Selected Publications by Grantees, 2002

Center for Outcomes and Effectiveness Research

AHRQ grantees often publish in peer-reviewed journals. This listing contains some of the publications resulting from research grants overseen by Center for Outcomes and Effectiveness Research (COER) staff members.

Select to see a list of COER Funded Grants.

Topic Index

Breast Cancer
   Low Birthweight
Lower Respiratory Infection
Minority Health
Pelvic Inflammatory Disease


Title: Use of inhaled anti-inflammatory medication in children with asthma in managed care settings.
Publication: Archives of Pediatrics and Adolescent Medicine 2001 Apr;155(4):501-7.
Authors: Adams RJ et al.
Grant number: HS08368.
Principal Investigator: Kevin Weiss.
Project Officer: Lynn Bosco.
Abstract: BACKGROUND: Many factors affect use of inhaled therapy in asthma. Relatively little is known about current patterns of use of anti-inflammatory medication in children with asthma and whether variations occur with age and use of bronchodilator medication. OBJECTIVE: To study the factors associated with dispensing of anti-inflammatory (controller) asthma medication to children in 3 managed care organizations (MCOs). METHODS: Using automated databases, a 1-year cross-sectional study of children with asthma aged 3 to 15 years cared for in 3 MCOs was used to evaluate the association of age and other factors with controller medication use. RESULTS: A total of 13,352 children were studied. Significantly fewer children aged 3 to 5 years were dispensed any (> or =1) controller medication than older children (P<.001). Among children dispensed 6 or more beta-agonists, only 39 percent also received 5 or more controller dispensings, with adolescents significantly less likely than younger children to receive 5 or more controllers (33 percent; P<.001). Significant differences were seen among MCOs in proportions of patients dispensed controller medication. In a multiple logistic regression model, controlling for frequency of beta-agonist dispensing and MCO, significantly lower dispensing of any controller medication was seen for those aged 3 to 5 years (odds ratio [OR], 0.8; 95 percent confidence interval [CI], 0.7-0.9) and for girls (OR, 0.9; 95 percent CI, 0.8-0.96). In contrast, for repeated (> or =5) controller dispensing there were significantly fewer dispensings to adolescents (OR, 0.7; 95 percent CI, 0.6-0.9) and girls (OR, 0.8; 95 percent CI, 0.7-0.9). CONCLUSIONS: There may be differences in the use of preventive asthma medication in children that are affected by age, sex, and health care organization. Few children with frequent symptoms are using controllers regularly, as is recommended by national guidelines.

Title: Impact of inhaled antiinflammatory therapy on hospitalization and emergency department visits for children with asthma.
Publication: Pediatrics 2001 Apr;107(4):706-11.
Authors: Adams R et al.
Grant Number: HS08368.
Principal Investigator: Kevin Weiss.
Project Officer: Lynn Bosco.
Abstract: OBJECTIVE: Although the efficacy of inhaled anti-inflammatory therapy in improving symptoms and lung function in childhood asthma has been shown in clinical trials, the effectiveness of these medications in real-world practice settings in reducing acute health care use has not been well-evaluated. This study examined the effect of inhaled antiinflammatory therapy on hospitalizations and emergency department (ED) visits by children for asthma. DESIGN: Defined population cohort study over 1 year. Setting. Three managed care organizations (MCOs) in Seattle, Boston, and Chicago participating in the Pediatric Asthma Care-Patient Outcome Research and Treatment II trial. Participants. All 11,195 children, between 3 and 15 years old, with a diagnosis of asthma who were enrolled in the 3 MCOs between July 1996 and June 1997. OUTCOME MEASURES: We identified children with 1 or more asthma diagnoses using automated encounter data. Medication dispensings were identified from automated pharmacy data. Multivariate logistic regression analysis was used to calculate effects of inhaled antiinflammatory therapy on the adjusted relative risk (RR) for hospitalization and ED visits for asthma. RESULTS: Over 12 months, 217 (1.9 percent) of children had an asthma hospitalization, and 757 (6.8 percent) had an ED visit. After adjustment for age, gender, MCO, and reliever dispensing, compared with children who did not receive controllers, the adjusted RRs for an ED visit were: children with any (>/=1) dispensing of cromolyn, 0.4 (95 percent confidence interval [CI]: 0.3, 0.5); any inhaled corticosteroid (ICS), 0.5 (95 percent CI: 0.4, 0.6); any cromolyn or ICS combined (any controller), 0.4 (95 percent CI: 0.3, 0.5). For hospitalization, the adjusted RR for cromolyn was 0.6 (95 percent CI: 0.4, 0.9), for ICS 0.4 (95 percent CI: 0.3, 0.7), and for any controller 0.4 (95 percent CI: 0.3, 0.6). A significant protective effect for both events was seen among children with 1 to 5 and with >5 antiinflammatory dispensings. When the analysis was stratified by frequency of reliever dispensing, there was a significant protective effect for controllers on ED visits for children with 1 to 5 and with >5 reliever dispensings and on the risk of hospitalization for children with >5 reliever dispensings. CONCLUSIONS: Inhaled antiinflammatory therapy is associated with a significant protective effect on the risk for hospitalization and ED visits in children with asthma. Cromolyn and ICSs were associated with similar effects on risks, asthma drug therapy, inhaled antiinflammatory agents, health maintenance organizations, hospitalization, emergency department.

