Can Choosing Wisely prevent acute low back pain from becoming chronic?

More than a dozen Choosing Wisely campaign recommendations concern what not to do for patients with acute low back pain. Based on a clinical practice guideline from the American College of Physicians, the American Society of Anesthesiologists and several other groups recommend avoiding imaging studies within the first six weeks in patients without red flags or specific clinical indications. The American Academy of Orthopedic Surgeons and the American Academy of Physical Medicine and Rehabilitation (AAPMR) advise avoiding opioids for these patients unless other alternatives have not provided pain relief. The AAPMR and the North American Spine Society discourage bed rest as treatment for acute low back pain. These recommendations are intended to reduce downstream harms and costs: for example, a spurious finding on MRI could lead to unnecessary surgery; use of opioids could lead to physical dependence and opioid use disorder; bed rest and avoidance of physical activity could increase the risk of long-term disability.

Can guideline-discordant care for patients with acute low back pain increase the risk of progression to chronic low back pain? In an inception cohort study published in JAMA Network Open, researchers enrolled 5233 adults with acute low back pain from 77 U.S. primary care practices, assessed their baseline risk of transition to chronic pain using the Subgroups for Targeted Treatment (STarT) Back prognostic tool, and followed them for 6 months. 32% of participants met clinical criteria for chronic low back pain at the study's end. Characteristics associated with transition to chronic pain included obesity (adjusted odds ratio, 1.52), tobacco use (aOR, 1.56), severe baseline disability (aOR, 1.82), and a depression and/or anxiety diagnosis (aOR, 1.66). Researchers also examined associations between chronic low back pain and inappropriate care processes within 21 days of the initial visit: 1) any opioid prescriptions, or benzodiazepines or systemic steroids prescribed without an NSAID or skeletal muscle relaxant; 2) diagnostic imaging; 3) medical subspecialty referral for back pain. Compared to the 52% of participants who received none of these, patients with 1, 2, or 3 inappropriate care processes were 1.39, 1.88, and 2.16 times more likely to develop chronic low back pain after controlling for clinical characteristics.

Although adherence to Choosing Wisely recommendations was associated with a lower risk of patients developing chronic low back pain in this study, it is disappointing that almost half of them received at least some inappropriate care. Is care for back pain an outlier, or does it reflect national trends? A recent cross-sectional study examined the use of 32 low-value health services in Medicare fee-for-service beneficiaries. The study found modest progress from 2014 to 2018 in the percentage of persons receiving any low-value service (declined from 36.3% to 33.6%), number of low-value services per 1000 persons (declined from 678 to 633), and spending per 1000 persons on low-value care (declined from $52,766 to $46,922). Three services comprised about two-thirds of low-value care: preoperative laboratory testing, opioids for back pain, and antibiotics for upper respiratory infections. While preoperative testing decreased during the study period, opioid and antibiotic prescribing both increased.

Since the campaign's inception in 2012, Choosing Wisely recommendations have been widely disseminated in AFP, FPM (formerly Family Practice Management), and other family medicine journals. The American Academy of Family Physicians periodically updates and adds new "don't do" recommendations, most recently in 2018. Other studies have recognized that clinicians in underserved or "safety net" practices are as likely to provide low-value care as clinicians in better resourced settings. A 2018 AFP editorial by Dr. Jennifer Middleton recognized that increasing awareness of best practices is necessary but not sufficient to drive implementation: "For meaningful change to occur, the workflows and systems we operate within must change so that new habits become routine." The Medicare study suggests that workflows and systems have not changed enough in the past decade to undo entrenched low-value practices.