What Is Usual Care for Low Back Pain?

A Systematic Review of Health Care Provided to Patients With Low Back Pain in Family Practice and Emergency Departments

Steven J. Kamper; Gabrielle Logan; Bethan Copsey; Jacqueline Thompson; Gustavo C. Machado; Christina Abdel-Shaheed; Christopher M. Williams; Christopher G. Maher; Amanda M. Hall

Disclosures

Pain. 2020;161(4):694-702.

Methods

Prospectively registered systematic review, PROSPERO 2018 CRD42018070241.

Data Sources and Searches

An electronic search was conducted in 3 databases (EMBASE, PubMed-Medline, and CINAHL) using search terms related to "back pain," "guideline recommendations," and "medical records" from inception to May 2019 (eTable 1, available as supplemental digital content at https://links.lww.com/PAIN/A913). Further potentially relevant studies were identified through consultation with experts and citation tracking on the included studies.

Study Selection

Studies were included if they (1) reported family practice or ED physicians' assessment and/or treatment of adult patients (aged >18 years) with LBP of any duration and (2) had a quantitative design assessing actual treatment records. Qualitative studies and studies that measured usual care through recall or hypothetical scenarios/vignettes were not included. Studies that analysed data from before 2000 were excluded as we were not interested in historical patterns of practice. Gray literature including non–peer-reviewed literature, theses, and letters to the editor was not included. Non–English-language studies were included and translated as necessary. A full list of the eligibility criteria appears in eTable 2 (available as supplemental digital content at https://links.lww.com/PAIN/A913). Two reviewers independently screened all titles and abstracts, and then potentially eligible full texts. Disagreements were resolved by discussion, arbitrated by a third reviewer as needed.

Data Extraction

Two reviewers independently extracted study characteristics and outcomes data into an Excel spreadsheet. Study characteristics included the following: health care setting, LBP duration, period of data collection, data source, and sample size. Family practice was defined as primary-contact outpatient/ambulatory care that was not in ED. For each outcome, data were extracted on collection method, metric used to assess utilisation (eg, proportion or rate), and the denominator used (eg, episodes of care and number of patients). Studies most commonly reported the proportion of patients that received a particular aspect of care, which could have been at a single appointment or over a number of visits, we categorised this as "per patient." Fewer studies reported the proportion of visits that involved that aspect of care, we categorised this as "per episode" of care. One study reported the proportion of physicians that delivered that aspect of care, "per physician."

Reporting and Methodological Quality

The STROBE (STrength of Reporting in OBservational Studies in Epidemiology) Statement and its extension statement entitled RECORD (REporting of studies Conducted using Observational Routinely collected health Data) were used to assess the transparency of reporting. We used items from key domains for assessing susceptibility to bias in observational studies as recommended in Sanderson et al.^[46] This includes items in 4 domains: representativeness of the sample, potential misclassification of patients, potential misclassification of outcomes, and inconsistent data. Because we used methodological quality to prioritise interpretation of findings, we also considered precision as an indicator of study quality. Included studies were considered high quality if they met criteria for ≥4 of 5 items.

Data Synthesis

Findings from included studies were divided by health care setting (family practice or ED) and organised according to outcome category: assessments, treatment advice, imaging, medication, and referrals. Within each outcome category (eg, imaging), individual types are described separately (eg, X-ray, CT [computed tomography], MRI [magnetic resonance imaging], and any image). We planned meta-analysis of single proportions; however, clinical heterogeneity prevented meta-analysis for any outcome. We present all available estimates in the tables and focus our interpretation on the range of estimates that came from the high-quality studies. A narrow range of high-quality estimates from several studies provided greater confidence in the findings and vice versa.

