Schers H, Braspenning J, Drijver R, Wensing M, Grol R
Centre for Quality of Care Research, University of Nijmegen, The Netherlands.
Br J Gen Pract. 2000 Aug;50(457):640-4.
Although guidelines for the management of low back pain have been published in the past decade, there is potential for further improvement in back pain care.
To document the management of non-specific low back pain by general practitioners (GPs) in the Netherlands, to determine how this management of care is related to patient and physician factors, and to explore possible reasons for not adhering to the guidelines.
A prospective study was set up in which 57 GPs in 30 general practices completed a computerised questionnaire after each consultation for low back pain during a four-month period.
Of 1640 back pain contacts, 1180 referred to non-specific low back pain. Diagnostic tests were ordered in 2% of first consultations and in 7% of follow-up consultations within one episode. The advice to stay active despite pain was given in 76% and 69% of these cases respectively. Patients were prescribed an analgesic in 53% and 41% of cases respectively (mainly NSAIDs [80%]). Patients were referred to a physiotherapist in 22% of first and in 50% of follow-up consultations. Older patients were physically examined less often, prescribed analgesics more often, and were told less often that staying active could benefit them. The advice to remain active was omitted more often when symptoms lasted longer. Only a small part of the variance in management was accounted for by patient characteristics or by differences between practices.
The management of low back pain met the guidelines to a large extent. Management decisions were often related to characteristics in which the guidelines lack differentiation. Important reasons for non-adherence were perceived patients' preferences. Further implementation of guidelines will be difficult unless doctors' and patients' views are more explicitly known.
尽管在过去十年中已发布了腰痛管理指南，但腰痛护理仍有进一步改善的潜力。
记录荷兰全科医生（GP）对非特异性腰痛的管理情况，确定这种护理管理与患者和医生因素之间的关系，并探讨不遵守指南的可能原因。
开展了一项前瞻性研究，30家普通诊所的57名全科医生在为期四个月的时间里，每次为腰痛患者会诊后完成一份电脑化问卷。
在1640次腰痛就诊中，1180次被诊断为非特异性腰痛。在一次发作的首次会诊中有2%以及随访会诊中有7%的患者接受了诊断测试。在这些病例中，分别有76%和69%的患者被建议尽管疼痛也要保持活动。患者分别在53%和41%的病例中被开了镇痛药（主要是非甾体抗炎药[80%]）。在首次会诊中有22%以及随访会诊中有50%的患者被转介给物理治疗师。老年患者接受身体检查的频率较低，开镇痛药的频率较高，被告知保持活动有益的频率较低。当症状持续时间较长时，保持活动的建议被遗漏的频率更高。管理差异中只有一小部分可由患者特征或诊所之间的差异来解释。
腰痛管理在很大程度上符合指南。管理决策往往与指南中缺乏区分度的特征有关。不遵守指南的重要原因是患者的偏好。除非更明确了解医生和患者的观点，否则指南的进一步实施将很困难。
