Why back pain patients shouldn't be seeing primary care MDs.
Editorial Staff
What causes acute low back pain (LBP) to become chronic? This is the question explored in a new study1 from a research group centered at the University of Pittsburgh looking to identify the relevant risk factors. The startling answer suggests acute LBP patients shouldn't be going to primary care medical doctors for their pain.
The study evaluated the care provided to 5,233 patients with acute LBP in 77 primary care practices. Among the potential factors leading to chronicity, the authors considered "nonconcordant" care, or care not consistent with established guidelines. Surprisingly, almost half (48%) of patients received at least one form of nonconcordant care.
Nonconcordant care was divided into three categories: pharmacologic, diagnostic and medical subspecialty referral. Almost 50% of patients received at least one form of nonconcordant care within the first 21 days– many for non-guideline-recommended medications such as opioids.
The authors note that "nonconcordant care can lead to direct and indirect harm, given that it has been linked with medicalization and unnecessary health care utilization."
Patients were stratified into three levels based upon their likelihood of transitioning to chronic LBP: low, medium or high risk. Overall, about a third (32% unadjusted) transitioned from acute to chronic: approximately one fifth of low-risk patients, a third of medium-risk patients and almost half of high-risk patients.
A patient whose medical PCP provided two or more forms of nonconcordant care was more likely to transition to chronic than a patient stratified in the medium-risk category. The nonconcordant actions of the MD effectively moved the patient from low risk (one in five chance of becoming chronic) to med-ium risk (one in three chance) or almost high risk (even chance). Overall, exposure to one, two or three forms of nonconcordant care increased the odds of transitioning to chronicity incrementally (adjusted odds ratios: 1.39, 1.88 and 2.16, respectively, for one, two or three forms of nonconcordant care).
Editor's Note: Click here to read Publisher Don Petersen's Report of My Findings in this issue for additional perspective regarding this important study.
Reference
Stevans JM, Delitto A, Khoja SS, et al. Risk factors associated with transition from acute to chronic low back pain in US Patients seeking primary care. JAMA Netw Open, 2021;4(2):e2037371.
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