title: Effect of an intervention to enhance guideline adherence of occupational physicians on return-to-work self-efficacy in workers sick-listed with common mental disorders A theory-based cross-sectional survey demonstrated the important role of awareness in guideline implementation. Evaluation of a Theory-Informed Implementation Intervention for the Management of Acute Low Back Pain in General Medical Practice: The IMPLEMENT Cluster Randomised Trial How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners? A survey of UK general practitioners and physiotherapists Use of low-back pain guidelines by occupational therapists: a qualitative study of barriers and facilitators. Routine primary care management of acute low back pain: adherence to clinical guidelines The Effect of Adherence to Practice Guidelines on Depression Outcomes Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society Low back pain in Australian adults. health provider utilization and care seeking.
abstract: Background Since a higher level of self-efficacy in common mental disorders is associated with earlier return-to-work ( RTW ) , it is important to know if work related self-efficacy can be increased by occupational health care . The primary aim of this study was to evaluate whether an intervention to enhance guideline adherence of occupational physicians lead to an increase in RTW self-efficacy in workers three months later . The secondary aim was to evaluate whether the intervention modified the association between RTW self-efficacy and return-to-work three months later . Methods A total of 66 occupational physicians participated in the study . They were r and omized into two groups ; the intervention group received a training , the control group did not . The training aim ed to enhance adherence to a mental health guideline that contained strategies that are supposed to enhance RTW self-efficacy . In 128 sick-listed workers guided by these occupational physicians , RTW self-efficacy , RTW , and personal , health-related and work-related variables were measured at baseline and three months later . Generalized linear mixed models analysis and linear mixed models analysis were used for the evaluations . Results In workers whose occupational physicians had received the training RTW self-efficacy increased significantly more than in workers whose occupational physicians had participated in the control group ( t = −2.626 , p ≤ .05 ) . Higher baseline RTW self-efficacy scores were significantly more often associated with full RTW than with no RTW three months later ( OR 2.20 , 95 % CI 1.18–4.07 ) , but the intervention did not affect this association . Conclusions This study showed that a training to enhance guideline adherence of occupational physicians leads to increased RTW self-efficacy in workers sick-listed with common mental disorders during the first months of sickness absence in a real-life occupational health care setting . This insight is helpful for optimizing the recovery and RTW process , and for underst and ing the role of RTW self-efficacy in this process . Trial registration IS RCT OBJECTIVE To assess physiotherapists ' adherence to the  Dutch guidelines  for nonspecific low back pain , the motivational determinants related to guideline adherence , and the role of physiotherapists ' awareness of their performance in this respect . STUDY DESIGN & SETTING This was a cross-sectional survey among a r and om sample of 1,500 private practice physiotherapists in the Netherl and s. The actual  guideline adherence  was measured by means of vali date d clinical vignettes and self-reported adherence by asking the physiotherapists to report their own level of adherence . The assessment of motivational determinants was based on a theoretical framework . RESULTS The  response rate was 31.5 % ( N=472 ) . The average guideline adherence rate was 50.4 % ( SD=16.8 ) . Only 38.5 % of the physiotherapists had realistic perceptions of their personal performance . Awareness levels seriously interfered with the relationship between motivational determinants and actual guideline adherence . Actual adherence was mainly related to the perceived relative advantages and awareness of adherence to the perceived social norm . CONCLUSION The moderating role of awareness in this study confirms the view that motivational determinants of a particular behavior can only be accurately assessed if people hold realistic perceptions of that behavior . Our approach illustrates the added value of a theory-based approach in guideline implementation studies Introduction This cluster r and omised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain ( LBP ) in general practice . Methods General practice s were r and omised to either  access to a guideline for acute LBP ( control ) or facilitated interactive workshops ( intervention ) . We measured behavioural predictors ( e.g. knowledge , attitudes and intentions ) and fear avoidance beliefs . We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner ( GP ) level : behavioural simulation ( clinical decision about vignettes ) and rates of x-ray and CT-scan ( medical administrative data ) . All those not involved in the delivery of the intervention were blinded to allocation . Results 47 practice s ( 53 GPs ) were r and omised to the control and 45 practice s ( 59 GPs ) to the intervention . The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information ; a minimum of 38 GPs were available from the intervention group , and a minimum of 40 GPs from the control group . For the behavioural constructs , although effect estimates were small , the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral . For behavioural simulation , intervention group GPs were more likely to adhere to guideline recommendations about x-ray ( OR 1.76 , 95%CI 1.01 , 3.05 ) and more likely to give advice to stay active ( OR 4.49 , 95%CI 1.90 to 10.60 ) . Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear ; rate ratio 0.87 ( 95%CI 0.68 , 1.10 ) for x-ray or CT-scan . Conclusions The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence -based guideline , but it did not result in statistically significant changes in actual behaviour . Trial Registration Australian New Zeal and Clinical Trials Registry & NA ; Guidelines for the management of low back pain ( LBP ) have existed for many years , but adherence to these by health care practitioners ( HCPs ) remains suboptimal . The aim of this study was to measure the attitudes , beliefs and reported clinical behaviour of UK physiotherapists ( PTs ) and general practitioners ( GPs ) about LBP and to explore the associations between these . A cross‐sectional postal survey of GPs ( n = 2000 ) and PTs ( n = 2000 ) was conducted that included the  Pain Attitudes and Beliefs Scale ( PABT.PT )  , and a vignette of a  patient with non‐specific LBP ( NSLBP )  with questions asking about recommendations for work , activity and bedrest . Data from 1022 respondents ( 442 GPs and 580 PTs ) who had recently treated patients with LBP were analysed . Although the majority of HCPs reported providing advice for the vignette patient that was broadly in line with guideline recommendations , 28 % reported they would advise this patient to remain off work . Work advice was significantly related to the PABS.PT scores with higher biomedical ( F1,986 = 77.5 , p < 0.0001 ) and lower behavioural ( F1,981 = 31.9 , p < 0.001 ) scores associated with advice to remain off work . We have demonstrated that the attitudes and reported practice behaviour of UK GPs and PTs for patients with NSLBP are diverse . Many HCPs held the belief that LBP necessitates some avoidance of activities and work . The attitudes and beliefs of these HCPs were associated with their self‐reported clinical behaviour regarding advice about work . Future studies need to investigate whether approaches aim ed at modifying these HCP factors can lead to improved patient outcomes OBJECTIVE Identify barriers and facilitators related to the use of low-back pain guidelines as perceived by occupational therapists ( OTs ) . METHODS AND PARTICIPANTS A qualitative approach was used . Nine OTs with varied characteristics were r and omly selected . Participants were asked to use the guidelines with at least two clients .  Semi-structured interviews were done to identify barriers and facilitators related to use . Transcripts of the interviews were analyzed . RESULTS Participants agreed with the guidelines , found them compatible with their current practice , and believed using them would help in preventing persistent disability . Some question ed if their work organization , based on group therapy , would limit their use of the guidelines . Because of the guidelines ' biopsychosocial perspective , they anticipated problems regarding client expectations and collaboration with other health professionals . CONCLUSIONS Participating OTs raised few barriers related to them . Barriers were mostly related to client expectations , work organization and peers . It appears the guidelines would be easily implemented by OTs , but environmental elements could limit this One of the major challenges for general practitioners is to manage individuals with acute low back pain appropriately to reduce the risk of chronicity . A prospect i ve study was design ed to assess the actual management of acute low back pain in one primary care setting and to determine whether existing practice patterns conform to published guidelines . Twenty-four family physicians from public primary care centers of the Basque Health Service in Bizkaia , Basque Country ( Spain ) , participated in the study . A total of 105 patients aged 18–65 years presenting with acute low back pain over a 6-month period were included . Immediately after consultation , a research assistant performed a structured clinical interview . The patients ’ care provided by the general practitioner was compared with the Agency for Health Care Policy and Research ( AHCPR ) guidelines and guidelines issued by the Royal College of General Practitioners . The diagnostic process showed a low rate of appropriate use of history ( 27 % ) , physical examination ( 32 % ) , lumbar radiographs ( 31 % ) , and referral to specialized care ( 33 % ) . Although the therapeutic process showed a relatively high rate of appropriateness in earlier mobilization ( 77 % ) and educational advice ( 65 % ) , only 23 % of patients were taught about the benign course of back pain . The study revealed that management of acute low back pain in the primary care setting is far from being in conformance with published clinical guidelines Context Do clinicians who follow  depression practice guidelines have better patient outcomes ? Contribution This observational study from 45 primary care practice s found that clinicians adhered well to only one third of the guideline recommendations for depression . Most clinicians initially recognized and treated depression ; however , they often did not address suicide risk , assess alcohol use , adjust treatment appropriately , or follow through on long-term treatment