EFFECTS OF PRACTICE STYLE IN MANAGING BACK PAIN

Objective: To assess the effects of a practice style of back pain management consistent with self-care (infrequent prescribing of pain medications and bed rest) on long-term functional outcomes, costs of care, and patient satisfaction. Design: A quasi-experimental observational study in which primary care physicians (n = 44) were categorized according to one of three practice style groups defined by a low, moderate, or high frequency of prescribing pain medications and bed rest for many patients (average, 24 patients per physician). Setting: Primary care practices of a large, staff model health maintenance organization, Group Health Cooperative of Puget Sound. Patients: Consecutive patients with back or neck pain of participating primary care physicians. Patients were interviewed 1 month (n = 1071) and 1 year and 2 years (n = 911) after their index visits. Results: Patients in the three practice style groups rated similarly the quality of medical care received for back pain. Patients treated by physicians who infrequently prescribed pain medications and bed rest were more satisfied with education about back pain. On a scale of 0 to 10, the mean rating of agreement with the statement, ''After your visit with the doctor, you fully understood how to take care of your back problem,'' was 5.6 +/- 3.6 among patients of physicians who frequently prescribed medication and rest and was 6.6 +/- 3.5) among those who infrequently prescribed medication and bed rest. At 1 month, 30% of patients of physicians who infrequently prescribed medications and bed rest were graded as having moderate to severe activity limitation because of back pain, whereas 37% of patients in the moderate group had this grading, and 46% of patients of physicians who frequently prescribed were graded as having moderate to severe activity limitation. Differences in activity limitation by practice style group were no longer evident at 1 or 2 years of follow-up. The total 1-year costs of back care were higher among patients seen by physicians who frequently prescribed bed rest and pain medications (cost, $768 +/- $1592) than among those seen by physicians who infrequently prescribed (cost, $428 +/- $665), due largely to differences in inpatient and specialty care costs. The adjusted difference in costs, after controlling for case-mix variables, was $277 (95% Cl, $85.50 to $471.32). Conclusions: A practice style consistent with back pain self-care yielded similar long-term pain and functional outcomes at lower cost and was associated with higher satisfaction with patient education compared with a practice style characterized by more frequent prescribing of pain medications and bed rest.