Back Pain Patient Outcomes Assessment Team (BOAT)

Principal Investigator: Richard A. Deyo, M.D., M.P.H., University of Washington School of Medicine, Seattle.
Grant Number: HS 06344.
Project Period: September 1989 to September 1994.

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The back pain PORT, supported by AHCPR, analyzes back surgery practice variations and examines the relative effectiveness of alternate ways of diagnosing and treating low back pain.

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Back Pain PORT Contents (Summer 1994)

• Introduction
• Findings
• Dissemination
• Implications
• Bibliography

Introduction

The problem of back pain is widespread (affecting up to 8 of every 10 adults some time in life), causes suffering and stress, and is the second leading reason why Americans see physicians. Back pain also affects the Nation's economy. According to some estimates, back pain costs as much as $50 billion a year for medical care, workers compensation payments, and time lost from work. However, the true economic impact of back pain is more extensive, because these estimates include neither unrealized earnings due to physical limitations caused by back pain nor employer productivity losses.

To determine what treatment strategies work best and for whom, the back pain PORT is examining the relative value of diagnostic tests such as myelography, computed tomography, magnetic resonance imaging, and thermography. The PORT is also examining surgical procedures (such as fusion, laminectomy, and discectomy) and nonsurgical interventions (such as traction and therapeutic injections).

The multidisciplinary team studying back pain includes orthopedic surgeons, primary care physicians, physical therapists, epidemiologists, and economists. Other professions, including chiropractors, are represented on the team's advisory committee. The research is being carried out at sites in the State of Washington and one site in Maine.

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Findings

The final results of the back pain PORT will be known after the researchers complete their work in the third quarter of 1994. However, they have already published a large number of articles describing findings from their comprehensive review of the back pain literature and on variations in the rates that different procedures are used to diagnose and treat back pain.

Among their findings are the following:

• There is no evidence that spinal fusion—one of the most common operations for low back problems—is superior to other surgical procedures for common degenerative conditions of the spine.
• Patients who undergo spinal fusions have more complications, longer hospital stays, and higher hospital charges than do patients undergoing other types of back surgery.
• Morbidity and mortality rates as well as hospital charges increase with age among persons having lumbar spine surgery.
• Evidence is growing against conventional spinal traction for the treatment of sciatica or herniated disks, against the use of transcutaneous electrical nerve stimulation for chronic low back pain, and against the use of special corsets.
• Spinal thermography, a test advocated by some physicians and chiropractors for diagnosing disk abnormalities, is inaccurate and poorly validated. The PORT researchers recommend that its use be limited to research settings.
• Evidence is growing against bed rest as therapy, even for a period of 1 to 2 weeks.
• A county-by-county analysis of rates for all types of back surgery procedures performed on Washington State residents in 1985 revealed a fifteenfold difference between the highest and lowest rates.

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Dissemination

Dissemination of research findings is key to helping health care practitioners and consumers make informed decisions regarding therapy. The back pain PORT has contributed to this goal through broad dissemination of its findings to the medical community and the public.

To date, Dr. Deyo and his colleagues have had 70 journal articles, editorials, and book chapters published. Their articles have appeared in such journals as the Journal of the America Medical Association, Annals of Internal Medicine, Journal of Family Practice, Journal of Bone and Joint Surgery, Spine, and Chiropractic Technique. The Back Letter, a newsletter for back care specialists, also has published information from the PORT. Members of the back pain research team have appeared on 2 nationally televised medical programs for physicians and have presented their findings at 235 meetings of professional groups in the United States and abroad.

Dissemination Summary: Back Pain PORT

Presentations:	235
Professional Articles:	70
Health Industry Articles:	43
Mentions:	22
Consumer Print:	25
Consumer Broadcast:	6
Total:	401

The general public is learning about the back pain PORT's findings through an increasing number of newspaper and magazine articles. They include reports in U.S. News and World Report, Better Homes and Gardens, American Health, Allure, Fortune, and the Chicago Tribune, New York Times, and Wall Street Journal. Seattle radio has also interviewed the researchers.

The PORT's findings have been incorporated in an interactive video disk for patients that is now being commercially marketed to physicians.

The back pain PORT has published a brochure for consumers called Back in Action that teaches consumers about low back pain and what they can do about it.

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Implications

It is too early to know if these preliminary findings are affecting physician behavior. However, anecdotal evidence in the State of Washington suggests that the findings of the AHCPR-supported PORT may be contributing to a decline in spinal fusion and perhaps other back surgery procedure rates. Similar to back surgeons in other States, those practicing in Washington have learned about the PORT's findings from articles in professional journals and from the presentations made by the team's researchers at national, State, and local professional meetings. Unlike those in other States, back surgeons in Washington also benefit from a unique community physician feedback program that is part of the back pain PORT's dissemination program.

