Medical guidelines help doctors understand the best way to treat health conditions. Surprisingly, many doctors do not adhere to them, and this is a problem, according to a new study by scientists at University of Utah Health and MDGuidelines. People with lower back pain injury miss 11 more days of work in a year when they only receive treatments for lower back pain that are not recommended by medical guidelines compared to people treated according to guidelines. The findings were published in PLOS ONE on June 17.
"The closer people's care follows evidence-based guidelines, the faster their back pain resolves, by quite a bit," says the study's senior author Kurt Hegmann, M.D., director of the University of Utah Rocky Mountain Center for Occupational and Environmental Health.
That may be so, but 65% of the people included in the study received at least some non-recommended treatments for lower back pain. Among the nearly 60,000 people whose medical claims were analyzed:
- 14% received non-recommended treatments only,
- 51% received a mix of non-recommended and recommended treatments,
- 14% received recommended treatments only,
- and 21% did not receive any medical intervention.
People who received recommended treatments combined with non-recommended treatments saw an intermediate benefit, missing a median of eight workdays within the year as compared to those who exclusively received recommended treatments.
The most common non-recommended treatments were prescriptions for opioids, which are discouraged because they reinforce debility instead of exercise and can be addictive, and X-rays, which can lead to inaccurate diagnoses. The most common recommended treatments were nonsteroidal anti-inflammatory drugs and muscle relaxants.
The data came from California workers' compensation claims between 2009 to 2018 from employees who had uncomplicated, acute lower back pain or strain, the most prevalent injury in the workplace. The researchers tracked whether treatments prescribed in clinic visits within the first week after injury were categorized as recommended or non-recommended in the peer-reviewed American College of Occupational and Environmental Medicine (ACOEM) guidelines, with the assumption that similar treatment patterns would continue in any subsequent clinic visits. The scientists then calculated the number of lost workdays within the first year after injury.
While a large proportion of workers received non-recommended treatments, health care providers improved adherence to medical guidelines over time. In 2009, 10% were treated according to guidelines, but that rose to 18% by 2018. The treatment practice that changed most drastically was opioid prescriptions, which fell by 86% over those nine years.
The reduction in opioids prescription is particularly impressive," Hegmann says. "In this case, the insurer is likely to not pay for opioids even if they are prescribed. It suggests what's possible when the 'carrot' of good health care is missed and instead the 'stick' of compliance with a guideline is in place."
Kurt Hegmann, M.D., Study Senior Author and Director of University of Utah Rocky Mountain Center for Occupational and Environmental Health
Clinical practice guidelines are based on systematic reviews of scientific evidence and are designed to guide health care providers as they decide how to treat their patients' health conditions. Typically, guidelines are updated every few years, which can make it difficult for health care providers to keep up. Doctors may not adhere to guidelines because they aren't aware of them, don't know how to implement the recommended treatments, prefer to continue practices they've used in the past, or for other reasons.
Regardless, the large reductions in opioid prescriptions for lower back pain suggest that added incentives, such as insurance refusing to pay for non-recommended treatments, increases adherence to guidelines. Hegmann and the study's first author, Fraser Gaspar, Ph.D., say that implementing decision support tools and other ways to promote adherence to guidelines will be better for patients.
"Being out of work impacts many facets of your life," says Gaspar, who carried out the research when he was a scientist at MDGuidelines. "In addition to the physical disability that's causing the person to miss work, the worker is making less money, while they often incur additional costs and experience mental strain. Getting people back to their normal lives is really important, and our research shows that following guidelines makes that happen faster."
Gaspar, F. W., et al. (2021) Guideline adherence and lost workdays for acute low back pain in the California workers' compensation system. PLOS ONE. doi.org/10.1371/journal.pone.0253268.