How Fast is the Medical System Adopting Low Back Guidelines | Podcast Ep. 374

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. This week we are back with research and it's a great study. It came out in late 2022 and it's all around how things are evolving in terms of back pain care at a hospital level. It's titled the Slow De Implementation of Non Evidence Based treatments in Low Back Pain Hospital Care Trends in Treatment Using Dutch Hospital Register data from 1991 to 2018. We all know that the guidelines have changed dramatically. The question is, are doctors changing their habits? That's what this study looks at. Lot of great clinical pearls, a lot of great useful information. If you're out there building relationships with other healthcare providers as well, we're gonna dive into that in just one moment. Before we get started, I wanna say a few words about the smart chiropractor and patient pilot. If you would like to generate consistent reactivations from the most valuable asset you have in your practice, your email list, head on over. Book a demo at the smartchiropractor. Com. Our average doc has 26 reactivations per month. That's over five reactivations per week on Autopilot utilizing our system within patient pilot. If you wanna see if we're able to do that for you, we will ask you a bunch of questions, understand exactly what your email list looks like and then be based on our data, predict what we expect from a result perspective. So 3x ROI guarantee. Head over to thesmartchiropractor.com and schedule your demo today. But as I said at the top on this episode, we're talking about a new study that came out. I'm gonna drop a link to the study down in the show notes. But we've discussed extensively on this podcast the changes that have happened in neuromusculoskeletal and spine related care over the last decade or so. There's been a lot of changes in the guidelines and now nearly every single guideline out there supports non pharmacological care and specifically spinal manipulation, spinal adjustments. What we do as a first line treatment option for a host of challenges, headaches, neck pain, low back pain, et cetera. But we see that this is so slow to change the habits of docs in each individual community. Now that's a great opportunity for us to build relationships because there's just unabashed opportunity. But it's frustrating and it's challenging when we know patients are quite frankly getting inadequate care. And again, I think back to the Hippocratic oath. Do no harm. A lot of what's being prescribed by the medical profession for back pain and neuromusculoskeletal care does and perform has direct harm. Make no mistake about it. Opioid crisis, anybody overdone elective surgeries, et cetera. These things have been proven to cause direct harm. Yet they still happen all the time, every single day? Yes. Even in your community, Wherever you're listening. So this study takes a look at it holistically and says, okay, over like a 20 year period. What's going on? We've seen the guidelines change. What's actually happening. This is in a hospital based setting. So a couple foundational items here. We all know low back pain affects more people at some point in their life than just about anything else. It's also the leading cause of disability worldwide. I think feel like we hear that so many times that become numb to it. But that's a big deal. That also goes to stand that I believe all of us listening and me talking right now. Chiropractic can do so much more than just take care of low back pain. But the fact that low back pain affects pretty much everybody and is a leading cause of disability worldwide and there's only about 60,000 practicing chiropractors around the world, the fact that all of us are not having a waiting list is a communication and marketing issue. Let's make no mistake about it. If your practice is not full with a waiting list, it's a marketing and a communication issue because what you do technically works. So this is not about, oh well, I just need to get this one more certification. Oh, I just need this one. You know what to do. You have a marketing and communication issue. Be super clear on this. If your practice is not full, clearly that's what we do with the smart chiropractor patient pilot is help the consumer based marketing as well as with the evidence based chiropractor on the referral side from other healthcare providers. So take a hard look at your practice this year, take a hard look at it right now, before it's the end of the year and understand where are your marketing and communication issues. Because if you're not full, it's not. Because there's not people out there that need your help. Now in the US specifically, medical costs for low back pain are the highest of all diseases. That's insane. People are spending a ton. Again, if you're in the US listening to this, people are spending a ton of money on this. Are they spending it in the right place? Which is probably your practice this is estimated at over $134 billion per year and that was in 2016. So that's only gone up since then. Now why does this cost so much? Well, medically intensive approaches to care cost a lot of money. And you know, imaging, advanced imaging, early on pain medication and invasive treatments we see, I mean I still see people being referred for MRIs and CT scans from their primary care doctor office when they go in with low back pain. It's like that is so early for advanced imaging. Systematic reviews have indicated that the evidence for this type of stuff is marginal at best and it has harmful side effects. Things like bed rest that used to be proposed. These things just cause issues. You know, surgery, pain medication, fusion surgery, non steroidal, anti inflammatories, antidepressants, all of these