rest and other forms of activity limitation; 4) discourages self-care; 5) and thereby increases the likelihood of a poor functional outcome and continuing use of health care services for back pain [4, 5]. Experts increasingly regard back pain as a condition amenable to self-care for most patients seen by primary care physicians [4-6]. In fact, most persons with back pain apply self-care rather than seek medical attention. Features characterizing a practice style inculcating self-care among patients with back pain might include the following: 1) Adequate and accurate information about the probable course of back pain is provided [it is usually recurrent, sometimes chronic, whereas severe flare-ups are usually time limited]; 2) prescription pain medications are prescribed less frequently, and a time-limited and time-scheduled regimen is used when they are; 3) bed rest, particularly extended bed rest, is prescribed less frequently as a palliative measure; 4) patients are referred for surgical evaluation less frequently and based on positive signs rather than failure to improve alone; and 5) patients are more often advised to plan graded increases in activity levels and return to function regardless of whether back pain is completely relieved. An approach to back pain management that places greater emphasis on self-care than on medical cure may encourage patients to experiment with various approaches to managing back pain on their own. For example, patients may find exercise, other lifestyle changes, relaxation techniques, over-the-counter medications, massage, learning to cope with severe flare-ups, or seeking advice and support from friends helpful. Such experimentation may increase the likelihood that patients learn to manage back pain without ongoing or recurrent medical attention. We contrasted naturally occurring differences in physician style of managing patients with back pain in which greater emphasis is placed on medical management rather than self-care. We assessed the consequences of physician differences in style of managing patients with back pain in terms of long-term functional outcomes, patient satisfaction, and costs of care. Methods Setting and Sample The setting was Group Health Cooperative of Puget Sound, a Seattle-area staff model health maintenance organization with more than 350 000 enrollees. Patients making visits for back pain to participating Group Health Cooperative primary care physicians during 1989 and 1990 were eligible if they were between 18 and 75 years old and had been enrolled continuously for at least 1 year. We excluded patients if they planned to disenroll or did not have a telephone. Reasons for visits were ascertained from the clinic's appointment log or an encounter form completed by the provider. We excluded visits to emergency room and walk-in facilities. Thus the resulting sample was a cross-section of patients with back pain seen by primary care physicians during a 1-year period, including acute and chronic cases. We excluded a few patients with kyphosis, scoliosis, lordosis, instability, and alignment disorders (n = 27). We excluded no patient based on the location of back pain (we included cervical pain). We excluded interviewed patients if they were seen by a physician with fewer than 10 enrolled participants (n = 59), if they did not consent to medical records abstraction (n = 18), or if their medical record was not abstracted for other reasons (n = 47). Data Collection Three to six weeks after the index visit, patients were asked to participate in a 30-minute telephone interview. Twenty-minute follow-up interviews were done by telephone 1 year and 2 years later. Patients provided informed consent for all interviews and for abstraction of medical records. Patient Care Processes We assessed patient care processes by information obtained from patient interviews, from automated health care information systems, and by abstraction of medical records. We used the following variables in the analyses reported here. Advice Regarding Surgery In the initial interview, patients were asked if their physicians had discussed surgery. If so, they were asked about the nature of the physician's advice (surgery was harmful, not necessary, possible if pain continues, probably needed, or definitely needed). Because of small numbers of participants, we combined patients who were told that surgery was possibly, probably, or definitely needed. Opioid Prescriptions We obtained information on prescription of opioid medications by patient report and from automated pharmacy records. Among patients who filled an opioid prescription from a Group Health Cooperative pharmacy within 14 days of their index visit, 88.3% reported receiving a prescription for an opioid medication in the initial interview. We report interview data on the percentage of patients given opioids for back pain and the percentage who said they had been instructed to use opioids for 14 or more days or until their back pain improved (extended use instructions). Sedative-Hypnotic Medications We identified prescriptions of sedative-hypnotic agents and muscle relaxants. Among patients who filled a prescription for these medications at a Group Health Cooperative pharmacy within 14 days of the index visit, 80.8% reported receiving a prescription for a sedative-hypnotic medication. We report the percentage who said they received a prescription for a sedative-hypnotic medication for back pain and the percentage who reported receiving extended use instructions as defined for opioids. Multiple Medications Some patients reported receiving prescriptions for three or more classes of back pain medication. The classes included opioid, sedative-hypnotic, anti-inflammatory, and antidepressant medications. Bed Rest We determined the percentage of patients who said their physician prescribed bed rest and the percentage prescribed extended bed rest. Extended bed rest was defined as advice to rest for 7 or more days or advice recommending extended bed rest. Satisfaction with Medical Care Patients rated the quality of care they received from their physician on a scale of 0 to 10, where 0 was false and 10 was completely true. We used results for the following criteria to assess global satisfaction with care: The doctor was very thorough in asking questions to understand the nature of your back problem; was very thorough in the physical examination of your back; let you tell your story and asked thoughtful questions; showed interest in you as a person; and treated you as if your back pain was an important problem and not something imagined. Satisfaction with Patient Education We also report results for the following ratings assessing the quality of patient education: Your doctor checked to make sure you understood what you were told about your back pain and its treatment; after your visit with the doctor, you fully understood the causes of your back problem; after your visit with the doctor, you fully understood how to care for your back problem; and your visit to the doctor helped you feel that you could control your back pain. These ratings were made on the same scale of 0 to 10 as the items assessing satisfaction with medical care. Medical Record Diagnoses We used diagnoses recorded during the index episode of care (defined as the month before and after the index visit) in case-mix adjustments. We combined diagnoses of disc disorder and sciatica because they often overlapped. A second diagnostic group included patients with arthritis. The remaining diagnostic categories included muscle strains, injuries, and back pain not otherwise specified. We assessed the agreement between abstractors in identifying and coding medical record diagnoses for a sample of records (n = 29), which was high (86% agreement). We also obtained information regarding the location of back pain from the medical record. Pain and Pain-Related Disability We assessed pain status by measures of pain intensity, chronicity, and disability. Pain Intensity We obtained ratings of pain intensity during the interview: usual (or average) back pain intensity when the patient was in pain in the previous 6 months, and worst pain intensity in the previous 6 months on scales of 0 to 10, where 0 was no pain and 10 was worst possible pain [7]. Back Pain Days We obtained the number of days in the previous 6 months in which the patient had back pain. We defined chronic back pain as pain present for 90 or more days in the previous 6 months [7]. Activity Limitation Days We recorded the number of days in the previous 6 months that the patient was kept from usual activities (work, school, housework) because of back pain [7]. Disability Score We tabulated the mean of three 0 to 10 back pain disability ratings (interference with daily activities; change in ability to participate in recreational, social, and family activities; and reduced ability to work, including housework) [7]. Pain Impact Scale Score This scale included a subset of items from the Roland back pain disability scale [8] supplemented by other criteria relevant to assessing pain-related activity limitation [7]. Patients were asked if they had been limited in specific activities because of back pain in the previous 2 weeks. The scale score was the proportion of 16 items that was positive, indicating the presence of a specific activity limitation. Typical items included whether the pat