Low value care still too high for low back pain: Prof Buchbinder

A Victorian rheumatologist is calling for locally-tailored, evidence-based approaches to low back pain after her research revealed many emergency department patients receive low-value care.

Professor Rachelle Buchbinder was co-investigator in a study that reviewed hospital records for 450 patients  diagnosed with non-specific low back pain by Cabrini Malvern’s private ED in 2015.

It found that over one-third of patients (39%) received lumbar spine imaging, 62% had pathology tests and 87% received medications such as opioids, NSAIDs, benzodiazepines and pregabalin.

While the researchers weren’t able to access clinicians’ justifications for these tests and treatments, they said the results suggested that many may have been unnecessary and “at odds with recommendations from evidence-based guidelines”.

“Major issues include underuse of advice, education and exercise prescription and overuse of diagnostic imaging in the absence of clinical features suggestive of serious or specific pathology, as well as overuse of opioids, spinal injections and surgery,” the article published in Emergency Medicine Australia noted.

“Most of the medicines that were prescribed, other than NSAIDs in selected patients without contraindications to their use, are no longer recommended first- or second-line treatment options for low back pain. This is due to high certainty evidence of their lack of efficacy and/or significant potential for harm, particularly when used in combination.”

Of the 450 patients included in the study, 66% received opioids and 11% received an opioid with paracetamol.

The liberal use of testing and treatments may be due to “a perceived obligation to perform imaging when patients present for emergency care”, a need to check for infections or contraindications to treatment, routine testing of ED-admitted patients, and “standard practice of providing opioids in emergency care for patients who report pain for any reason above a score of 7 out of 10”.

Professor Buchbinder, Director of Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, said rheumatologists had an important role in optimising low back pain-patient care.

“Rheumatologists are experts in the evidence-informed management of low back pain and GPs and ED physicians may seek their advice, regarding appropriate care,” she told the limbic.

“This care should reduce medicalisation of simple non-specific low back pain, including overuse of low-value imaging, pathology tests, opioid medication, hospitalisation and invasive therapies, while emphasising provision of advice and education and self management.”

Although overall ED practices were “unlikely to have changed” since 2015, a recent stepped-wedge, cluster, randomised trial in four NSW-based EDs showed an evidence-based care model reduced opioid use by 12%, the study authors noted.

The researchers now plan to “locally adapt and evaluate” an evidence-based care model that was tested in the SHAPED trial, with the help of “relevant ED and other clinicians”.

“It will include provision of recovery expectations and same or next day access outpatient rehabilitation services to provide patients with ongoing support,” the paper said.

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