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Title: The practicality and validity of directly elicited and SF-36 derived health state preferences in patients with low back pain.
Publication: Health Economics 2002 Jan;11(1):71-85.
Authors: Hollingworth W et al.
Grant Number: HS09499.
Principal Investigator: Jeffrey Jarvik.
Project Officer: Mary Cummings.
Abstract: Recent research has derived preference scores from the SF-36. We compare the practicality and construct validity of SF-36 derived preference scores with directly elicited time trade off (TTO) and visual analogue scale (VAS) scores. In this observational study, low back pain (LBP), patients were asked to complete disease specific, generic (SF-36), and health state preference (VAS and TTO) instruments. Baseline SF-36 responses were converted to preference scores using six published algorithms. Response rates for the SF-36 derived and TTO preference values were 354 of 379 (93 percent) and 303 of 379 (80 percent) respectively. Thirty patients were excluded from the TTO exercise because of difficulties comprehending the scaling task. Choice based methods (standard gamble, TTO) yielded higher and more uniform estimates of preference (0.77 to 0.79) than non-choice based methods (VAS) (0.42 to 0.70). Directly elicited TTO values were variable and had less power to distinguish among patients with differing severity of LBP. All SF-36 derived preferences exhibited a minimum threshold implying a potential floor effect for severely ill patients. SF-36 derived preferences demonstrated good practicality and construct validity in this setting, however different methods will yield disparate estimates of marginal benefit. This emphasizes the need for a standardized algorithm for deriving SF-36 preference scores.

Title: Occult and secondary injuries missed by plain radiography of the cervical spine in blunt trauma patients.
Publication: Emergency Radiology 2001;8:200-6.
Authors: Mower WR et al.
Grant Number: HS08239.
Principal Investigator: William Mower.
Project Officer: Lynn Bosco.
Abstract: Background: Plain radiography does not visualize every cervical spine injury sustained by blunt trauma victims. The purpose of this study was to examine the prevalence and types of injuries missed by plain radiographs of the cervical spine and determine how frequently such radiography fails to detect any cervical spine injury. Methods: Images from all radiographic studies performed on blunt trauma victims presenting to 21 participating institutions were reviewed to compile an exhaustive list of all CSIs sustained by each individual. These injuries were then compared with the injuries detected by plain radiography alone. Patients were classified as having a "sentinel" injury if one or more of their injuries were visible on plain radiographs. Patients were classified as having a radiographically "occult" injury if none of their injuries were visible on plain radiographs. The number and types of injuries missed on plain radiographs were then separately tabulated for the sentinel and occult injury groups. Results: Plain radiographs were completed in 570 of 818 victims of acute cervical spine injury and revealed 702 of 1,056 injuries. Plain films failed to detect 98 occult injuries present in 60 patients (10.5 percent), and failed to detect 256 secondary injuries in 510 patients (89.5 percent) who had a sentinel injury identified. Plain radiographs failed to reveal 79 of 136 (58.1 percent) lateral mass injuries and 67 of 105 (63.8 percent) lamina injuries, making these the most frequent sites of missed injury. Conclusions: Plain radiographs frequently fail to reveal injuries to the cervical spine, particularly those involving the lamina and lateral mass. The majority of the missed injuries represent secondary injuries in patients with a sentinel injury identified on these films. However, plain films fail to detect any injury in a minority of injured patients.