plans . Better clinician adherence to recommendations was associated with a lower probability of persistent depressive symptoms among patients . Caution Data on depression-related care were based on patients ' self-report . Implication Clinicians should try harder to deliver guideline -concordant depression care . The Editors Depression practice guidelines for primary care represent expert consensus , based on systematic review of several r and omized clinical trials and other relevant literature , on how depression should be diagnosed and treated . Guidelines provide guidance for depression assessment , referral to mental health specialists , and follow-up in primary care ( 13 ) . Numerous studies document low rates of adherence to guideline recommendations on antidepressant use or psychotherapy ( 46 ) and less-than-optimal outcomes in usual care ( 7 ) . Far fewer studies have assessed adherence to the broader set of recommendations on additional aspects of care ranging from detection of depression symptoms to treatment discontinuation . National efforts to improve care ( 8) rely substantially on 1 or 2 guideline recommendations ( for example , completion of a short-term care course of antidepressant medication ) . Knowing the strengths and gaps in care for primary care patients with depression could provide a stronger basis for quality improvement . We sought to determine whether adherence to the broader set of depression guideline recommendations improves depression outcomes and , if so , to identify which guideline recommendations are most and least likely to be followed . To achieve these aims , we used expert panel methods to develop 20 guideline -based quality indicators for depression care ( 9 , 10 ) . We applied the indicators to secondary data from surveys of 1131 representative depressed patients from 45 diverse and geographically dispersed primary care practice s. We analyzed the link between performance on our measure and depression outcomes at 12 , 18 , and 24 months and assessed the level of performance on each of our indicators to identify which aspects of depression care were most and least in need of improvement . Methods We performed secondary analysis of data collected through the Quality Improvement for Depression ( QID ) collaboration ( 11 ) between 1996 and 1998 . The 4 studies in this collaboration used cluster r and omized design s to evaluate encouragement strategies for implementing Agency for Healthcare Research and Quality guidelines for depression ( 13 ) in primary care . One QID study used self-administered surveys ( 12 ) , which had some questions that were worded differently from questions in the other 3 studies . We included only the 3 QID studies that used virtually identical telephone-administered surveys . Among these 3 studies , only 1 showed statistically significant improvement in depression-specific outcomes ( 13 , 14 ) . In the QID studies , experimental-group clinician leaders were given training , material s , and protocol s to encourage them to provide collaborative care for depression-based quality improvement ( Figure ) . Additional details on the encouragement approach used by each study are published elsewhere ( 1114 ) . For our observational analyses , we combined the usual care and experimental groups . The study was approved by the institutional review board at each study site . Figure . Quasi-experimental design of studies in the Quality Improvement for Depression collaboration . Setting Patients and clinicians were recruited from 45 primary care practice s within 4 health care organizations in 13 states . Organizations included a multistate family practice network ( 11 ) , 2 staff-model managed care organizations ( Kaiser Permanente and Veterans Affairs [ 14 ] ) , and a network model managed care organization whose patients were cared for in private practice s throughout Maryl and ( 11 , 15 ) . Sample Research ers consecutively approached patients visiting participating practice s to identify those with symptoms of depression on a brief self-report depression screening instrument derived from the World Health Organization Composite International Diagnostic Interview ( CIDI ) ( 16 ) . Telephone interviewers used the full CIDI for Affective Disorders to assess consenting patients who tested positive on the CIDI screening instrument . We included 1019 patients who were positive for a major depressive disorder or dysthymia on the CIDI and 112 patients who were negative despite reporting at least 5 of 9 depression criteria ( 17 ) at recruitment ( 18 ) . In the QID studies , follow-up surveys were completed by 85 % of the enrolled patients at 12 months , 77 % at 18 months , and 78 % at 24 months . Measures We measured the process of care , case mix ( based on prognosis ) , and outcomes for depression ( Figure ) . Process-of-care measures included 139 self-report items ( 19 ) . Case-mix measures ( 20 ) included 70 items used to create 5 scales ( baseline severity of depression on the modified Center for Epidemiologic Studies Depression [ CES-D ] scale , severity of physical symptoms common among people with depression , social support , number of depression symptoms lasting 2 years , and appropriate antidepressant use during 3 months in the past 6 months ) that formed the basis for a vali date d depression prognostic index ( DPI ) ( 14 , 21 , 22 ) . Higher DPI scores indicate worse prognosis . Outcome measures included depression symptoms ( continuous ) and persistent depression ( dichotomous ) at 12 , 18 , and 24 months after baseline ( the date of study enrollment ) . We measured depression symptoms by using a modified version of the CES-D scale ( 23 , 24 ) that more closely approximates criteria from the Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition ; lower scores on the modified CES-D scale reflect fewer depression symptoms ( range , 0 to 100 ) . We measured the presence or absence of persistent depression by using a previously vali date d measure ( 25 ) that approximates current major depression . We defined persistent depression as scores that fell in the depressed range ( according to previously established cutoff values ) on each of 3 measures : the modified CES-D scale ( score 20 , equivalent to 16 on the original CES-D ) , the mental health composite score of the Short Form-12 ( 26 ) ( score 1 SD below the general population mean of 50 ) , and stem items from the CIDI screening instrument that identifies current probable depression ( 16 ) . Unlike the CIDI structured diagnosis instrument , the CIDI screening instrument requires the presence of depressed mood and anhedonia in the past month . Because patients must score in the depressed range on all 3 measures according to st and ard depression cutoffs ( the measures map closely to diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition ) and major symptoms must be current , the patients identified by the composite measure for persistent depression are substantially and currently impaired . Development of the Depression Quality Index We developed preliminary quality review criteria based on Agency for Healthcare Research and Quality guidelines ( 13 ) and refined them through an expert panel process . We translated quality review criteria into scored , survey-based quality indicators , without testing any indicators against outcome until the index was complete . We vali date d the index by evaluating the relationship between quality scores and depression outcomes , adjusting for case mix . We developed clinical algorithms for identifying st and ard , above-st and ard , or below-st and ard care relative to guideline statements . In st and ard care , a care process would be likely to ensure good to excellent outcomes for most patients , whereas below-st and ard care would lead to poor outcomes among some patients and above-st and ard care would have a high likelihood of leading to optimal outcomes . We then su bmi tted preliminary quality review criteria to an independent group of depression care experts ( 5 primary care practitioners and 2 mental health specialists ) from the MacArthur Foundation Initiative on Depression and Primary Care , using a modified Delphi process ( 27 ) . Seven experts participated in 3 rounds of review and revision of the criteria and 1 final round of review to assess consensus on the final measure . The consensus process result ed in 20 quality review criteria ( 19 ) . A strength of these criteria is that they account for the complexity of care decisions made over time on the basis of response to treatment . We translated the final quality review criteria into measurable quality indicators based on survey variables . Each indicator identifies a patient population ( for example , patients with persistent symptoms at 6 months ) to which a care process or processes identified by the quality review criterion applies ( for example , the patient should be seen by a mental health specialist ) . Scoring further divides the indicator into st and ard , above-st and ard , or below-st and ard care subsets on the basis of additional conditions specified in the quality review criterion ( for example , per our panel 's recommendations , care is below st and ard for suicide assessment only when the patient came for a scheduled visit with no new medical problems ) . Each indicator generates a raw score of 9 to 9 , with st and ard care as zero . Statistical Analysis We used weighting and multiple imputation to account for difficult-to-survey sub population s ( such as ethnic minority groups ) . Weighting accounted for the probability of enrollment and attrition at each step , beginning with data on patients approached for screening Low back pain is the fifth most common reason for all physician visits in the United States ( 1 , 2 ) . Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months ( 2 ) , and 7.6 % reported at least 1 episode of severe acute low back pain ( see Glossary ) within a 1-year period ( 3 ) . Low back pain is also very costly : Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $ 26.3 billion in 1998 ( 4 ) . In addition , indirect costs related to days lost from work are substantial , with approximately 2 % of the U.S. work force compensated for back injuries each year ( 5 ) . Many patients have self-limited episodes of acute low back pain and do not seek medical care ( 3 ) . Among those who do seek medical care , pain , disability , and return to work typically improve rapidly in the first month ( 6 ) . However , up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode , and 1 in 5 report substantial limitations in activity ( 7 ) . Approximately 5 % of the people with back pain disability account for 75 % of the costs associated with low back pain ( 8) . Many options are available for evaluation and management of low back pain . However , there has been little consensus , either within or between specialties , on appropriate clinical evaluation ( 9 ) and management ( 10 ) of low back pain . Numerous studies show unexplained , large variations in use of diagnostic tests and treatments ( 11 , 12 ) . Despite