The PORT's principal investigator, Dr. Richard A. Deyo, cautions that there is no scientific evidence at this point to prove that the research project's activities are changing physician behavior. A rigorous evaluation of the physician feedback program is under way.

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Bibliography

Batti, M. C., Cherkin, D. C., Dunn, R., and Wheeler, K. J. (in press). Managing low back pain: Attitudes and treatment preferences of physical therapists. Physical Therapy.

Batti, M. C., Videman, T., Gill, K., Moneta, G. B., Nyman, R., Kaprio, J., and Koskenvuo, M. (1991). Smoking and lumbar intervertebral disc degeneration: An MRI study of identical twins. Spine 16(9), 1015-1021.

Bigos, S. J., Batti, M. C., Fisher, L. D., Hansson, T. H., Spengler, D. M., and Nachemson, A. L. (1992). A prospective evaluation of preemployment screening methods for acute industrial back pain. Spine 17(8), 922-926.

Bush, T., Cherkin, D. C., and Barlow, W. (in press). The impact of physician attitudes on patient satisfaction with care for low back pain. Archives of Family Medicine.

Cain, K. C., and Diehr, P. (1992). Testing the null hypothesis in small area analysis. Health Services Research 27(3), 267-294.

Cherkin, D. C. (1990). Patient satisfaction as an outcome measure. Chiropractic Technique 2(3), 138-142.

Cherkin, D. C. (1992). Family physicians and chiropractors: What's best for the patient (Editorial). Journal of Family Practice 35(5), 505-506.

Cherkin, D. C., and Deyo, R. A. (1993). Non-surgical hospitalization for low back pain: Is it necessary? Spine 18(13), 1728-1735.

Cherkin, D. C., Deyo, R. A., and Berg, A. O. (1991). Evaluation of a physician education intervention to improve primary care for low-back pain II: Impact on patients. Spine 16(10), 1173-1178.

Cherkin, D. C., Deyo, R. A., Berg, A. O., Bergman, J. J., and Lishner, D. M. (1991). Evaluation of a physician education intervention to improve primary care for low-back pain I: Impact on physicians. Spine 16(10), 1168-1172.

Cherkin, D. C., Deyo, R. A., Loeser, J. D., Bush, T., and Waddell, G. (in press). An international comparison of back surgery rates. Spine.

Cherkin, D. C., Deyo, R. A., Volinn, E., and Loeser, J. D. (1992). Use of the international classification of diseases (ICD-9-CM) to identify hospitalizations for mechanical low back problems in administrative databases. Spine 17(7), 817-825.

Cherkin, D. C., Deyo, R. A., Wheeler, K., and Ciol, M. A. (in press). Physician variation in diagnostic testing for low back pain: Who you see is what you get. Arthritis and Rheumatism.

Ciol, M. A., Deyo, R. A., Kreuter, W., and Bigos, S. J. (in press). Patient's characteristics associated with reoperation following lumbar spine surgery in Medicare beneficiaries. Spine.

Deyo, R. A. (Guest Commentator) (1990). Determining the cause of low back pain. Hospital Physician 26(10), 34-39.

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Deyo, R. A. (1991). The quality of life, research, and care (Editorial). Annals of Internal Medicine 114(8), 695-697.

Deyo, R. A. (1991). Fads in the treatment of low back pain. New England Journal of Medicine 325, 1039-1040.

Deyo, R. A. (1991). Non-surgical care of low back pain. Neurosurgery Clinics of North America 2(4), 851-862.

Deyo, R. A. (1993). Adapting a clinical comorbidity index for use with ICD-9-CM administrative data: A response. Journal of Clinical Epidemiology 46(10), 1081-1082.

Deyo, R. A. (1993). Clinical strategies for controlling costs and improving quality in the primary care of low back pain. Journal of Back and Musculoskeletal Rehabilitation 3(4), 1-13.

Deyo, R. A. (1993). Newer thinking on diagnosis and therapy. Consultant 33(2), 88-100.

Deyo, R. A. (1993). Results of discectomy compared with discectomy and fusion. Acta Orthopaedic Scandinavica 64(Suppl), 45-46.

Deyo, R. A. (in press). Exercise in the prevention and treatment of low back pain. In L. Goldberg and D. Elliot, (Eds.) Exercise for the Prevention and Treatment of Medical Illness. Philadelphia: F. A. Davis Comp.

Deyo, R. A., Bigos, S. J., and Maravilla, K. R. (1989). Diagnostic imaging procedures for the lumbar spine. Annals of Internal Medicine 111(11), 865-867.

Deyo, R. A., and Carter, W. B. (1992). Strategies for improving and expanding the application of health status measures in clinical settings. Medical Care 30(5S), MS176-MS186.

Deyo, R. A., Cherkin, D. C., and Ciol, M. A. (1992). Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. Journal of Clinical Epidemiology 45(6), 613-619.

Deyo, R. A., Cherkin, D. C., and Conrad, D. (1990). The Back pain Outcome Assessment Team. Health Services Research 25(5), 733-737.