Title: Racial differences in the use of lumbar spine radiographs.
Publication: Spine 2001;26(12):1364-69.
Authors: Selim AJ et al.
Grant Number: HS08194.
Principal Investigator: Richard Deyo.
Project Officer: Mary Cummings.
Abstract: STUDY DESIGN: We analyzed data from the Veterans Health Study, a longitudinal study of male patients receiving VA ambulatory care. OBJECTIVE: To determine whether clinical differences and/or race account for disparities between white and nonwhite patients in the use of lumbar spine radiographs. SUMMARY AND BACKGROUND DATA: Four hundred one patients with low back pain (LBP) receiving ambulatory care services in four VA outpatient clinics in the greater Boston area were followed for 12 months. METHODS: Participants were mailed the Medical Outcome Study Short Form Health Survey (SF-36) and had scheduled interviews that included the completion of a low back questionnaire, a comorbidity index, and a straight leg raising (SLR) test. Using self-reported racial data, patients were grouped as whites (315 patients) and nonwhites (among whom 22 were black, 4 nonwhite Hispanics, and 1 other race). RESULTS: Nonwhite patients had lumbar spine films more often (13 of 27, 48 percent) than white patients (87 of 315, 27 percent)(P = 0.02). Nonwhite patients had higher pain intensity scores than white patients (63 +/- 21 vs.. 48 +/- 21, P < 0.01) and were more likely to have radiating leg pain (20 of 27, 76 percent; compared with 171 of 315, 55 percent; P = 0.01) than white patients. Nonwhite patients had worse physical functioning (P = 0.01), general health perception (P = 0.05), social functioning (P = 0.02), and role limitations because of emotional problems (P < 0.01). At higher LBP intensity level, nonwhite patients received more lumbar spine films (20 of 27, 74 percent) than did white patients (155 of 315, 50 percent)(P < 0.01). Among patients with positive SLR test, nonwhite patients also had lumbar spine films more often (5 of 22, 23 percent) than white patients (29 of 315, 11 percent) (P < 0.01). However, after adjusting for multiple clinical characteristics, race was no longer found to be an independent predictor of lumbar spine radiograph use. A positive SLR test remained to be associated with higher radiograph use, whereas better mental health status was associated with lower radiograph use. CONCLUSIONS: There was greater use of lumbar spine radiographs by nonwhite patients compared with white patients. This remained true when patients were subcategorized by severity of LBP or SLR test. However, race had no influence when multiple clinical characteristics of the patients were controlled for simultaneously. This study demonstrates the importance of careful and comprehensive case-mix adjustment when assessing apparent differences in the use of medical services.

Title: Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain.
Publication: Archives of Internal Medicine 2001 Apr 23;161(8):1081-8.
Authors: Cherkin DC et al.
Grant Number: HS09351.
Principal Investigator: Daniel Cherki.
Project Officer: Mary Cummings.
Abstract:BACKGROUND: Because the value of popular forms of alternative care for chronic back pain remains uncertain, we compared the effectiveness of acupuncture, therapeutic massage, and self-care education for persistent back pain. METHODS: We randomized 262 patients aged 20 to 70 years who had persistent back pain to receive Traditional Chinese Medical acupuncture (n= 94), therapeutic massage (n = 78), or self-care educational materials (n = 90). Up to 10 massage or acupuncture visits were permitted over 10 weeks. Symptoms (0-10 scale) and dysfunction (0-23 scale) were assessed by telephone interviewers masked to treatment group. Followup was available for 95 percent of patients after 4, 10, and 52 weeks, and none withdrew for adverse effects. RESULTS: Treatment groups were compared after adjustment for prerandomization covariates using an intent-to-treat analysis. At 10 weeks, massage was superior to self-care on the symptom scale (3.41 vs. 4.71, respectively; P =.01) and the disability scale (5.88 vs.. 8.92, respectively; P<.001). Massage was also superior to acupuncture on the disability scale (5.89 vs.. 8.25, respectively; P =.01). After 1 year, massage was not better than self-care but was better than acupuncture (symptom scale: 3.08 vs.. 4.74, respectively; P =.002; dysfunction scale: 6.29 vs. 8.21, respectively; P =.05). The massage group used the least medications (P<.05) and had the lowest costs of subsequent care. CONCLUSIONS: Therapeutic massage was effective for persistent low back pain, apparently providing long-lasting benefits. Traditional Chinese Medical acupuncture was relatively ineffective. Massage might be an effective alternative to conventional medical care for persistent back pain.