wide variations in practice , patients seem to experience broadly similar outcomes , although costs of care can differ substantially among and within specialties ( 13 , 14 ) . The purpose of this guideline is to present the available evidence for evaluation and management of acute and chronic low back pain ( see Glossary ) in primary care setting s. The target audience for this guideline is all clinicians caring for patients with low ( lumbar ) back pain of any duration , either with or without leg pain . The target patient population is adults with acute and chronic low back pain not associated with major trauma . Children or adolescents with low back pain ; pregnant women ; and patients with low back pain from sources outside the back ( nonspinal low back pain ) , fibromyalgia or other myofascial pain syndromes , and thoracic or cervical back pain are not included . These recommendations are based on a systematic evidence review summarized in 2 background papers by Chou and colleagues in this issue ( 15 , 16 ) from an evidence report by the American Pain Society ( 17 ) . The evidence report ( 17 ) discusses the evidence for the evaluation , and the 2 background papers ( 15 , 16 ) summarize the evidence for management . Methods The literature search for this guideline included studies from MEDLINE ( 1966 through November 2006 ) , the Cochrane Data base of Systematic Review s , the Cochrane Central Register of Controlled Trials , and EMBASE . The literature search included all English- language articles reporting on r and omized , controlled trials of nonpregnant adults ( age > 18 years ) with low back pain ( alone or with leg pain ) of any duration that evaluated a target medication and reported at least 1 of the following outcomes : back-specific function , generic health status , pain , work disability , or patient satisfaction .  The American College of Physicians ( ACP ) and the American Pain Society ( APS ) convened a multidisciplinary panel of experts to develop the key questions and scope used to guide the evidence report , review its results , and formulate recommendations . The background papers by Chou and colleagues ( 15 , 16 ) provide details about the methods used for the systematic evidence review . This guideline grade s its recommendations by using the ACP 's clinical practice guidelines grading system , adapted from the classification developed by the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) work group ( Appendix Table 1 ) ( 18 ) . The evidence in this guideline was first evaluated by the ACP/APS panel by using a system adopted from the U.S. Preventive Services Task Force for grading strength of evidence , estimating magnitude of benefits , and assigning summary ratings ( Appendix Tables 2 , 3 , and 4 ) ( 19 ) . The evidence was independently review ed by the ACP 's Clinical Efficacy Assessment Subcommittee . The ratings for individual low back pain interventions discussed in this guideline are summarized in Appendix Table 5 for acute low back pain ( < 4 weeks ' duration ) and in Appendix Table 6 for chronic/subacute low back pain ( > 4 weeks ' duration ) . This guideline considered interventions to have proven benefits only when they were supported by at least fair- quality evidence and were associated with at least moderate benefits ( or small benefits but no significant harms , costs , or burdens ) . Figures 1 and 2 present an accompanying algorithm . Appendix Table 1 . The American College of Physicians Clinical Practice Guidelines Grading System Appendix Table 2 . Methods for Grading the Strength of the Overall Evidence for an Intervention Appendix Table 3 . Definitions for Estimating Magnitude of Effects Appendix Table 4 . Recommendations and Summary Ratings Appendix Table 5 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Acute Low Back Pain Appendix Table 6 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Chronic or Subacute Low Back Pain Figure 1 . Initial evaluation of low back pain ( LBP Figure 2 . Management of low back pain ( LBP Recommendations : Evaluation of Low Back Pain Recommendation 1 : Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy or spinal stenosis , or back pain potentially associated with another specific spinal cause . The history should include assessment of psychosocial risk factors , which predict risk for chronic disabling back pain ( strong recommendation , moderate- quality evidence ) . More than 85 % of patients who present to primary care have low back pain that can not reliably be attributed to a specific disease or spinal abnormality ( nonspecific low back pain [ see Glossary ] ) ( 20 ) . Attempts to identify specific anatomical sources of low back pain in such patients have not been vali date d in rigorous studies , and classification schemes frequently conflict with one another ( 21 ) . Moreover , no evidence suggests that labeling most patients with low back pain by using specific anatomical diagnoses improves outcomes . In a minority of patients presenting for initial evaluation in a primary care setting , low back pain is caused by a specific disorder , such as cancer ( approximately 0.7 % of cases ) , compression fracture ( 4 % ) , or spinal infection ( 0.01 % ) ( 22 ) . Estimates for prevalence of ankylosing spondylitis in primary care patients range from 0.3 % ( 22 ) to 5 % ( 23 ) . Spinal stenosis ( see Glossary ) and symptomatic herniated disc ( see Glossary ) are present in about 3 % and 4 % of patients , respectively . The cauda equina syndrome ( see Glossary ) is most commonly associated