Occupational Medicine Advance Access originally published online on August 21, 2008
Occupational Medicine 2008 58(7):485-489; doi:10.1093/occmed/kqn097
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Do occupational health assessments match guidelines for low back pain?
1 Department of Occupational Health, Stockport NHS Foundation Trust, Stepping Hill Hospital, Stockport, UK
2 Department of Occupational Health, Central Manchester and Manchester Children’s University Hospitals NHS Trust, Manchester, UK
3 Centre for Occupational and Environmental Health, The University of Manchester, Manchester, UK
4 Biostatistics Group, Health Methodology Research Group, School of Community Based Medicine, The University of Manchester, Manchester, UK
Correspondence to: Luke Walsh, Mediscreen Occupational Health Service, North Manchester General Hospital, Delaunays Road, Crumpsall, Manchester M8 5RB, UK. Tel: +44 161 720 2727; fax: +44 161 720 2728; e-mail: luke.walsh{at}pat.nhs.uk
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Abstract |
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Background Audit is an important facet of clinical governance and good occupational health practice. There are well-established clinical guidelines for the management of low back pain. Occupational Health Guidelines for the Management of Low Back Pain at Work were launched by the Faculty of Occupational Medicine in March 2000, based on an extensive, systematic review of the scientific literature predominantly from occupational settings or concerning occupational outcomes.
Aim To determine whether documented National Health Service occupational health assessment of low back pain in the North West region of England conforms to the published guidelines.
Methods A retrospective audit of case notes was conducted. Six performance indicators were derived from the Occupational Health Guidelines for the Management of Low Back Pain at Work in order to evaluate the performance by occupational physicians. Two hundred and seventy-seven case notes were identified from eight different occupational health departments.
Results Low rates of compliance with national standards were observed for recording of some performance indicators, notably for the assessment and documentation of ‘red’ and ‘yellow flags’. Our findings suggest that the quality of documentation of key information in the notes leaves significant room for improvement.
Conclusions For future audits, we recommend having two external auditors and seek to demonstrate a high degree of agreement between observers by conducting a reproducibility exercise. Future Faculty guidelines should emphasize documentation of the assessment and perhaps consider assessment tools to improve documentation.
Keywords Audit; back pain; guidelines; occupational health
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Introduction |
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An important challenge facing the quality of practice in occupational medicine is a limited evidence base, but equally important is the need to translate good evidence into high quality practice [1]. Evaluation of quality of practice may be conducted by means of an audit. Audit is defined as ‘a systematic critical analysis of the quality of medical care, including the procedures used in diagnosis and treatment, the use of resources, and the resulting outcome for the patient’ [2]. It is important to trace deviations from ‘good practice’ to enable improvements in the quality of care.
Back pain is one of the most commonly encountered challenges in the occupational health setting. The longer an employee is absent from work with low back pain, the lower his or her chances are of returning to work [3].
Occupational Health Guidelines for the Management of Low Back Pain at Work were launched by the Faculty of Occupational Medicine (FOM) in March 2000 [4]. These clinical guidelines for the management of low back pain in the occupational setting are based on an extensive, systematic review of the scientific literature. The guidelines are now well established.
Occupational health guidelines for the assessment of the worker presenting with low back pain are shown in Figure 1 [4]. According to the FOM guidelines, the starting point for the first consultation with the occupational physician is a focused history and physical examination screening for features of serious spinal pathology (‘red flags’) and psychosocial risk factors for developing chronic pain and disability or ‘yellow flags’ (Figure 2) [4]. The employee’s condition should be diagnosed according to one of three broad categories of low back pain: simple mechanical back pain, nerve root involvement and serious spinal pathology.
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The guidelines provide a standard against which routine care can be measured. A randomized controlled trial in the Netherlands did not show a significant positive effect of early intervention by occupational physicians on work resumption by employees with low back pain [5]. This may reflect an overestimation of compliance with their guidelines. It may also illustrate that successful management of employees with low back pain is dependant upon multiple factors. It was therefore decided that it would be more appropriate to focus on measures of quality in the process of assessment rather than outcome measures such as work resumption when evaluating compliance with back pain guidelines.
