Variations Among Primary Care Physicians in Exercise Advice, Imaging, and Analgesics for Musculoskeletal Pain: Results From a Factorial Experiment

Abstract

Objective To examine whether medical decisions regarding evaluation and management of musculoskeletal pain conditions varied systematically by characteristics of the patient or provider. Methods We conducted a balanced factorial experiment among primary care physicians in the U.S. Physicians (N=192) viewed two videos of different patients (actors) presenting with pain: (1) undiagnosed sciatica symptoms or (2) diagnosed knee osteoarthritis. Systematic variations in patient gender, socioeconomic status (SES), race, physician gender and experience (<20 vs. ≥20 years in practice) permitted estimation of unconfounded effects. Analysis of variance was used to evaluate associations between patient or provider attributes and clinical decisions. Quality of decisions was defined based on the current recommendations of the ACR, American Pain Society, and clinical expert consensus. Results Despite current recommendations, under one-third of physicians would provide exercise advice (30.2% for osteoarthritis, 32.8% for sciatica). Physicians with fewer years in practice were more likely to provide advice on lifestyle changes, particularly exercise (P<0.01), and to prescribe NSAIDs for pain relief, both of which were appropriate and consistent with current recommendations for care. Newer physicians ordered fewer tests, particularly basic laboratory investigations or urinalysis. Test ordering decreased as organizational emphasis on business or profits increased. Patient factors and physician gender had no consistent effects on pain evaluation or treatment. Conclusion Physician education on disease management recommendations regarding exercise and analgesics, and implementation of quality measures may be useful, particularly for physicians with more years in practice.

Key Strategies for Physical Activity Interventions Among Older Women: Process Evaluation of a Clinical Trial

“…Recent guidelines from the American Heart Association recommend that providers include regular assessment of and recommendations for PA during routine medical visits. 49,50 However, this practice is yet to be widespread, 51 and studies find less than one third to 50% of providers advise regarding PA. 52,53 Other research finds that a lack of interest is a major barrier to PA, 38,47 although our study did not support this. We hypothesize this is likely due to selection bias as noninterested women probably would not have volunteered to participate.…”

Long term use of analgesics and risk of osteoarthritis progressions and knee replacement: propensity score matched cohort analysis of data from the Osteoarthritis Initiative

“…On the other hand, continued use of conventional analgesics (such as NSAIDs) is not necessarily associated with complete pain relief either 30 . While a great portion of OA patients are frequent users of analgesics 19,20 still many patients suffer from inadequate pain relief (IPR), which is also a common reason for impaired quality of life (QoL) 30 .…”

Dose‐Response Effects of Tai Chi and Physical Therapy Exercise Interventions in Symptomatic Knee Osteoarthritis

“…Furthermore, because higher perceived benefits of exercise were associated with the timing of response, we speculate that clinicians can improve the effectiveness of exercise among older adults through frequent encouragement, specific guidance, and regular use of exercise prescriptions. Although clinician recommendation is the single most important determinant for exercise engagement in OA [61], less than one‐third of physicians in the United States provide any exercise advice for these patients [62]. Thus, physicians may play an important role in improving exercise outcomes in knee OA.…”