with massive midline disc herniation but is rare , with an estimated prevalence of 0.04 % among patients with low back pain ( 24 ) . A practical approach to assessment is to do a focused history and physical examination to determine the likelihood of specific underlying conditions and measure the presence and level of neurologic involvement ( 24 , 25 ) . Such an approach facilitates classification of patients into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy ( see Glossary ) or spinal stenosis ( suggested by the presence of sciatica [ see Glossary ] or pseudoclaudication ) , and back pain potentially associated with another specific spinal cause . The latter category includes the small proportion of patients with serious or progressive neurologic deficits or underlying conditions requiring prompt evaluation ( such as tumor , infection , or the cauda equina syndrome ) , as well as patients with other conditions that may respond to specific treatments ( such as ankylosing spondylitis or vertebral compression fracture ) . Diagnostic triage into 1 of these 3 categories helps guide subsequent decision making . Clinicians should inquire about the location of pain , frequency of symptoms , and duration of pain , as well as any history of previous symptoms , treatment , and response to treatment . The possibility of low back pain due to problems outside the back , such as pancreatitis , nephrolithiasis , or aortic aneurysm , or systemic illnesses , such as endocarditis or viral syndromes , should be considered . All patients should be evaluated for the presence of rapidly progressive or severe neurologic deficits , including motor deficits at more than 1 level , fecal incontinence , and bladder dysfunction . The most frequent finding in the cauda equina syndrome is urinary retention ( 90 % sensitivity ) ( 24 ) . In patients without urinary retention , the probability of the cauda equina syndrome is approximately 1 in 10000 . Clinicians should also ask about risk factors for cancer and infection . In a large , prospect i ve study from a primary care setting , a history of cancer ( positive likelihood ratio , 14.7 ) , unexplained weight loss ( positive likelihood ratio , 2.7 ) , failure to improve after 1 month ( positive likelihood ratio , 3.0 ) , and age older than 50 years ( positive likelihood ratio , 2.7 ) were each associated with a higher likelihood for cancer ( 26 ) . The posttest probability of cancer in patients presenting with back pain increases from approximately 0.7 % to 9 % in patients with a history of cancer ( not including nonmelanoma skin cancer ) . In patients with any 1 of the other 3 risk factors , the likelihood of cancer only increases to approximately 1.2 % ( 26 ) . Features predicting the presence of vertebral infection have not been well studied OBJECTIVE To determine the characteristics of Australian adults who seek care for low back pain ( LBP ) , including the type of care they choose and any factors associated with making those choices . DESIGN A population -based mailed survey . SUBJECTS An age , gender , and state stratified r and om sample of 2768 Australian adults selected from the Electoral Roll . METHODS A self-administered , fully structured question naire included a series of questions relating to care seeking for LBP , choice of provider , and types of treatment received . In addition , a series of questions were asked relating to demographic characteristics , socioeconomic variables , severity of LBP , cigarette smoking , anthropometric variables , perceived cause of LBP , lifetime emotional distress , job satisfaction , lifetime physical fitness , past 5-year health status , and fear of LBP causing future impairment . RESULTS The response rate was 69.1 % . The sample proved to be similar to the Australian adult population . The majority of respondents with LBP in the past 6 months did not seek care for it ( 55.5 % ) . Factors that increased care seeking were higher grade s of pain and disability severity , fear of the impact of pain on future work and life , and female sex . Factors decreasing the likelihood for seeking care were identified as the cause of pain being an accident at home and also never being married . General medical practitioners and chiropractors are the most popular providers of care . CONCLUSION This study shows that a majority of people did not seek care for their LBP . The reasons for care seeking proved to be independent of social or economic status
target: Clinicians believed that guidelines were categorical , prescriptive , and constrained professional practice ; however , popular clinical practice s superseded the guidelines .
  Imaging referrals were used to manage consultations and to obtain definitive diagnoses .
  Clinicians ' perceptions reflected a lack of content knowledge and underst and ing of how guidelines are developed .
  DISCUSSION Addressing misconceptions and other barriers to uptake of evidence -based guidelines for managing LBP is needed to improve knowledge transfer and close the evidence - practice gap in the treatment of this common condition
background: INTRODUCTION Despite the availability of evidence -based guidelines for the management of low back pain ( LBP ) that contain consistent messages , large evidence - practice gaps in primary care remain .
  OBJECTIVES To perform a systematic review and meta synthesis of qualitative studies that have explored primary care clinicians ' perceptions and beliefs about guidelines for LBP , including perceived enablers and barriers to guideline adherence .