An audit of medical files of employees with low back pain was conducted. The aim of this audit was to determine whether documented National Health Service (NHS) occupational health assessment of low back pain in the North West region of England conforms to the published FOM guidelines.
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It is possible to evaluate the quality of the documented assessment by occupational physicians by deriving performance indicators from practice guidelines and calculating performance rates [6,7,8].
In this audit, the quality of occupational health assessment was evaluated by means of different performance indicators derived from the guidelines for the assessment of employees with low back pain [4]. In addition, advice about return to work was considered as this is an essential task and a measurable output of an occupational physician and every medical record should contain this information. This approach of deriving performance indicators was analogous to the method used in an audit of occupational health care for employees with low back pain by van der Weide [8].
For each performance indicator, a performance rate was calculated. The performance rate represents the number of case notes with documentation consistent with the guidelines, divided by the total number of cases assessed with back pain. The six performance rates used to assess the quality of the occupational health process are given in Table 1.
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A proforma was developed to assist uniform data collection from the clinical files. A pilot audit was undertaken at two NHS occupational health departments. No major changes were implemented as a result of the pilot study. The inclusion criteria were all patients who presented to an occupational health department with a new episode of back pain within the time period 1 September 2004–31 August 2005 and were seen by an occupational physician.
All nine consultant-led NHS occupational health departments represented within the North West (Greater Manchester and Lancashire regions) NHS Audit group were visited between January and March 2006 and data collection was undertaken from the clinical records by a single audit facilitator. The audit facilitator was not medically trained but had coding experience in the health care setting and was provided with training specific for this audit. All occupational physicians within the audit group were asked to provide the audit facilitator with a list of key words and phrases commonly used in their day to day practice to assist identification of performance indicators. Further guidance and supervision was provided by two occupational physicians from within the audit group.
The medical files of workers who were referred to occupational health with back pain were examined for evidence that there had been consideration of the principal recommendations for occupational health management of low back pain. The audit facilitator recorded the presence or absence of documentary evidence of the performance indicators.
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Results |
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A total of 330 cases were identified from the different occupational health departments taking part in the audit. Fifty-three of these cases did not meet the inclusion criteria (either because the index consultation fell outside the defined time period for the audit, the presentation was not for low back pain or the case notes could not be located) and were excluded. One of the occupational health departments was also excluded from the audit because identification of relevant cases proved too difficult for the purposes of our study. Therefore, the material studied consisted of 277 case notes identified as suitable for the audit. These cases were seen by one of 25 different occupational physicians (10 consultants, 7 specialists in training and 8 clinical assistants) in one of eight different occupational health departments.
The majority (265/277) of cases were management referrals, and the remainder (12/277) were self-referrals. The mean time from receiving a management referral to the date of the first appointment offered was 19 days (SD 13.4 days).
Table 1 shows the performance rates for the recording of information in the medical records. Of note, a clear working diagnosis was recorded in 78% of records and advice to managers regarding fitness was recorded in 95% of reviewed records. Documentation of screening for red and yellow flags was low at 15 and 23%, respectively.
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Discussion |
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The clear working diagnosis recorded in 78% of medical notes compares favourably with 53% in a smaller audit of 35 back pain cases in the UK NHS [8], but documentation of presence/absence of red flags was very low (15%) in our audit. The performance rate for documentation of presence/absence of yellow flags was also poor (23%). The latter is of concern as red flags for serious spinal pathology may have a major influence on the investigation and treatment for back pain and patients’ beliefs, behaviours and other psychosocial factors (yellow flags) may predict poor outcomes. Formal screening for red and yellow flags should be routinely included in the clinical decision-making process, and the low performance rates for red and yellow flags require further exploration.