Title: The longitudinal assessment of imaging and disability of the back (LAIDBack) Study.
Publication: Spine 2001 May 15; 26(10):1158-66.
Authors: Jarvik JJ et al.
Grant Number: HS08194/HS09499.
Principal Investigator: Richard Deyo/Jeffrey Jarvik.
Project Officer: Mary Cummings.
Abstract: STUDY DESIGN: Prospective cohort study of randomly selected Veterans Affairs (VA) outpatients. OBJECTIVE: To determine the prevalence of magnetic resonance imaging (MRI) findings in the lumbar spine among persons without current low back pain or sciatica and to examine which findings are related to age or previous back symptoms. SUMMARY OF BACKGROUND INFORMATION: Previous studies of patients without low back pain have not explored the possible association of various MRI findings to past symptoms. METHODS: We randomly selected an age-stratified sample of subjects without low back pain in the past 4 months from clinics at a VA hospital. We collected information on demographics, comorbidity, functional status, and quality of life. MR images were obtained using a standardized protocol through each of the five lumbar disc levels. RESULTS: Of 148 subjects, 69 (46 percent) had never experienced low back pain. There were 123 subjects (83 percent) with moderate to severe desiccation of one or more discs, 95 (64 percent) with one or more bulging discs, and 83 (56 percent) with loss of disc height. Forty-eight subjects (32 percent) had at least one disc protrusion and 9 (6 percent) had one or more disc extrusions. CONCLUSION: Many MR imaging findings have a high prevalence in subjects without low back pain. These findings are therefore of limited diagnostic use. The less common findings of moderate or severe central stenosis, root compression, and extrusions are likely to be diagnostically and clinically relevant.

Title: Evaluating and Managing Acute Low Back pain in the Primary Care Setting.
Publication: Journal of General Internal Medicine 2001 Feb;16(2): 120-31.
Authors: Atlas SJ et al.
Grant Number: HS06344/HS08194/HS09804.
Principal Investigator: Richard Deyo/Robert Keller.
Project Officer: Mary Cummings.
Abstract: Acute low back pain is a common reason for patient calls or visits to a primary care clinician. Despite a large differential diagnosis, the precise etiology is rarely identified, although musculoligamentous processes are usually suspected. For most patients, back symptoms are nonspecific, meaning that there is no evidence for radicular symptoms or underlying systemic disease. Because episodes of acute, nonspecific low back pain are usually self-limited, many patients treat themselves without contacting their primary care clinician. When patients do call or schedule a visit, evaluation and management by primary care clinicians is appropriate. The history and physical examination usually provide clues to the rare but potentially serious causes of low back pain, as well as to identify patients at risk for prolonged recovery. Diagnostic testing, including plain x-rays, is often unnecessary during the initial evaluation. For patients with acute, nonspecific low back pain, the primary emphasis of treatment should be conservative care, time, reassurance, and education. Current recommendations focus on activity as tolerated (though not active exercise while pain is severe) and minimal if any bed rest. Referral for physical treatments is most appropriate for patients whose symptoms are not improving over 2 to 4 weeks. Specialty referral should be considered for patients with a progressive neurologic deficit, failure of conservative therapy, or an uncertain or serious diagnosis. The prognosis for most patients is good, although recurrence is common. Thus, educating patients about the natural history of acute low back pain and how to prevent future episodes can help ensure reasonable expectations.

Title: Finding Cancer in Primary Care Outpatient with Low Back Pain.
Publication: Journal of General Internal Medicine 2001;16:14-23.
Authors: Joines JD et al.
Grant Number: HS06344.
Principal Investigator: Richard Deyo.
Project Officer: Mary Cummings.
Abstract: OBJECTIVE: To compare strategies for diagnosing cancer in primary care patients with low back pain. Strategies differed in their use of clinical findings, erythrocyte sedimentation rate [ESR]), and plain x-rays prior to imaging and biopsy. DESIGN: Decision analysis and cost effectiveness analysis with sensitivity analyses. Strategies were compared in terms of sensitivity, specificity, and diagnostic cost effectiveness ratios. SETTING: Hypothetical. MEASUREMENTS: Estimates of disease prevalence and test characteristics were taken from the literature. Costs were represented by the Medicare reimbursement for the tests and procedures employed. MAIN RESULTS: In the baseline analysis, using magnetic resonance imaging (MRI) as the imaging procedure prior to a single biopsy, strategies ranged in sensitivity from 0.40 to 0.73, with corresponding diagnostic costs of $14 to $241 per patient and average cost effectiveness ratios of $5,283 to $49,814 per case of cancer found. Incremental cost effectiveness ratios varied from $8,397 to $624,781; five strategies were dominant in the baseline analysis. Use of a higher ESR cutoff point (50 mm/hour) improved specificity and cost effectiveness for certain strategies. Imaging with MRI, or bone scan followed in series by MRI, resulted in a fewer unnecessary biopsies than imaging with bone scan alone. Cancer prevalence was an important determinant of cost effectiveness. CONCLUSIONS: We recommend a strategy of imaging patients who have a clinical finding (history of cancer, age > or = 50 years, weight loss, or failure to improve with conservative therapy) in combination with either an elevated ESR (> 50 mm/hour) or a positive x-ray, or using the same approach but imaging directly those patients with a history of cancer.

