Troy Brown, RN
October 29, 2013
Full Story (may require free registration): http://www.medscape.com/viewarticle/813451
Fewer than one third of physicians are following current recommendations and giving exercise advice to patients with osteoarthritis or sciatica, according to a balanced factorial experiment among 192 primary care physicians in the United States.
Nancy N. Maserejian, ScD, a senior research scientist and associate director of epidemiology at New England Research Institutes, Inc, Watertown, Massachusetts, and colleagues report their findings in an article published online October 8 in Arthritis Care & Research.
“[T]his experiment found variation in the quality of musculoskeletal pain management decisions, particularly to provide exercise and other lifestyle advice, associated with physicians’ years in practice and organizational cultural values. Generally, newer physicians had greater adherence to current recommendations,” the authors write.
The physicians watched 2 videos of different patients (actors) who presented with pain from either undiagnosed sciatica symptoms or diagnosed knee osteoarthritis and completed short interviews after regarding what their recommendations would be to the patient.
Unconfounded effects were estimated by analyzing systematic variations in patient sex, socioeconomic status, race, and physician sex and experience (<20 vs >20 years in practice).
Associations between patient or provider attributes and clinical decisions were evaluated using variance analysis.
Current recommendations of the American College of Rheumatology, American Pain Society, and clinical expert consensus were used to judge the quality of decisions.
Less than one third of physicians reported they would give exercise advice (30.2% for osteoarthritis, 32.8% for sciatica). Physicians in practice for fewer years were more likely to give advice on lifestyle changes (P = .01), especially regarding exercise habits (39.6% of newer physicians vs 26.0% of more experienced physicians for sciatica or 20.8% of more experienced physicians for osteoarthritis).
Newer physicians were also more likely to prescribe nonsteroidal anti-inflammatory drugs for pain relief (68.8% vs 52.1 [P = .01] for the sciatica patient; 80.2% vs 67.7% [P = .02] for the osteoarthritis patient).
Newer physicians were less likely to order tests (sciatica, mean 1.9 vs 2.5 tests [P = .01]; osteoarthritis, 2.4 vs 2.9 tests [P = .07]), especially basic laboratory tests (eg, complete blood count or metabolic panel, 9.4% vs 21.9%; P = .02) and urinalysis (4.2% vs 16.7%; P = .003), particularly for sciatica. For the patient with osteoarthritis only, X-rays were more often ordered by newer physicians (85.4% vs 69.8%).
Test ordering fell as the organization’s emphasis on business or profits rose.
Patient factors and sex of the physician had inconsistent effects on the evaluation and treatment of pain.
“Overall, the observed variations in decision-making were still largely unexplained even after accounting for all the patient, provider, and organizational variables that were statistically significant in the multivariable models,” the authors write. “Methods to more effectively disseminate current recommendations for diagnosis and management of pain conditions should be developed and tested to improve the quality of care for these common clinical problems,” they conclude.
This article received financial support from an Award from the National Institute of Arthritis and Musculoskeletal and Skin Disorders at the National Institutes of Health. One coauthor has received research support from CVS-Caremark for studies of medication adherence. The other authors have disclosed no relevant financial relationships.
Arthritis Care Res. Published online October 8, 2013. Abstract