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Table 1. Included studies.
Author, country	Data collection	LBP duration	Data source, n = 166,986	Sample	Denominator	Quality
Family practice
Rego,⁴⁴ Australia	2014	Mixed	Hospital medical records	146	Per episode	High
Piccoliori,³⁸ Italy	2006	Mixed	Questionnaire	487	Per episode	High
Kale,²⁶ USA	2008–2009	Acute	NHAMCS	102,980	Per patient	Low
Mafi,³³ USA	1999–2010	Mixed	NHAMCS and NAMCS	23,918	Per patient	High
Michaleff,³⁴ Australia	2000–2010	Mixed	BEACH	21,350	Per patient	High
Breen,⁶ United Kingdom	2007–2008	Acute/Subacute	EMIS, Vision, ISOFT, Synergy databases	648	Per patient	Low
Williams,⁵³ Australia	2005–2008	Acute	BEACH	1706	Per patient	High
Crow,⁸ USA	2002–2005	Chronic	NHAMCS	1327	Per patient	Low
Lin,³¹ Australia	2011	Mixed	Aboriginal medical services; "Communicare" electronic clinical records system	44	Per episode	Low
Ramanathan,⁴² Australia	2009–2010	Mixed	Medical record reviews using a web-based tool	6588	Per episode	Low
Chen,⁷ USA	2013	Mixed	EMR chart review	100	Per patient	Low
Bishop b,⁵ Canada	NR	Acute	Workers compensation board patient reports	428	Per patient	Low
Muntion-Alfaro,³⁵ Spain	2003	Mixed	Clinical histories audit	538	Per episode	Low
Bishop a,⁴ Canada	NR	Acute	Workers compensation board patient reports	139	Per physician	Low
Fritz,¹⁷ USA	2004–2008	Acute	SelectHealth, intermountain EMR	2184	Per episode	High
Suman,⁴⁹ Netherland	2014	Mixed	Electronic medical records	1242	Per patient	High
Zafar,⁵⁵ USA	2012–2015	Mixed	Computerised physician order system, Dept. Medical Affairs	2513	Per patient	Low
Kovacs,²⁸ Spain	NR	Mixed	Observational study	648	Per patient	High
Author, country	Data collection	LBP duration	Data source, n = 27,402	Sample	Denominator	Quality
Emergency department
Lee,²⁹ USA	2009–2011	Acute	Worker's compensation administrative database	2887	Per episode	High
Friedman,¹⁶ USA	2002–2006	Mixed	NHAMCS	4097	Per patient	High
Potier,³⁹ United Kingdom	2013	Mixed	Clinical records/case notes	100	Per patient	Low
Rao,⁴³ USA	2013	Mixed	Electronic medical records	100	Per patient	Low
Nunn,³⁷ Canada	2009–2015	Nonurgent	EDIS	325	Per patient	Low
Raja,⁴¹ USA	2013–2014	Mixed	Electronic health records	3766	Per episode	High
Schlemmer,⁴⁷ USA	2011–2012	Mixed	HEDIS	14,838	Per patient	High
Rizzardo,⁴⁵ Italy	2013	Mixed	Hospital database	1289	Per patient	Low

BEACH, Bettering the Evaluation and Care of Health survey; EDIS, Emergency Department Information System; EMIS, Egton Medical Information Systems; EMR, Electronic Medical Record; HEDIS, Healthcare Effectiveness Data and Information Set; ISOFT, IT software database; LBP, low back pain; NHAMCS, National Hospital Ambulatory Medical Care Survey; NAMCS, National Ambulatory Medical Care Survey; NR, not reported.

Table 2. Rates of treatment advice.
Advice	Setting	Study	Measure	Proportion (95% CI)	Range of high-quality estimates
Education and reassurance	Family practice	Williams ⁵³	Per patient	21% (18–23%)	21–23%
		Michaleff ³⁴	Per patient	23% (22–24%)
		Breen⁶	Per patient	0.3% (0–1%)
		Bishop a⁴	Per physician	7% (3–11%)
		Bishop b⁵	Per patient	7% (3–11%)
		Lin30	Per patient	20% (11–35%)
		Chen⁷	Per patient	55% (45–64%)
	ED	Potier³⁹	Per patient	11% (6–19%)	—
Exercise	Family practice	Michaleff ³⁴	Per patient	19% (18–20%)	19%
		Breen⁶	Per patient	1% (0.1–1%)
		Bishop a⁴	Per physician	43% (35–51%)
		Bishop b⁵	Per patient	43% (35-51%)
	ED	Nunn³⁷	Per patient	3% (1–5%)	—
Bed rest	Family practice	Muntion-Alfaro³⁵	Per patient	2% (1–3%)	—
		Ramanathan⁴²	Per episode	3% (1–7%)
		Chen⁷	Per patient	12% (6–18%) (advised against)
		Bishop b⁵	Per patient	17% (11–23%)
		Bishop a⁴	Per physician	21% (14-28%)
Return to work	Family practice	Bishop b⁵	Per patient	17% (11–23%) —
		Bishop a⁴	Per physician	22% (15–29%)
Sickness certificate	Family practice	Michaleff ³⁴	Per patient	3% (3–4%)	3%
		Muntion-Alfaro³⁵	Per patient	20% (17–24%)
		Breen⁶	Per patient	26% (23–30%)

