Original Research

Training in Back Care to Improve Outcome and Patient Satisfaction Teaching Old Docs New Tricks

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References

The improved reported performances of physicians and patient outcomes were noted in both arms of the manual therapy trial, compared with those of patients in the earlier cohort study, though there was no difference in time to full functional recovery between the 2 studies. The inconsistency between outcomes (Roland-Morris scores and time to functional recovery) is probably explainable by the fact that they measure different patient perceptions of back problems—specific versus global recovery. This inconsistency of measures has been noted in other studies of low back pain interventions.18

The improved outcomes of patients in the randomized trial compared with those in the cohort may be because of specific elements of the study applicable to all patients or may have been due to unmeasured baseline differences. The patients in the randomized trial were more impaired at baseline, which would tend toward worse rather than better outcomes if severity was not completely controlled for. There are several possible explanations for these findings: (1) workshop training did improve physician knowledge and skills; (2) involvement of patients in a clinical trial in which an intervention (enhanced care) was given in both arms of the study (one also receiving manual therapy) could heighten the overall positive effect; (3) the clinical trial involved more visits (average=3.6) than with patients in the first study (1.3)—this could add significantly to patient satisfaction and perceptions of good care; and (4) the recruited physicians were a special group of interested and motivated individuals who by their nature would produce better outcomes in a clinical trial.

Limitations

There are limitations to our findings and conclusions. There were differences in exclusion criteria that might have reduced the number of unhealthy people recruited into the manual therapy trial compared with the cohort study. This could have led to better outcomes, though we doubt that these differences made much impact given the average age of the patients (40 years).

Although we adjusted for baseline differences (income, workers’ compensation, and employment status), we are not sure why these differences occurred. One possibility is that the rapid population and commercial growth and high employment rates that occurred in the state of North Carolina in the time between the 2 studies improved the economic characteristics of patients presenting to the physicians over time. It is also possible that patients with higher incomes and fewer employment difficulties would be more likely to rate physician communication and management more highly and improve more rapidly.

The global effect on clinician knowledge, skills, and performance of a 3-year span of evolving clinical practice and involvement in low back pain studies (other than participating in a training workshop) cannot be quantified. For example, improved performance and outcomes might have been related to the publication of the AHCPR back pain guidelines in 1994, approximately 6 months before the start of the manual therapy study.16 However, at the low back pain workshop (where only the AHCPR “red flags” were presented) the participants seemed to be only minimally aware of these guidelines.

If the improved outcomes noted in this study were mainly because of the passage of time rather than workshop training, this provides an interesting insight into how practice changes for the better.

Patient satisfaction with care has been shown to correlate with outcomes.19,20 Deyo and Diehl suggested that dissatisfaction with care for low back pain was related to failure to obtain an adequate explanation from the physician, while Cherkin and colleagues proposed that lack of confidence in management and negative attitudes of clinicians might be key issues to be addressed in achieving better outcomes.8-10,21,22 However, didactic training to remedy these problems did not appear to be very effective in improving satisfaction. Following up on these suggestions, Smucker and coworkers,12 using the large North Carolina cohort study, showed that clinician self-confidence (allopathic and chiropractic physicians) did not predict patient outcomes but commented that communication, time spent with the patient, and manual evaluation and treatment skills might be important variables affecting outcome.12

The margin of differences in outcomes shown in our preintervention and postintervention analysis leads us to suggest that allopathic physicians using a brief systematic evaluation and hands-on regional physical examination, sound advice on pain management and prevention, and an increasingly active exercise program can modestly improve early patient functioning and satisfaction in acute low back pain. Whether training in limited manual therapy adds to this benefit is unclear and must be taken into account in relation to the current expansion of CME in manipulative skills for allopathic physicians. The costs and benefits of providing this training—with the possibility of needing one extra office visit or more to fully implement enhanced care—would need to be assessed.23

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