Can evidence change the rate of back surgery? A randomized trial of community-based education.

CONTEXT: Timely adoption of clinical practice guidelines is more likely to happen when the guidelines are used in combination with adjuvant educational strategies that address social as well as rational influences. OBJECTIVE: To implement the conservative, evidence-based approach to low-back pain recommended in national guidelines, with the anticipated effect of reducing population-based rates of surgery. DESIGN: A randomized, controlled trial. SETTING: Ten communities in western Washington State with annual rates of back surgery above the 1990 national average (158 operations per 100,000 adults). PARTICIPANTS: Spine surgeons, primary care physicians, patients who were surgical candidates, and hospital administrators. INTERVENTION: The five communities randomized to the intervention group received a package of six educational activities tailored to local needs by community planning groups. Surgeon study groups, primary care continuing medical education conferences, administrative consensus processes, videodisc-aided patient decision making, surgical outcomes management, and generalist academic detailing were serially implemented over a 30-month intervention period. OUTCOME MEASURE: Quarterly observations of surgical rates. RESULTS: After implementation of the intervention, surgery rates declined in the intervention communities but increased slightly in the control communities. The net effect of the intervention is estimated to be a decline of 20.9 operations per 100,000, a relative reduction of 8.9% (P = 0.01). CONCLUSION: We were able to use scientific evidence to engender voluntary change in back pain practice patterns across entire communities.