title: Physicians' initial management of acute low back pain versus evidence-based guidelines. Influence of sciatica.
abstract: BACKGROUND
  Little information is available on physician characteristics and patient presentations that may influence compliance with evidence-based guidelines for acute low back pain.
  
  
  OBJECTIVE
  To assess whether physicians' management decisions are consistent with the Agency for Health Research Quality's guideline and whether responses varied with the presentation of sciatica or by physician characteristics.
  
  
  METHODS
  Cross-sectional study using a mailed survey.
  
  
  METHODS
  Participants were randomly selected from internal medicine, family practice, general practice, emergency medicine, and occupational medicine specialties.
  
  
  METHODS
  A questionnaire asked for recommendations for 2 case scenarios, representing patients without and with sciatica, respectively.
  
  
  RESULTS
  Seven hundred and twenty surveys were completed (response rate=25%). In cases 1 (without sciatica) and 2 (with sciatica), 26.9% and 4.3% of physicians fully complied with the guideline, respectively. For each year in practice, the odds of guideline noncompliance increased 1.03 times (95% confidence interval [CI]=1.01 to 1.05) for case 1. With occupational medicine as the referent specialty, general practice had the greatest odds of noncompliance (3.60, 95% CI=1.75 to 7.40) in case 1, followed by internal medicine and emergency medicine. Results for case 2 reflected the influence of sciatica with internal medicine having substantially higher odds (vs case 1) and the greatest odds of noncompliance of any specialty (6.93, 95% CI=1.47 to 32.78), followed by family practice and emergency medicine.
  
  
  CONCLUSIONS
  A majority of primary care physicians continue to be noncompliant with evidence-based back pain guidelines. Sciatica dramatically influenced clinical decision-making, increasing the extent of noncompliance, particularly for internal medicine and family practice. Physicians' misunderstanding of sciatica's natural history and belief that more intensive initial management is indicated may be factors underlying the observed influence of sciatica.
authors.affiliation: Center for Disability Research, Liberty Mutual Research Institute for Safety, Hopkinton, MA 01748, USA. barbara.webster@libertymutual.com
authors.forename: Barbara S
authors.initials: BS
authors.lastname: Webster
authors.forename: Theodore K
authors.initials: TK
authors.lastname: Courtney
authors.forename: Yueng-Hsiang
authors.initials: YH
authors.lastname: Huang
authors.forename: Simon
authors.initials: S
authors.lastname: Matz
authors.forename: David C
authors.initials: DC
authors.lastname: Christiani
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D019317:Evidence-Based Medicine; D005260:Female; D019983:Guideline Adherence; D019538:Health Care Surveys; D006801:Humans; D017116:Low Back Pain / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D005791:Patient Care / Q000379:methods* / Q000592:standards; D011320:Primary Health Care / Q000379:methods*; D012585:Sciatica / Q000150:complications / Q000209:etiology / Q000628:therapy*