Nonconcordant Care for Acute Low Back Pain Puts Patients at Risk for Chronic Pain

The investigators were trying to determine if the transition from acute to chronic low back pain is associated with risk strata and/or with early exposure to guideline nonconcordant care.

Patients with acute low back pain (LBP) who were exposed early to Subgroups for Targeted Treatment Back tool (SBT) nonconcordant care were at increased risk of transitioning to chronic LBP. These findings from a large inception cohort study were published in JAMA Network Open.

This analysis was based on data from the Targeted Interventions to Prevent Chronic Low Back Pain in High-Risk Patients (TARGET) clinical trial. Patients who were at high risk were enrolled in a randomized clinical trial, and patients who had medium or low risk were enrolled in a cohort study. Recommendations provided by primary care providers were compared with LBP status at 6 months.

Participants were mostly women (58%) with axial LBP (74%). Most were White (83%) and either overweight (31%) or obese (44%). Patients were at high (25%), intermediate (41%), or low (34%) risk for transitioning to chronic LBP.

Of participants, 30% were prescribed nonrecommended medications (65% of them received opioids), 24% were ordered radiography, and 6% were referred to a specialist.

At 6 months, 32% of patients had transitioned from acute to chronic LBP (low risk: 19%; intermediate: 33%; high: 49%). Transition to chronic LBP was associated with exposure to nonrecommended pharmacotherapies (P <.001), having radiography (P <.001), and referral to a specialist (P <.001).

Patients who received 1 (adjusted odds ratio [aOR], 1.39; 95% CI, 1.21-2.32), 2 (aOR, 1.88; 95% CI, 1.53-2.32), or 3 (aOR, 2.16; 95% CI, 1.10-4.25) nonconcordant processes had increased risk (P <.001) for transitioning to chronic pain.

Transition to chronic LBP at 6 months was more frequent among patients who were Black (aOR, 1.31; 95% CI, 1.04-1.65; P =.05), had Medicaid (aOR, 1.91; 95% CI, 1.53-2.38; P <.001) or Medicare (aOR, 1.43, 95% CI, 1.21-1.69; P <.001), were obese (aOR, 1.52; 95% CI, 1.28-1.80; P <.001), or currently smoked (aOR, 1.56; 95% CI, 1.29-1.89; P <.001).

Transition to chronic LBP was also associated with the clinical characteristics of depression/anxiety (aOR, 1.66; 95% CI, 1.28-2.15; P <.001), severe (aOR, 1.82; 95% CI, 1.48-2.24; P <.001) or very severe (aOR, 2.08; 95% CI, 1.60-2.68; P <.001) Oswestry Disability Index, intermediate (aOR, 1.59; 95% CI, 1.33-1.89; P <.001) or high (aOR, 2.45; 95% CI, 2.00-2.98; P <.001) risk for transition, and concurrent leg pain (aOR, 1.16; 95% CI, 1.00-1.35; P =.04).

This study was limited by its low response rate (55%) at 6 months.

These data indicated receiving guideline nonconcordant care from primary care clinicians for LBP increased the risk for transitioning from acute to chronic pain. Strategies for effective dissemination of guideline information among primary care clinicians are needed.

Disclosure: An author declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Stevans JM, Delitto A, Khoja SS, et al. Risk factors associated with transition from acute to chronic low back pain in US patients seeking primary care. JAMA Netw Open. 2021;4(2):e2037371. doi:10.1001/jamanetworkopen.2020.37371