Estimates from high-quality studies in bold.
ED, emergency department.

Table 3. Rates of imaging.
Image	Setting	Study	Measure	Proportion (95% CI)	Range of high-quality estimates
X-ray	Family practice	Mafi ³³	Per episode	16% (15 to 16%)	16–20%
		Kovacs ²⁸	Per patient	16% (13 to 18%)
		Michaleff ³⁴	Per patient	19% (18 to 20%)
		Williams ⁵³	Per patient	20% (18 to 22%)
		Breen⁶	Per patient	5% (3.5 to 7)
		Piccioliori³⁸	Per patient	22% (18 to 26%)
		Kale²⁶	Per episode	23% (18 to 28%)
		Crow⁸	Per episode	62% (59 to 65%)
	ED	Friedman ¹⁶	Per episode	30% (29 to 32%)	30%
		Rizzardo⁴⁵	Per patient	41% (38 to 44%)
		Potier³⁹	Per patient	7% (3 to 14%)
		Rao⁴³	Per patient	8% (4 to 15%)
		Nunn³⁷	Per patient	27% (22 to 32%)
CT	Family practice	Kovacs ²⁸	Per patient	2% (1 to 3%)	2–6%
		Piccoliori ³⁸	Per patient	4% (3 to 6%)
		Williams ⁵³	Per patient	6% (5 to 7%)
	ED	Friedman ¹⁶	Per episode	6% (4 to 7%)	6%
		Rizzardo⁴⁵	Per patient	3% (2 to 4%)
		Rao⁴³	Per patient	3% (1 to 8%)
		Nunn³⁷	Per patient	5% (2 to 7%)
MRI	Family practice	Williams ⁵³	Per patient	<1% (0 to <1%)	<1–5%
		Kovacs ²⁸	Per patient	3% (1 to 4%)
		Piccoliori ³⁸	Per patient	5% (4 to 8%)
		Crow⁸	Per episode	3% (2 to 4%)
		Zafar⁵⁵	Per patient	5% (4 to 6%)
		Breen⁶	Per patient	9% (7 to 11%)
	ED	Friedman ¹⁶	Per episode	3% (2 to 4%)	3–25%
		Raja ⁴¹	Per patient	18% (17 to 19%)
		Lee ²⁹	Per patient	25% (23 to 27%)
		Nunn³⁷	Per patient	0.6% (0 to 1.4%)
		Rizzardo⁴⁵	Per patient	1% (1 to 2%)
		Rao⁴³	Per patient	15% (9 to 23%)
MRI or CT	Family practice	Mafi ³³	Per episode	10% (9 to 10%)	10%
	ED	Friedman ¹⁶	Per episode	7% (6 to 7%)	7–18%
		Schlemmer ⁴⁷	Per patient	10% (10 to 11%)
		Raja ⁴¹	Per patient	18% (17 to 19%)
Any image	Family practice	Suman ⁴⁹	Per patient	11% (9 to 13%)
		Michaleff ³⁴	Per patient	24% (23 to 25%)	11–26%
		Fritz ¹⁷	Per patient	26% (25 to 29%)
		Bishop a⁴	Per physician	22% (15 to 29%)
		Muntion-Alfaro³⁵	Per patient	26% (22 to 30%)
		Rego⁴⁴	Per episode	58% (49 to 65%)
		Raja ⁴¹	Per patient	29% (27 to 30%)
	ED	Schlemmer ⁴⁷	Per patient	37% (36 to 37%)	29–37%
		Nunn³⁷	Per patient	30% (25 to 35%)
		Rizzardo⁴⁵	Per patient	44% (41 to 47%)
		Rao⁴³	Per patient	46% (37 to 56%)

Estimates from high-quality studies in bold.
ED, emergency department.

