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 US. Physicians (n = 192) viewed 2 videos of different patients (actors) presenting with pain: undiagnosed sciatica symptoms or diagnosed knee osteoarthritis. Systematic variations in patient gender, socioeconomic status, and race and physician gender and experience (<20 versus ≥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 American College of Rheumatology, American Pain Society, and clinical expert consensus.

Results: Despite current recommendations, less than one-third of physicians would provide exercise advice (30.2% for osteoarthritis and 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 nonsteroidal antiinflammatory drugs 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.

Figure 1. Physician Experience (years in practice) and Appropriate Advice Given to the Pain Patient

Columns represent the percentage of physicians that would provide advice on the particular topic for pain management, all of which are appropriate for the patient cases. *P<0.05. **P<0.01.

Figure 2. Effects of Physician Experience (years in practice) on Test Ordering and Analgesics Prescribed

Columns represent the percentage of physicians that would order the particular test or prescribe the class of medications for the newly diagnosed pain patient; exception of the first column, which represents the mean total number of tests that the physicians would order. Basic lab work included complete blood count, basic metabolic/chemistry panel, and lipid profile tests. *P<0.05. **P<0.01.

Figure 2. Effects of Physician Experience (years in practice) on Test Ordering and Analgesics Prescribed

Columns represent the percentage of physicians that would order the particular test or prescribe the class of medications for the newly diagnosed pain patient; exception of the first column, which represents the mean total number of tests that the physicians would order. Basic lab work included complete blood count, basic metabolic/chemistry panel, and lipid profile tests. *P<0.05. **P<0.01.