Title: Helping patients decide about back surgery: a randomized trial of an interactive video program.
Publication: Spine 2001 Jan 15;26(2):206-11;discussion 212.
Authors: Phelan EA et al.
Grant Number: HS08079.
Principal Investigator: Richard Deyo.
Project Officer: Mary Cummings.
Abstract:STUDY DESIGN: A randomized trial of 100 patients with low back pain who were potential surgical candidates. OBJECTIVES: To determine whether an interactive videodisc with a booklet is superior to a booklet alone for informing patients about back surgery. SUMMARY OF BACKGROUND DATA: Substantial geographic variation has been observed in lumbar spine surgery. Informed patient preferences should play an important role in decisions about surgery. However, little is known about optimal strategies for informing patients. METHODS: Subjects were randomized to receive an interactive videodisc (with a booklet) or a booklet alone. A knowledge test administered at baseline and followup was used to measure improvement in knowledge about treatment options for lumbar spine problems. Patients' reactions to the videodisc and booklet and preferences for treatment were also assessed. RESULTS: The patients' knowledge improved after exposure to either intervention. Multivariate analyses adjusted for baseline score, age, education, gender, and diagnosis showed a significant advantage for the videodisc with booklet over the booklet alone. The videodisc-booklet group showed significantly greater gains in knowledge among subjects with the worst baseline knowledge scores. A larger proportion of subjects in the videodisc-booklet group rated the materials easy to understand (93 percent vs..- 72 percent,P = 0.04), containing the right amount of information (93 percent vs..- 80 percent,P = 0.3), and adequate to assist in choice of treatment (75 percent vs..- 51 percent,P = 0.2). Those who viewed the videodisc expressed a somewhat lower preference for surgery than those who received the booklet alone (23 percent vs..- 42 percent,P = 0.4). CONCLUSIONS: Both the booklet alone and the combination of videodisc and booklet improved knowledge. The combination produced greater knowledge gains than the booklet alone for the subgroup with the least knowledge at baseline. Patients preferred the combination and had a slightly lower preference for surgery if they had viewed the video presentation. For some patients, the video may enhance involvement in clinical decisions.

Title: Epidemiology of thoracolumbar spine injury in blunt trauma.
Publication: Academic Emergency Medicine 2001 Sep;8(9):866-72.
Authors: Holmes JF, Miller PQ, Panacek EA, Lin S, Horne NS, Mower WR.
Grant Number: HS08239.
Principal Investigator: William Mower.
Project Officer: Lynn Bosco.
Abstract: OBJECTIVE: To evaluate the prevalence, distribution, and demographics of thoracolumbar (TL) spine injuries following blunt trauma. METHODS: Prospective, cross-sectional study of a consecutive sample of all blunt trauma patients presenting initially to the emergency department (ED) of a Level 1 trauma center and undergoing thoracic and/or lumbar spine radiography from August 1997 to November 1998. The age, sex, and mechanism of injury of each patient as well as location and type of spine injury were recorded for those patients with vertebral fractures, dislocations, or subluxations. RESULTS: Two thousand and four hundred and four blunt trauma patients were enrolled. Vertebral injuries were identified in 152 individuals (6.3 percent, 95 percent CI = 5.4 percent to 7.4 percent). Two hundred and sixty distinct anatomic levels of injury were identified in these 152 individuals. Of these 260 injuries, 42 (16.2 percent) occurred at L1, 38 (14.6 percent) at L2, 29 (11.1 percent) at L3, and 27 (10.4 percent) at T12, making these the most commonly injured vertebrae. Injuries were most common (34 patients) in those aged 30-39 years and were least common (12 patients) in those under 18 years. Compression fractures (52 percent) were the most common injury in the thoracic spine, while transverse process fractures (48 percent) were the most common injuries in the lumbar spine. CONCLUSIONS: The prevalence of TL injuries in ED blunt trauma patients undergoing TL radiographs is 6.3 percent. The most commonly injured area of the TL spine is the thoracolumbar junction.

