title: Investigating the Primary Care Management of Low Back Pain: A Simulated Patient Study.
abstract: A limitation of existing studies of primary care for low back pain (LBP) is that they are not based on direct observation of the clinical encounter and so may underestimate or overestimate the extent of evidence-practice gaps. This was a cross-sectional observational study that observed the management recommendations for LBP provided in primary care using a simulated patient approach. Trained actors requested an over-the-counter medicine or asked for management advice for 1 of 2 simulated patient scenarios: nonspecific LBP (NSLBP) or vertebral compression fracture. Visits were audiorecorded to allow data capture, validation, and review. We evaluated concordance with key recommendations provided in evidence-based LBP guidelines on pain medicines, patient self-care advice, and referral. Visits were conducted across 534 pharmacies comprising 336 nonspecific scenarios and 198 fracture scenarios. Recommendations for pain medicines, but not patient self-care advice and referral, were typically consistent with guidelines. For the NSLBP scenario, the concerns were infrequent provision of reassurance of favorable outcome (8%), advice to stay active (5%), advice to avoid bed rest (0%), advice to use superficial heat (24%), and excessive endorsement of referral (57.4%) and imaging (22.7%). For the fracture scenario, the concerns were a low rate of prompt medical referrals (50.0%) and low endorsement of rest (1.0%).
  
  
  CONCLUSIONS
  We observed primary care that aligned closely with some aspects, but was at odds with other aspects, of evidence-based LBP guidelines. Problems included inadequate self-care advice and failing to appropriately recommend imaging or prompt medical review when indicated. These results can inform implementation strategies to improve primary care management of LBP.
authors.affiliation: Faculty of Pharmacy, University of Sydney, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, New South Wales, Australia.
authors.forename: Christina
authors.initials: C
authors.lastname: Abdel Shaheed
authors.affiliation: Australian College of Pharmacy, Canberra, Australian Capital Territory, Australia.
authors.forename: Brett
authors.initials: B
authors.lastname: McFarlane
authors.affiliation: The George Institute for Global Health, Sydney, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.
authors.forename: Chris G
authors.initials: CG
authors.lastname: Maher
authors.affiliation: Graduate School of Health, University of Technology Sydney, Broadway, New South Wales, Australia.
authors.forename: Kylie A
authors.initials: KA
authors.lastname: Williams
authors.affiliation: Australian College of Pharmacy, Canberra, Australian Capital Territory, Australia.
authors.forename: Jenny
authors.initials: J
authors.lastname: Bergin
authors.affiliation: Group Executive, Pharmacy Transformation Group, The Pharmacy Guild of Australia, Canberra, Australian Capital Territory, Australia.
authors.forename: Andrew
authors.initials: A
authors.lastname: Matthews
authors.affiliation: Faculty of Pharmacy, University of Sydney, Sydney, New South Wales, Australia; Centre for Education and Research on Ageing, University of Sydney and Concord Repatriation General Hospital, Sydney, New South Wales, Australia. Electronic address: andrew.mclachlan@sydney.edu.au.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: McLachlan
mesh_terms: D001510:Bed Rest; D003430:Cross-Sectional Studies; D019317:Evidence-Based Medicine; D019983:Guideline Adherence; D006801:Humans; D017116:Low Back Pain / Q000628:therapy*; D059408:Pain Management / Q000379:methods*; D017410:Practice Guidelines as Topic; D011320:Primary Health Care; D012648:Self Care
keywords: Primary care; evidence-based; guidelines; low back pain; simulated patient