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HPA&E Studies : Journal Publications

Evidence-based practice for low back pain in primary care: Patient outcomes and cost of care.

Author: Feuerstein M, Hartzell M, Rogers HL, Marcus SC.



Context:
Provider adherence with clinical practice guidelines (CPG) for acute low back pain (LBP) and the impact on clinical outcomes and cost are controversial.

Objective:
To determine the rate of provider adherence to the Department of Defense/Veteran's Administration CPG for Acute Low Back Pain and the extent to which provider adherence is associated with patient satisfaction, general health, functional outcome, and health care cost.

Design:
Longitudinal and cross-sectional design using health services and patient survey data one year before and three years after guideline implementation.

Setting:
The Military Health System with 9.3 million beneficiaries including active duty military, dependents, retired military, and their dependents.

Participants:
15,789 enrollees with a low back pain diagnosis (CPG) and 14,409 enrollees with upper extremity diagnoses (no CPG).

Main Outcome Measures:
Guideline adherence score based on Current Procedural Terminology (CPT) codes and specialist visits. Patient satisfaction and perceived health obtained from a survey of health care beneficiaries and provider-rated functional disposition at office visit. Cost of care for services within and outside military facilities.

Results:
Between 10- 40% of cases received CPG adherent care during guideline specified intervals within a 75 day period of care. This was observed prior to and 3 years following system wide implementation. No differences were found between LBP and upper extremity diagnoses groups in their rates of change in the four outcomes over years. Multivariable regression analyses controlling for a number of demographic and clinical variables indicated that CPG adherence was related to better functional outcomes, +Odds Ratio (OR) = 1.45, [95% CI=1.31-1.60] and lower health care costs, B=-230.15, p<.001. Cases who received higher levels of adherent care also reported higher levels of patient satisfaction, B =.09, p<.05 and general health, OR =1.44, [95% CI=1.29-1.60].

Study Limitations:
Measures of patient satisfaction and general health are related to any health care service and are not specific to low back pain.

Conclusions:
Although receipt of CPG adherent care was related to better outcomes provider adherence was low and did not improve over years.

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