Abstract
BackgroundInappropriate imaging and low-value care for low back pain (LBP) are common. A new patient-education booklet was created to overcome identified barriers to the delivery of recommended care, including the use of inappropriate imaging. Our aim was to assess the effectiveness of this booklet as part of primary care for LBP patients in comparison to usual care.MethodsA cluster-randomized trial was performed. The intervention involved providing practitioners with the new patient-education booklet and a 30-min training session on its use. The booklet was provided during the clinical consult to all consenting LBP patients in the intervention group. Primary outcomes were the proportion of patients presenting with LBP who underwent imaging examinations during the first three months of follow-up and PROMIS PF-20 (Patient-Reported Outcomes Measurement Information System, 20-item physical functioning short form) change between baseline and three-month follow-up. Secondary outcomes, including sick leave and imaging examinations at 12 months, were investigated. Logistic regression using GEE-estimation was used for dichotomous outcomes, Poisson regression using GEE-estimation for count outcomes, and linear mixed models for continuous outcomes.ResultsUsing the patient education booklet appeared to substantially reduce the proportion of LBP patients who underwent an imaging examination at three months, but the result was not statistically significant (OR 0.57, 95% confidence interval (Cl) 0.27 to 1.22). At 12 months, the effect was slightly larger and statistically significant (OR 0.50, 95%Cl 0.30 to 0.83, p = 0.008). No difference was observed in the PROMIS PF-20 T-score change between baseline and 3 months or 12 months (p = 0.365 and p = 0.923, respectively). The number of sick leave days in the intervention group was less than that in the control group at 3 months (RR 0.47, 95%Cl 0.26 to 0.83, p = 0.010) and at 12 months (RR 0.36, 95%Cl 0.18 to 0.72, p = 0.004).ConclusionsThe booklet appeared to be effective in reducing the proportion of LBP patients who underwent imaging examinations over 12 months. The intervention had no discernible effect on the PROMIS PF20 T-score change. The number of sick leave days was substantially lower in the intervention group.Trial registrationISRCTN, ISRCTN14389368, Registered 4 April 2019—Retrospectively registered.
Highlights
Inappropriate imaging and low-value care for low back pain (LBP) are common
Poisson regression was used for count outcomes, providing an estimated difference between the groups expressed as risk ratio (RR) with a 95% confidence interval
The first contacted professional was a physician for 44% and a physiotherapist for 43% of the patients, in comparison to 28% and 62% in the control group, respectively
Summary
Inappropriate imaging and low-value care for low back pain (LBP) are common. A new patient-education booklet was created to overcome identified barriers to the delivery of recommended care, including the use of inappropriate imaging. Management of LBP is often inconsistent with guidelines, and low-value care, such as inappropriate imaging, is common [4, 5]. One third to one half of LBP patients undergo inappropriate imaging [6], which has been associated with increased health care costs, increased downstream health care utilization and increased disability [7,8,9,10]. The implementation of clinical guidelines for LBP is complicated and has several physician- and patientreported barriers [12, 13]. Preliminary evaluation by patients and practitioners in Finland has suggested that the booklet may be helpful in LBP management and in decreasing the need for LBP imaging [15]
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