A limitation of existing studies of primary care for low-back-pain (LBP) is that they are not based upon direct observation of the clinical encounter and so may under or over-estimate the extent of evidence practice gaps. This was a cross-sectional observational study which observed the management recommendations for LBP provided in primary care using a simulated patient approach. Trained actors requested an over-the-counter medicine or asked for management advice for one of two simulated patient scenarios; non-specific LBP (NSLBP) or vertebral compression fracture. Visits were audio-recorded to allow data capture, validation and review. We evaluated concordance with key recommendations provided in evidence-based LBP guidelines on pain medicines, patient self-care advice and referral. Visits were conducted across 534 pharmacies comprising 336 non-specific scenarios and 198 fracture scenarios. Recommendations for pain medicines, but not patient self-care advice and referral, were typically consistent with guidelines. For the NSLBP scenario the concerns were: infrequent provision of reassurance of favourable outcome (8%), advice to stay active (5%), advice to avoid bed rest (0%), advice to use superficial heat (24%) and excessive endorsement of referral (57.4%) and imaging (22.7%). For the fracture scenario the concerns were a low rate of prompt medical referrals (50.0%) and low endorsement of rest (1.0%). PERSPECTIVE: We observed primary-care that aligned closely with some aspects, but was at odds with other aspects, of evidence-based LBP guidelines. Problems included inadequate self-care advice and failing to appropriately recommend imaging or prompt medical review where indicated. These results can inform implementation strategies to improve primary-care management of LBP.
AD - Faculty of Pharmacy, University of Sydney, Sydney, NSW 2006 Australia; School of Medicine, Western Sydney University, Sydney, NSW 2560 Australia.A limitation of existing studies of primary care for low-back-pain (LBP) is that they are not based upon direct observation of the clinical encounter and so may under or over-estimate the extent of evidence practice gaps. This was a cross-sectional observational study which observed the management recommendations for LBP provided in primary care using a simulated patient approach. Trained actors requested an over-the-counter medicine or asked for management advice for one of two simulated patient scenarios; non-specific LBP (NSLBP) or vertebral compression fracture. Visits were audio-recorded to allow data capture, validation and review. We evaluated concordance with key recommendations provided in evidence-based LBP guidelines on pain medicines, patient self-care advice and referral. Visits were conducted across 534 pharmacies comprising 336 non-specific scenarios and 198 fracture scenarios. Recommendations for pain medicines, but not patient self-care advice and referral, were typically consistent with guidelines. For the NSLBP scenario the concerns were: infrequent provision of reassurance of favourable outcome (8%), advice to stay active (5%), advice to avoid bed rest (0%), advice to use superficial heat (24%) and excessive endorsement of referral (57.4%) and imaging (22.7%). For the fracture scenario the concerns were a low rate of prompt medical referrals (50.0%) and low endorsement of rest (1.0%). PERSPECTIVE: We observed primary-care that aligned closely with some aspects, but was at odds with other aspects, of evidence-based LBP guidelines. Problems included inadequate self-care advice and failing to appropriately recommend imaging or prompt medical review where indicated. These results can inform implementation strategies to improve primary-care management of LBP.
PY - 2015 SN - 1528-8447 (Electronic)