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To examine this question order cialis sublingual 20 mg free shipping, we asked the implementation team and providers in our 74 Evaluation of the Low Back Pain Practice Guideline Implementation focus group which practice changes they think occurred and any evi- dence they had that documented such changes. We also obtained reports from some sites with data they had developed on trends of low back pain encounters. Primary Care Services Three of the demonstration sites analyzed data on frequency of en- counters and length of treatment, the results of which suggested there was general adherence with conservative treatment of low back pain patients, as recommended by the guideline. One site reported that 47 percent of patients had only one encounter for low back pain. Another reported that two-thirds of its low back pain patients had no more than two encounters and another 20 percent of its patients had three encounters. Both sites reported that less than 2 percent of low back pain patients had seven or more encounters. A small number of patients had an unusually large number of low back pain encounters, and these patients were identified for follow-up and potential re- assessment. At the site that began to require all new low back pain patients to at- tend back class before they could be referred to physical therapy or specialty care, back class attendance increased, but there still were high no-show rates at the classes. This site also changed its practice in the emergency room, asking ER staff to triage patients presenting with low back pain for red-flag conditions, treat those with serious problems, and send the remaining patients directly to their primary care provider for conservative treatment. In the past, the ER staff would attempt to manage low back pain patients on a continuing basis. This change in procedure might result in an increase in ob- served follow-up visits. One site reported that 56 percent of its low back pain patients were in care for one month or less and another 16 percent between one and two months. Effects of Guideline Implementation 75 Change in Patterns of Referrals Primary care providers said they changed their patterns of specialty referrals to be more consistent with conservative treatment of acute back pain patients. Providers responding to our survey at the second site visits were asked: "Has the low back pain guideline led you to in- crease or decrease your referrals to the following services? In contrast with the primary care provider re- ports, neurosurgery and orthopedics specialists at the demonstration sites indicated that they continued to receive inappropriate referrals that represented an estimated 10 to 30 percent of the total patients referred to them. First, the reported changes reflect the providers’ percep- tions of changes in their behavior, which may have differed from ac- tual changes as measured with encounter data.