Should the gap be filled between guidelines and actual practice for management of low back pain in primary care - The Quebec experience

Study Design. A prospective cohort study. Objectives. To describe health services utilization for low back pain in the province of Quebec, Canada, and to compare it with North American guidelines. Summary of Background Data. The Quebec Task Force and the Agency for Health Care Planning and Research (United States) published guidelines for the management of low back pain in 1987 and 1994, respectively. Methods. A cohort of 2147 adults with low back pain identified at the Quebec Worker's Compensation Board ;were selected randomly and observed over 2 years' time for their health care utilization profile. Results. During the study period, 57.8% of the workers still under active care 7 weeks after their back injury had not yet been referred to a specialist. Specialized imaging techniques were obtained by 4.5% of the patients, with a delay of 7 weeks or more in 66% of them. Surgery was performed on 1.6% of the patients. The presence of an initial specific diagnosis and proximity to a university hospital significantly increased utilization rate and reduced the delays. Conclusion. Health services utilization for back pain in Quebec was equal or lower to what currently is practiced elsewhere, but access to specialists was not meeting the current recommendations. This would represent a 12% net increase in new specialist contacts and a quicker access in 39% who saw a specialist. Before such an effort can be considered, health care planners will ;need a better definition of the role of the specialist consultation in the guidelines and scientific evidence specifically addressing their benefit in primary care, especially in the absence of a specific diagnosis.