Effects of implementing evidence-based appropriateness guidelines for epidural steroid injection in chronic low back pain: the EAGER (Esi Appropriateness GuidElines pRotocol) study

[摘要] Objective Chronic low back pain is very common andoften treated with epidural steroid injections (ESIs). AsESI referrals had been rapidly increasing at our Veterans’Administration hospital, we were concerned that they weresupplanting more comprehensive care. The objective wasto determine how referral patterns and multidisciplinarycare might change with the implementation of evidencebased guidelines.Methods In this retrospective observational study,multidisciplinary evidence-based guidelines wereimplemented in 2014 (EAGER: Esi AppropriatenessGuidElines pRotocol) as part of the ordering process foran ESI. Time series analysis was performed to assessthe primary outcome of subspecialty referral pattern,that is, the number of patients receiving referrals toancillary services which might serve to provide a morecomprehensive approach to their back pain. Secondaryoutcomes included patient-level changes (ie, body massindex, number of injections, opioid use), which werecompared before and after protocol implementation.Results Comparing preimplementation andpostimplementation protocol periods, referrals to physicalmedicine/rehabilitation increased 11.7% (p=0.003) peryear and integrative health increased 2.1% (p<0.001) peryear among the 2294 individual patients who received ESIthrough the neurointerventional radiology service. Of 100randomly selected patients for patient-level analysis, themedian body mass index decreased from 31.57 to 30.22(p=<0.001) and the mean number of injections decreasedfrom 1.76 to 0.73 (p<0.001). The percentage of patientsusing oral opioid analgesics decreased from 72% to 49%(p=<0.001).Conclusion Implementation of evidence-basedguidelines for ESI referral helps guide patients into amore comprehensive care pathway for chronic low backpain and is correlated with patient-level changes such asdecreased body mass index and decreased opioid usage.

[学科分类] 药学