things that are commonly done, prescribed, recommend it in a hospital based setting. Pretty much all of them have almost no beneficial effect and if anything are harmful. So again, this study is looking at it and saying, well, what the heck is going on and how do things change? As we talked about at the top, international guidelines have now emphasized that first line care should focus on non pharmacological treatments and really leave these advanced diagnostics, advanced medical invasive treatments later on, if at all in the process. Now despite all of this evidence, it is, Ben, it has been and continues to be super difficult to de, implement these non recommended care options in so many places and at so many levels. So let's look at the break point on this. You think about, okay, well who are the early adopters? Like what percentage of medical doctors are gonna really make moves? It's about 16% is what's estimated. So number one, that's, you know, I guess better than better than 0% and will make you cry. If you think about how do the guidelines change. The Hippocratic oath is do no harm and they're still prescribing X, Y and Z. We'll get into some of the reasons on that in a minute. And it comes down to what you'd expect a lot of times, which is money. But 16% are going to be early adopters. Two thirds roughly are going to change after substantial lag of time. And then you look at the other side of things. About 16% are going to be the laggards and really late to the party. Now when we look at those middle 2/3, the question is, well, how long does it take them to really get, get with the program? And it's up to 17 years is what they're estimating. So an early adopter is less than that, a late adopter is more than that. But it ain't happening overnight. Clearly, when we're looking at things that take 17 years on average to de implement practices that are clear are not working, when we also just look at, take a step back, take off my chiropractor hat, put on just my healthcare consumer hat and say there's a lot more people than ever are struggling with back pain. It's costing more than ever. And are people more? Well, well, well, no. Well, it's costing a ton of money and more people are dealing with it. Clearly what is going on is not working. That's pretty much the definition of that. However, it takes a lot of time to change things. So in this study they focused on five frequently applied hospital low back pain treatments that they considered should be de implemented. One is bed rest for non specific low back pain, bed rest for herniated discs, disectomies for spinal stenosis, spinal fusion for non specific low back pain or degenerative issues, and invasive pain treatment for nonspecific low back pain or degenerative issues. So those are really what they looked at. And the four categories that they were able to pull out of the registry to kind of match these things up were herniated discs, number one, number two, degenerative low back pain issues, number number three, spinal stenosis, specifically lumbar, and number four, nonspecific low back pain, which is kind of a catch all bucket. About 90% of low back pain is deemed nonspecific. The irony being you come into a chiropractic practice, we're going to actually evaluate whether the facet joint is moving appropriately. We're actually going to evaluate what's going on biomechanically and quite often we can get down to the pain generator. However, in a hospital based setting, in a primary care setting, almost every single thing, unless there's a super obvious compressive pathology or a super obvious disc, everything's being bucketed. Nonspecific low back pain, is that true? Is that not true? I think it's a little lazy personally, but it's where things go. And I'll step to the side on this for a moment and just talk about this in terms of relationship building because I don't want it to sound like I'm completely dogging on the medical profession. I'm dogging on what they're choosing to do, don't get me wrong. But think about how little you must know about neuromusculoskeletal care to do what we just discussed, to move to fusion quickly, to have disectomies going on quickly, to go to pretty much any sort of pain management if it's not an extreme case, or to recommend something like bed. I mean, movement based care is where it's at. So most medical providers don't dislike the people in their community or they don't dislike their patients. They literally know that little, that they're making a lot of these recommendations. Now the secondary component to that is monetary. We'll discuss that in a few minutes. But that's something to keep in mind as you're getting out there and building relationships about how much you know. And we become blinded as movement based healthcare professionals. Often we become blinded to the fact of how much we know. And what becomes self evident to us is revolutionary to other people. So in this study they looked at the beginning of 1991 to the end of 2018 and they had some data and some statistics. In that 91 to 2018 period, there are 130,000 treatments of bed rest for nonspecific low back pain, about 400 grand. 