Are fear-avoidance beliefs in low back pain patients a risk factor for low physical activity or vice versa? A cross-lagged panel analysis

Objective: The assumption that low back pain (LBP) patients suffer from “disuse” as a consequence of high fear-avoidance beliefs is currently under debate. A secondary analysis served to investigate whether fear-avoidance beliefs are associated cross-sectionally and longitudinally with the physical activity level (PAL) in LBP patients

A randomized trial of telephone counseling to promote screening mammography in two HMOs

Tailored telephone counseling (TTC) is effective in increasing utilization of screening mammography, but has received limited testing on a large scale in a contemporary HMO setting in which most eligible women get regular screening. We conducted a randomized controlled trial comparing TTC to an active control (mailed reminders) among women aged 50-80 enrolled in two HMOs in New England (n=12,905). Over a 1-year period counselors attempted to contact women in the intervention arm who had not had a mammogram within the last 15 months. The absolute increase in mammography use due to the intervention was 4.9% (OR 1.3, 95% CI 1.0-1.6) in one HMO and 3.1% (OR 1.2, 95% CI 1.0-1.3) in the other. We estimated that one additional woman was screened for each 10.9 women eligible for counseling. An intervention process analysis documented a high level of acceptance of TTC and identified subgroups that could be targeted for counseling to improve the efficiency of TTC

Coronary heart disease multiple risk factor reduction. Providers\u27 perspectives

BACKGROUND: Although primary care physicians understand the importance of preventive services for patients with multiple risk factors (MRF) for coronary heart disease, physician intervention is limited. This study investigated (1) physicians\u27 views of challenges faced in managing patients with MRF; (2) the counseling and management methods they utilize; and (3) possible strategies to enhance MRF intervention in the primary care setting. METHODS: Two focus groups were conducted with primary care physicians from varying settings to gain insight into these issues noted above. Each group was co-facilitated by a physician and a behavioral scientist using a previously developed semistructured interview guide. The group discussions were tape recorded and subsequently transcribed. Transcripts were analyzed using the constant comparative method for analysis. RESULTS: Physicians are challenged by knowledge limitations (contribution of individual risk factors to overall risk); limited support (guidelines, materials, and staff); and logistic difficulties (organizational issues, time limitations). Their approach to MRF management tends to be highly individualized with an initial preference for lifestyle change interventions rather than prescription of medications with some qualifying circumstances. Physicians favored a serial rather than a parallel approach to MRF intervention, starting with behaviors that the patient perceives as a priority. Proposed solutions to current challenges emphasize physician education and the development of innovative approaches that include physician assistance and a team approach. CONCLUSIONS: Physicians are aware of and sensitive to the complexity of MRF management for their patients and themselves. However, future MRF interventions will require nonphysician staff involvement and increased systems support

Evaluating the accuracy of a simple heuristic to identify serious causes of low back pain

Background. Among patients presenting with low back pain (LBP), GPs have to identify those with serious, treatable conditions. However, excluding these conditions in every patient with LPB is time consuming and of low yield. We have suggested that identifying those patients where these serious conditions need to be considered can be made more efficient through asking patient if they feel their LBP is new or unfamiliar in some way. Objective. To evaluate the diagnostic validity of a simple heuristic based on the patient's view of the familiarity of LBP. Methods. Cross-sectional diagnostic study with delayed-type reference standard, nested within a three-arm randomized trial of quality improvement for LBP. A total of 1378 patients presenting, with LBP, to one of 126 participating GPs were included. They were asked whether their LBP was familiar or not (index test). At 1 year, patients were interviewed with regard to relevant conditions that in hindsight might explain their LBP. Reviewers deciding on disease status (reference standard) were blinded to the results of the index test. Results. Totally 1190 patients answered the index test question and were available for interview at 1 year. Only four of these had a serious cause of their LBP. Two of these were identified by the familiarity heuristic, resulting in low sensitivity. Conclusion. The number of diseased patients was too small to obtain a reliable estimate of sensitivity. Low prevalence of serious disease in primary care poses difficulties for diagnostic research. In hindsight we would question whether an RCT-setting emphasizing non-specific LBP is suitable for this kind of research. At present, the familiarity heuristic cannot be recommended for patients presenting with LBP

Primary Care Provider Concerns about Management of Chronic Pain in Community Clinic Populations

BACKGROUND: Chronic pain is a common patient complaint in primary care, yet providers and patients are often dissatisfied with treatment processes and outcomes. OBJECTIVE: To assess provider satisfaction with their training for and current management of chronic pain in community clinic settings. To identify perceived problems with delivering chronic pain treatment and issues with opioid prescribing for chronic pain. DESIGN: Mailed survey to primary care providers (PCPs) at 8 community clinics. RESULTS: Respondents (N=111) included attendings, residents, and nurse practioners (NPs)/physician assistants (PAs). They reported 37.5% of adult appointments in a typical week involved patients with chronic pain complaints. They attributed problems with pain care and opioid prescribing more often to patient-related factors such as lack of self-management, and potential for abuse of medication than to provider or practice system factors. Nevertheless, respondents reported inadequate training for, and low satisfaction with, delivering chronic pain treatment. CONCLUSIONS: A substantial proportion of adult primary care appointments involve patients with chronic pain complains. Dissatisfaction with training and substantial concerns about patient self-management and about opioid prescribing suggest areas for improving medical education and postgraduate training. Emphasis on patient-centered approaches to chronic pain management, including skills for assessing risk of opioid abuse and addiction, is required