Guideline implementation for low back pain in German healthcare: a tale of overuse and underuse

Low back pain (LBP) is the leading cause of disability globally and clinical practice guidelines recommend active and conservative management. However, little is known regarding guideline adherence among German healthcare practitioners.

We conducted an online, cross-sectional clinical vignette-based survey of 658 German medical doctors, physiotherapists, and sport scientists between May 2022 and March 2023 to assess implementation of diagnostic and treatment recommendations for chronic non-specific LBP, specific LBP (axial spondyloarthritis), and acute lumbar radiculopathy. Guideline implementation was assessed for the survey responses against recommendations from four German national guidelines. Adherence was quantified using a predefined adherence matrix that translated agreement with guideline recommendations into percentage scores. The use of clinical practice guidelines and determinants of guideline adherence were calculated. Multiple regression analyses examined predictors of guideline adherence.

Among 658 healthcare practitioners, overall guideline adherence was 57.8% (treatment: 59.8%; diagnostic: 50.6%). Adherence was highest for chronic non-specific LBP, while imaging was frequently overused for lumbar radiculopathy (MRI recommended by 84.3% (95% CI 81.1-87.5). Awareness of axial spondyloarthritis was poor, with only 32.7% (95% CI 29.2 to 36.4) correctly identifying the condition. Correct triage across the three vignettes emerged as the strongest predictor of overall guideline adherence.

Diagnostic and treatment adherence to national guidelines among German healthcare practitioners appears inadequate. Overuse of imaging for acute lumbar radiculopathy, delays in axial spondyloarthritis diagnosis, correct triage for specific LBP, and underutilization of active rehabilitation for chronic non-specific LBP are important areas for optimizing clinical care.