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.

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.…”

What Do People With Knee or Hip Osteoarthritis Need to Know? An International Consensus List of Essential Statements for Osteoarthritis

“…With respect to the transmission of evidence-based messages regarding selfmanagement, most barriers reside at the level of the health care provider. Despite current evidence-based recommendations, less than one-third of primary care providers deliver advice about exercise and/or lifestyle changes for patients with osteoarthritis (26). In addition, a 2011 survey of adults in the US suggested there is a low occurrence of shared decision-making in the clinical setting (27).…”

Variation in the utilization and positivity rates of CT pulmonary angiography among emergency physicians at a tertiary academic emergency department

“…Previous studies examining physician experience and test ordering have shown higher cost profiles in physicians with less experience [27,34,35]. Variable data is available on the relationship between physician gender and practice patterns, with some showing no consistent effect on test ordering [36], and others demonstrating significantly higher ordering rates by female physicians [27,37]. With regard to adherence to clinical guidelines, Ferrier et al showed female and younger physicians were more likely to use practice guidelines than their male and older counterparts [38].…”