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The Slow De-Implementation of Non-Evidence-Based Treatments in Low Back Pain Care – Trends in Inpatient Treatments Using Dutch Hospital Register Data from 1991 to 2018
42 Pages Posted: 21 Jul 2021
More...Abstract
Background: Low back pain (LBP) is the leading cause of disability worldwide and has an excessive societal and economic burden, partly due to a medically intensive approach to treat LBP. Accumulating evidence has shown that some medical approaches such as imaging in the absence of clear indications, medication and some invasive treatments may contribute to the problem rather than alleviating it. In this study we determined the extent of de-implementation of non-evidence-based inpatient treatments for LBP care in the Netherlands in the last three decades.
Methods: We used Dutch hospital register data, providing a nearly complete coverage of hospital admissions in the Netherlands between 1991 and 2018. We assessed five frequently applied non-evidence-based and harmful inpatient treatments for LBP: 1) bed rest for non-specific LBP, 2) bed rest for hernia nuclei pulposi, 3) discectomy for spinal stenosis, 4) spinal fusion and 5) invasive pain treatment for non-specific LBP, degenerative low back problems and spinal stenosis. Time trends in treatment incidence (absolute numbers and per 100,000 inhabitants) were plotted and analysed using Poisson generalised linear modelling.
Findings: In the study period the use of bed rest for both non-specific LBP and hernia nuclei pulposi, and discectomy for spinal stenosis decreased 91%, 81% and 86% since the availability of evidence/guidelines, respectively. De-implementation, beyond 84%, was reached after 18 and 17 years for bed rest for non-specific LBP and discectomy respectively, while was reached after 28 years for bed rest for hernia nuclei pulposi. For spinal fusion and invasive pain treatment there was an initial increase followed by a reduction, and overall these treatments reduced by 85% and 75%, respectively.
Interpretation: In the Netherlands, de-implementation of five non-recommended inpatient LBP treatments, if at all, took several decades after availability of evidence and published guidelines. Although de-implementation was substantial, these treatments are still performed in the Dutch healthcare system, and slow de-implementation has likely resulted in considerable waste of resources and avoidable harm to many patients. Adjustment of reimbursement systems for LBP care based on and together with professional guidelines/scientific evidence may accelerate behaviour change.
Funding: There was no specific funding for this project.
Declaration of Interest: None to declare.
Keywords: Low back pain, de-implementation, evidence based medicine, evidence based practice
Suggested Citation: Suggested Citation