Title: Distracting painful injuries associated with cervical spinal injuries in blunt trauma.
Publication: Academic Emergency Medicine 2001 Jan;8(1):25-9.
Authors: Ullrich A, Hendey GW, Geiderman J, Shaw SG, Hoffman J, Mower WR.
Grant Number: HS08239.
Principal Investigator: William Mower.
Project Officer: Lynn Bosco.
Abstract: Distracting painful injuries (DPIs) may mask symptoms of spinal injury in blunt trauma victims and form an important element in a decision instrument used to identify individuals who require cervical spine radiography. OBJECTIVE: To identify the types and frequencies of injuries that actually act as DPIs among blunt trauma patients undergoing cervical spinal radiography. METHODS: This was a prospective observational study of consecutive blunt trauma victims presenting to an urban Level 1 regional trauma center between April 1, 1998, and September 30, 1998. Prior to cervical spinal radiography, treating physicians evaluated each patient to determine whether a DPI was present or absent and, if present, what type of injury was sustained. Injuries were categorized as fractures, soft-tissue injuries and lacerations, burns, visceral injuries, crush injuries, or other injuries. RESULTS: Data were collected for 778 patients, between 1 month and 98 years old, of whom 264 (34 percent) were considered to have DPIs. Physicians were unable to determine the DPI status in 47 (6 percent) additional cases. Fractures accounted for a majority of DPIs (154, or 58 percent), 42 (16 percent) were soft-tissue injuries or lacerations, and 86 (34 percent) were due to a variety of other entities, including visceral, crush, burn, or other miscellaneous injuries. Among the 37 (5 percent) patients with an acute cervical spinal injury, 20 (54 percent) had a DPI, including three (8 percent) who had DPI as the only indication for cervical radiography. CONCLUSIONS: A significant number of blunt trauma patients are believed by clinicians to have DPIs that can possibly mask the presence of cervical spinal injury. Fractures and trauma to soft tissues are the most common types of DPI.

Title: A prospective multicenter study of cervical spine injury in children.
Publication: Pediatrics 2001 Aug;108(2):E20.
Authors: Viccellio P et al.
Grant Number: HS08239.
Principal Investigator: William Mower.
Project Officer: Lynn Bosco.
Abstract: The lower cervical spine is the most common site of cervical spine injury in children, and fractures are the most common type of injury. CSI is rare among patients aged 8 years of less. The Nexus decision instrument performed well in children, and its use could reduce pediatric cervical spine imaging by nearly 20 percent.

Title: The research framework.
Publication: AJR Am J Roentgenol 2001 Apr;176(4):873-8.
Authors: Jarvik JG.
Grant Number: HS09499.
Principal Investigator: Jeffrey Jarvik.
Project Officer: Mary Cummings.

Title: Can evidence change the rate of back surgery? A randomized trial of community-based education.
Publication: Effective Clinical Practice 2001 May-Jun;4(3):95-104.
Authors: Goldberg HI et al.
Grant Number: HS08194/HS06344.
Principal Investigator: Richard Deyo.
Project Officer: Mary Cummings.
Abstract: CONTEXT: Timely adoption of clinical practice guidelines is more likely to happen when the guidelines are used in combination with adjuvant educational strategies that address social as well as rational influences. OBJECTIVE: To implement the conservative, evidence-based approach to low-back pain recommended in national guidelines, with the anticipated effect of reducing population-based rates of surgery. DESIGN: A randomized, controlled trial. SETTING: Ten communities in western Washington State with annual rates of back surgery above the 1990 national average (158 operations per 100,000 adults). PARTICIPANTS: Spine surgeons, primary care physicians, patients who were surgical candidates, and hospital administrators. INTERVENTION: The five communities randomized to the intervention group received a package of six educational activities tailored to local needs by community planning groups. Surgeon study groups, primary care continuing medical education conferences, administrative consensus processes, videodisc-aided patient decision making, surgical outcomes management, and generalist academic detailing were serially implemented over a 30-month intervention period. OUTCOME MEASURE: Quarterly observations of surgical rates. RESULTS: After implementation of the intervention, surgery rates declined in the intervention communities but increased slightly in the control communities. The net effect of the intervention is estimated to be a decline of 20.9 operations per 100,000, a relative reduction of 8.9 percent (P = 0.01). CONCLUSION: We were able to use scientific evidence to engender voluntary change in back pain practice patterns across entire communities.

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