Low back pain (LBP) is the most common occupational disorder in North America. In the period from 2012 to 2016, indirect costs were US$2.2 billion for LBP in Brazil, accounting for approximately 67% of medical expenses. Previously published studies lacked major interventions, requiring further research to improve the evidence. Findings from this review can raise awareness among clinicians and promote significant savings if they follow clinical guidelines.

To investigate the effectiveness of implementation strategies to reduce the proportion of low-value care and increase the proportion of high-value care in the management of low back pain.

This review was registered to the to the Open Science Framework (OSF) (https://osf.io/7jfpr/). Searches were performed in the following electronic databases: MEDLINE, Embase, CINAHL and Cochrane Library. Two independent reviewers performed study selection, data extraction and risk of bias assessment. Clinical trials investigating the effect of evidence-in-practice implementation strategies on reducing low-value care and promoting low-value care were included. Studies including adults with non-specific LBP were considered eligible. The primary outcome of this systematic review was outcomes related to the practices of health professionals. However, the primary outcomes were determined considering two recent clinical care standards. Meta-analyses were calculated using random effect models, the risk of bias by the Cochrane Risk of Bias Tool and the overall quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

Thirty-two articles were included. Interventions focusing on implementing clinical guidelines were not effective in referral to specialists (5 studies, n=6223; RR=0.88; 95% CI: 0.62, 1.25), referral to physical therapists (3 studies, n=7937; RR=1.42 ; 95% CI: 0.74, 2.72) or for prescribing non-opioid drugs (6 studies, n=7297; RR = 0.75, 95% CI: 0.52, 1.10) when compared to the control group. However, the implementation of clinical guidelines was effective in reducing the number of imaging requests (12 studies, n= 44,689; RR = 0.83, 95% CI: 0.70, 0.99), opioid prescription (5 studies, n=6681; RR = 0.60, 95% CI: 0.44, 0.80), and promote active approaches (exercise, counseling, etc.) (6 studies, n=2553; RR = 1.36, 95% CI: 1.04, 1.76). Confidence of all meta-analyses was low, as most studies were assessed at high risk of bias because they were not randomized clinical trials and because of serious inconsistency (I2 > 50%).

Although clinical guidelines are important to improve the quality of care for people with LBP, it is not always effective in clinical practice. The quality of evidence found was low. Better quality studies are still needed to confirm these findings.

Clinical guidelines are important tools that are effective in reducing imaging, prescribing opioids and promoting active approaches and were ineffective for referrals and prescribing non-opioids.