The audit facilitator was provided with FOM guidelines listing red and yellow flags. To assist interpretation of documentation in the notes, all occupational physicians within the audit group were asked to provide common words and phrases used in their notes to document presence/absence of red and yellow flags. The low performance rate for red and yellow flags may have been influenced by an unexpected difficulty interpreting the notes. Alternatively, it is possible that red and yellow flags were considered without subsequent formal documentation. This is suggested by the finding that the presence of yellow flags was more likely to be recorded than absence indicating a bias towards documentation of positive findings in the case notes (48 compared to 15). Negative findings and routine activities may not have been recorded as often, thereby resulting in an underestimation of the true performance. Another explanation is that occupational physicians do not always screen patients for red and yellow flags.
In 30% of case notes, there was no evidence that the patient had been examined. There is moderate evidence that examination findings are of limited value in planning occupational health management or in predicting the prognosis of non-specific low back pain according to FOM guidance. However, examinations should be conducted routinely for screening of red flags and to serve as a baseline marker for assessing progress. It is realized that activities of the occupational physician may be influenced by the timing of referral and other contextual aspects. Specific individual circumstances possibly influence deviations from standard activities.
The validity of our performance indicators could be questioned. Our criteria for performance may not accurately reflect the FOM guidelines [4] and may lack clinical relevance. The FOM group may not have intended the guidelines to become an audit standard. While guidelines provide benchmarks for assessment and improvement, there may be good reasons why they do not apply to some patients. However, it is difficult to justify failure to document red flags if good evidence is available that screening and diagnostic triage is important to exclude serious spinal pathology. Similarly, it is important to exclude beliefs and behaviours on the part of the patient that may predict poor outcomes.
An audit of medical files, as with any observational study, is susceptible to bias. This audit of case notes relies on accurate recording by the clinician. Information that is documented needs to be interpreted carefully. It is not possible to distinguish activities that have been executed but not recorded from activities that have not been registered because they were not executed in the first place. Much key information was not recorded.
There are many reasons for recording information in notes. The notes act as a record of the consultation for use in future consultations and in the event of litigation. The occupational physicians were unaware that their notes would be subject to audit. Future audit is another important reason for clear documentation of the clinical assessment in the notes. Information is less likely to be recorded if it is not felt to be important. Negative findings may be recorded less frequently than positive findings.
Although having a single audit facilitator for uniform collection of data was considered to be one of the strengths of the audit, it is possible that difficulty interpreting the clinical case notes may have resulted in poor performance scores for the assessment of red and yellow flags. For a more sensitive assessment of the quality of occupational health care in future audits, clearly defined criteria are needed to clarify the level of documentation that is considered adequate. For future audits, we recommend having two external auditors and seek to demonstrate a high degree of agreement between observers by conducting a reproducibility exercise [9].
Audit has an important role to play in addressing deviance from good practice. The exercise of measuring deviance from the guidelines through audit may help in improving education, sharpening clinical judgement and raising standards of practice. The audit cycle involves comparing observed practice with a set standard followed by making improvements and then closing the audit loop [9]. This audit is part of an ongoing programme of audit. The results have been reported to the audit group and future audit will be conducted to see whether or not practice has been influenced. To facilitate future audit, data must be recorded reliably in the clinical notes. A tool could be developed to prompt key questions in the history and findings in the examination that form the basis of the rehabilitation plan and advice to managers.
In conclusion, many of the performance rates were well below 50% and much lower than they should be on the basis of the occupational health guidelines. In particular, documentation of the presence or absence of red and yellow flags appeared to be poor, and this is an area that warrants further evaluation.
This study demonstrates that the quality of documentation of the initial assessment of employees with low back pain leaves significant room for improvement. Future FOM guidelines should emphasize documentation of the assessment and consider assessment sheets or other tools to improve documentation.
Key points
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Supra District NHS Clinical Audit coordinated by Bury Primary Care Trust.
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None declared.
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References |
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