Table 4. Rates of medication prescription.
Medication	Setting	Study	Measure	Proportion (95% CI)	Range of high-quality estimates
Paracetamol	Family practice	Piccioliori ³⁸	Per patient	6% (4–8%)	6–18%
		Michaleff ³⁴	Per patient	17% (16–18)
		Williams ⁵³	Per patient	18% (16–20%)
		Muntion-Alfaro³⁵	Per patient	36% (32–41%)
	ED	Friedman ¹⁶	Per episode	4% (4–5%)	4%
		Nunn³⁷	Per patient	22% (17–26%)
NSAIDs	Family practice	Michaleff ³⁴	Per patient	36% (35–37)	36–37%
		Williams ⁵³	Per patient	37% (35–40%)
		Kovacs²⁸	Per patient	57% (53–61%)
		Muntion-Alfaro³⁵	Per patient	59% (55–63%)
		Piccioliori³⁸	Per patient	82% (79–85%)
	ED	Friedman ¹⁶	Per episode	50% (49–52%)	50%
		Nunn³⁷	Per patient	35% (30–41%)
		Rizzardo⁴⁵	Per patient	62% (59–65%)
Muscle relaxants	Family practice	Michaleff ³⁴	Per patient	<1% (0 to <1)	1–8%
		Piccioliori ³⁸	Per patient	8% (6–11%)
		Kovacs²⁸	Per patient	15% (12–18%)
		Muntion-Alfaro³⁵	Per patient	30% (27–35%)
	ED	Friedman ¹⁶	Per episode	42% (40–43%)	42%
		Nunn³⁷	Per patient	7% (5–10%)
Opioids, inc. combination	Family practice	Williams ⁵³	Per patient	5% (4–6%)	5–31%
		Piccioliori ³⁸	Per patient	12% (10–15%)
		Mafi ³³	Per episode	29% (28-30%)
		Michaleff ³⁴	Per patient	31% (30–32%)
		Bishop a⁴	Per physician	40% (32–48%)
	ED	Lee ²⁹	Per patient	17% (15–18%)	17–61%
		Friedman ¹⁶	Per episode	61% (59–62%)
		Rizzardo⁴⁵	Per patient	40% (38–43%)
		Nunn³⁷	Per patient	50% (47–54%)

Estimates from high-quality studies in bold.
ED, emergency department; NSAID, nonsteroidal anti-inflammatory drug.

Table 5. Rates of referral.
Referrals	Setting	Study	Measure	Proportion (95% CI)	Range of high-quality estimates
Physiotherapy	Family practice	Michaleff ³⁴	Per patient	14% (13–15%)	14–17%
		Mafi ³³	Per episode	17% (16–17%)
		Williams ⁵³	Per patient	17% (15–19%)
		Breen⁶	Per patient	19% (16–22%)
		Bishop b⁵	Per patient	45% (37–53%)
Chiropractor	Family practice	Breen⁶	Per patient	1% (0.1–1.4%)	—
		Bishop b⁵	Per patient	6% (2–10%)
Surgery	Family practice	Williams ⁵³	Per patient	2% (1–2%)	2–6%
		Fritz ¹⁷	Per patient	3% (3–4%)
		Kovacs ²⁸	Per patient	6% (4–8%)
		Breen⁶	Per patient	<1% (0.1–1%)
	ED	Lee ²⁹	Per patient	8% (7–9%)	8%
		Rao⁴³	Per patient	8% (4–15%)
Specialist	Family practice	Michaleff ³⁴	Per patient	1% (1–2%)	1–19%
		Piccoliori ³⁸	Per patient	2% (1–4%)
		Suman ⁴⁹	Per patient	8% (7–10%)
		Fritz ¹⁷	Per patient	19% (18–21%)
		Muntion-Alfaro³⁵	Per patient	12% (10–15%)
		Crow⁸	Per episode	13% (11–15%)
		Bishop a⁴	Per physician	30% (22–38%)
	ED	Nunn³⁷	Per patient	11% (8–15%)	—