Deyo, R. A., Cherkin, D. C., Conrad, D., and Volinn, E. (1991). Cost, controversy, crisis: Low back pain and the health of the public. Annual Review of Public Health 12, 141-156.

Deyo, R. A., Cherkin, D. C., Loeser, J. D., Bigos, S. J., and Ciol, M. A. (1992). Morbidity and mortality in association with operations on the lumbar spine: The influence of age, diagnosis, and procedure. Journal of Bone and Joint Surgery 74-A(4), 536-543.

Deyo, R. A., Ciol, M. A., Cherkin, D. C., Loeser, J. D., and Bigos, S. J. (1993). Lumbar spine fusion: A cohort study of complications, reoperations, and resource use in the Medicare population. Spine 18(11), 1463-1470.

Deyo, R. A., Loeser, J. D., and Bigos, S. J. (1990). Herniated lumbar intervertebral disk. Annals of Internal Medicine 112(8), 598-603.

Deyo, R. A., Rainville, J., and Kent, D. L. (1992). What can the history and physical examination tell us about low back pain? Journal of the American Medical Association 268(6), 760-765.

Diehr, P., Cain, K. C., Kreuter, W., and Rosenkranz, S. (1992). Can small area analysis detect variation in surgery rates? The power of small area variation analysis. Medical Care 30(6), 484-502.

Diehr, P., Cain, K. C., Ye, Z., and Abdul-Salam, F. (1993). Small area variation analysis: Methods for comparing several diagnosis-related groups. Medical Care 31(5),YS45-YS53.

Einstadter, D., Kent, D. L., Finn, S. D., and Deyo, R. A. (1993). Variation in the rate of cervical spine surgery in Washington State. Medical Care 31(8), 711-718.

Fordyce, W. E., Bigos, S. J., Batti, M. C., and Fisher, L. D. (1992). MMPI scale 3 as a predictor of back injury report: What does it tell us? Clinical Journal of Pain 8(3), 222-226.

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Herron, L., Turner, J. A., Ersek, M., and Weiner, P. (1992). Does the Millon Behavioral Health Inventory (MBHI) predict laminectomy outcome? A comparison with the Minnesota Multiphasic Personality Inventory (MMPI). Journal of Spinal Disorders 5(2), 188-192.

Hoffman, R. M., Kent, D. L., and Deyo, R. A. (1991). Diagnostic accuracy and clinical utility of thermography for lumbar radiculopathy: A meta-analysis. Spine 16(6), 623-628.

Hoffman, R. M., Wheeler, K. J., and Deyo, R. A. (1993). Surgery for herniated lumbar discs: A literature synthesis. Journal of General Internal Medicine 8, 487-496.

Jensen, M. P., Strom, S. E., Turner, J. A., and Romano, J. M. (1992). Validity of the Sickness Impact Profile Roland scale as a measure of dysfunction in chronic pain patients. Pain 50, 157-162.

Kent, D. L. (1991). Decision analysis and assessment of the clinical impact of diagnostic tests. Laboratory Medicine 22(10), 718-724.

Kent, D. L., Haynor, D. R., Larson, E. B., and Deyo, R. A. (1992). Diagnosis of lumbar spinal stenosis in adults: A meta-analysis of the accuracy of CT, MR, and myelography. American Journal of Roentgenology 158, 1135-1144.

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Loeser, J. D., Deyo, R. A., Cherkin, D. C., Conrad, D., and Wiesman, J. (1993). Back Pain Outcome Assessment Team: Background and progress. Journal of Musculoskeletal Pain 1(2), 89-110.

Loeser, J. D., Van Konkelenberg, R., Volinn, E., and Cousins, M. J. (1993). Small area analysis of lumbar spine surgery in South Australia. Australian and New Zealand Journal of Surgery 63, 14-19.

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Parkerson, G. R., Jr., Deyo, R. A., Golden, W. E., Blim, R. D., Patrick, D. L., Tuteur, P. G., Ware, J. E., Jr., Bergner, M., Spilker, B., Feinstein, A. R., and Neugebauer, E. (1992). Strategies for improving and expanding the application of health status measures in clinical settings. Medical Care 30(5, Supplement), MS210-MS218.

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Street, J., Hunt, M., Cherkin, D. C., and Deyo, R. A. (1991). Back in action: A guide to understanding your low back pain and learning what you can do about it (pamphlet).

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Turner, J. A., Ersek, M., Herron, L., Haselkorn, J. K., Kent, D. L., Ciol, M. A., and Deyo, R. A. (1992). Patient outcomes after lumbar spinal fusions. Journal of the American Medical Association 268(7), 907-911.

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Von Korff, M. R., Ormel, J., Keefe, F. J., and Dworkin, S. F. (1992). Grading the severity of chronic pain. Pain 50, 133-149.

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