400,000 treatments for bed rest for herniated discs, about 200,000 for disease disectomies, for spinal stenosis, 18,000 disectomies or spinal fusion surgeries, excuse me. And 77,000 invasive pain treatments as defined in this study. So a lot of stuff going on. Hundreds of thousands of people getting non recommended care ultimately is what it comes down to. Hundreds of thousands. We look at that. This is in the Dutch population. Look at this in the United States, it's hundreds of millions of people getting non recommended. Now the most common, all treatments were common in the 40 to 49 year old age group except for the invasive pain treatment which was most common age 50 to 59. Again, older adults getting moved into pain treatments instead of movement based care. Absolute travesty in terms of what should be done. Bed rest for non specific low back pain and herniated discs and dissectomy for spinal stenosis did reduce gradually between 91 and 2018. So there were decreases over time, but it just took a ton of time to do so. So de implementation was gradual for bed rest for non specific low back pain. By 2018, its use had declined by 91%. So that is a big deal. Now DE implementation beyond 84% was reached after 7 to 18 years. So let me rephrase that a slightly different way. When they looked at the stats and they're saying, okay, how much, how often is this kind of Thing happening. Okay, great. Well, it's happening less. Well, what percentage less to reach? 84% less took 17 to 18 years. So that's a big deal. Now that still tells us about 16% of the time it's still being done, which makes no sense whatsoever. But this is a gradual long term process, no matter which way you slice it. Deimplification for spinal fusion was reached after 19 years while invasive pain treatment has not reached the 84% threshold of DE implementation. So that is a big deal. It's something all of us need to be understanding of, especially as we're getting out there in our community. This is what they're being recommended. This is also the other side of the coin. It's not only in terms of building relationships with other healthcare providers, being that asset where they just don't quite often don't know what to do or where to send people, but it's also understanding that people are walking into your practice with ridiculously mixed signals about what they should be doing and quite frankly, often getting bad advice. Other places actually detrimental advice. Not only, not only is it equivocal, it's worse than that, it's bad advice. So for example, as they say in this study, for example, in contrast to our data, admissions for low back pain and spinal fusions increased rather than decreased between 2005 and 2013 in Australia. In the United States, spinal fusions increased in approximately that same time period. That is, that's not good. United States invasive pain procedures increased between 2000 and 2008. So this is a, you know, it's, this is an interesting study. It highlights what's going on in the Dutch system. The Dutch system went to a nationalized health care system. You can think one way or the other about that, but that took out some of the legs of monetization and that's a big deal. An important driver, as they highlight for DE implementation, is reimbursement. And clinicians are rewarded by volume and complex treatments rather than quality of care. And in The Netherlands Until 2006, healthcare was covered by private health insurers and then they switched over more to a nationalized type service. So the thought is, is once they're, you know, the monetization aspect for big time fusion surgeries, pain treatments, et cetera, went out the window. What do you know, guidelines start being adhered to. Now we look at the US complete opposite. We see people just running it up right now in terms of opioids being as bad as they've ever been in the past. All gains from the last 10 years wiped out over the last three years. Be very clear about that. More elective surgeries being done than ever before and people quite frankly not being better off in terms of their spinal care compared to five years ago, 10 years ago, 15 years ago. So that illness is on us to get out there and tell this story at a higher level. So the conclusion on this was quote de implementation of 5 non evidence based Dutch hospital treatments for low back pain was substantial, which is great kudos to that system but took several decades. That's a long time. This has resulted in considerable waste of resources and avoidable harm to many patients. More attention is needed for effective strategies to accelerate the implementation of non evidence based care and work towards better diagnosis and updating treatment Description so some good news here, some bad news here, but all news is important for us as chiropractors to be aware of, understand what's going on and understand where we can really get our message out there. And that is one of the most important things I think of this research and of this podcast is not only identifying what the research saying but hopefully more importantly for you. How can you think about this and use this with the conversations that you're having with the patients in your practice? So before we go, I want to say a few words about Zingit. Zyngit integrates with your EHR and is a text based solution that works around the clock to get more patients into your practice. With Zyngit you can expect an average of 23 Google reviews in a month and a patient show rate of at least 94%. Check out what they have going on. If you're not using text zingitsolutions.com to schedule a demo today. Zingitsolutions.com Additionally, I'm going to say it again if you have not picked up your free sample pair of Power Step orthotics, what are you doing? Pro.powerstep.com sample Use the code EBC these were developed by a podiatrist over 30 years ago. They were I use what my dad uses. I like the company, love the product. This is something you got to do. Check it out. Pro.powerstep.com sample use the code EBC to get your free sample pair. If you have not left a rating or review for this podcast I would love it if you do so that helps us reach more and more docs. Thank you so much for tuning in. Thank you for being a chiro Bryter. Have an awesome week in practice and I will talk to you soon. Thank you for joining us on this episode of the Evidence of Based Chiropractor. 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