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Family physician management of Workers' Compensation Board patients with acute mechanical back pain
1150-20 U 1996
(96FS-22)
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Issue: |
Impact of new clinical practice guidelines on family physician treatment of accute mechanical lower back pain and the return to work of patients following treatment. |
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Agency: |
Spine Program, Department of Orthopaedics, University of British Columbia |
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Representative: |
Paul B. Bishop |
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Funding: |
$32,530 |
Context: Clinical practice guidelines developed from evidence-based medicine for the treatment of acute mechanical lower back pain had recently been distributed by WCB to family physicians. As family physicians are usually the first point of entry to the health care system, and are also usually the most reluctant to change, the impact of the new guidelines on the treatment of patients and return to work of those patients was examined.
Objectives: 1) To determine the degree of family physician compliance with clinical practice guidelines for the treatment of acute mechanical lower back pain. 2) To determine the impact of varying methods of providing information on clinical practice guidelines to family physicians and patients. 3) To determine the impact of adherence to clinical practice guidelines on return to pre-injury occupation.
Design: Randomized controlled study using five groups of patients. In group 1 the family physician received an intervention two weeks post injury. Group 2 was the same as group 1 but the patient also received an intervention two weeks post injury. In group 3 the family physician received interventions at 4, 8 and 12 weeks post injury. Group 4 was the same as group 3 but the patients also received interventions at 4, 8 and 12 weeks. Group 5 was the control group, which received no interventions.
Compliance was measured by comparing the clinical practice guidelines with the physician's WCB "First Report" and "Progress Reports" for a period of sixteen weeks from the date of injury. Return to work data was collected from WCB.
Setting: British Columbia, Canada
Subjects: 724 patients with acute mechanical lower back pain of less than two week duration and accepted WCB claim were assigned to the study.
Main Outcome Measures: Primary outcome measures were compliance with specific history taking items, physical examination procedures and specific treatment recommendations. Secondary outcome measures were time off work and actual return to pre-injury work.
Results: Family physicians from the control group demonstrated a high degree of compliance with the recommended history taking, physical examination and imaging guidelines, but poor compliance with guideline-recommended treatment. Compliance did not improve for those who received only one intervention. Those who received intervention at 4, 8 and 12 weeks showed significant improvement with some recommended treatment as well as significantly less use of inappropriate treatments. None of the recommendations significantly altered family physician recommendations with respect to time off work. Patients receiving single or multiple interventions returned to full pre-accident work activity at a slightly higher rate than those in the control group.
Conclusion: Family physicians in British Columbia had a high degree of compliance with clinical practice guidelines for evaluating patients with acute mechanical lower back pain, but poor compliance with recommended treatments. Providing patients and/or their family physicians with information regarding clinical practice guidelines for the management of acute mechanical lower back pain at three stages during treatment altered some aspects of improved compliance with the guidelines yet had no impact on the physician recommendations for time off work and a marginally higher rate of return to full pre-injury work activity.
Context: Caregivers are at a high risk of MSI due to a multitude of factors. Prevention strategies have varied from education, training, promotion of physical fitness, and application of ergonomics. A health promotion approach builds on knowledge to encourage a change in beliefs, values, attitudes, intentions and self-efficacy, to ensure individuals avoid health risk behaviours.
Objective: To determine the effects of a health and safety promotion campaign on several indicators of MSI prevention among health care workers.
Design: A quasi-experimental field study using non-equivalent comparison groups (a Solomon 4-Group Design) was used to assess the effect of the health promotion campaign. Two hospitals were selected as intervention sites and two as control sights. Pre-intervention surveys were conducted at one of each of the control and intervention sites. Project teams of six to seven members, representing all occupations within the hospitals’ caregiver populations, developed the key messages and strategies of the promotional campaign. The teams also completed situational assessments. Each campaign was delivered over a six-week period. Post-intervention surveys were conducted at all sites.
Setting: Four large hospitals in the Lower Mainland of BC.
Subjects: 220 caregivers from each hospital were randomly selected to receive the survey. Selection was weighted to reflect proportions of occupations. The numbers of pre-intervention surveys returned were 89 from the pre-test/control hospital and 98 from the pre-test/intervention hospital. Post-test responses numbers were: 85 from the no pre-test/control hospital, 56 from pre-test/control hospital, 93 from no pre-test/intervention hospital, and 66 from pre-test/intervention hospital.
Main Outcome Measures: The survey included items that measured: self-reported prevalence of back pain in the past year; individual knowledge; group norms and individual beliefs; use of safe work practices; exposure to physically demanding tasks as part of work; and other individual risk factors associate with back pain.
Results: The situational assessment identified expected safe work practices and barriers to their implementation. MSI was not identified as a primary concern among caregivers. Attendance at the project team meetings and participation in the intervention decreased over time, resulting in cancellation of the final project team meetings and final theme of the campaign. No effect was found for either the pre-test or the intervention.
Conclusion: The results of the study can be used to guide the development and implementation of other MSI prevention programs for caregivers. Some significant recommendations identified are that future programs involve front-line caregivers in their development and are timed to coincide with expressed concern for the prevention of MSI from within the caregiver population. Programs should use existing channels to convey messages, with face-to-face communication as the primary communication mode. Initiatives should focus on a few specific safe work practices and include concurrent changes within the organization to support the safe work practices. Also, interventions should address the multi-factorial nature of the risk factors by including environmental, psychosocial and individual strategies.