Barriers to following imaging guidelines for the treatment and management of patients with low-back pain in primary care: a qualitative assessment guided by the Theoretical Domains Framework

Abstract

Background Low back pain (LBP) is a leading cause of disability and is among the top five reasons that patients visit their family doctors. Over-imaging for non-specific low back pain remains a problem in primary care. To inform a larger study to develop and evaluate a theory-based intervention to reduce inappropriate imaging, we completed an assessment of the barriers and facilitators to reducing unnecessary imaging for NSLBP among family doctors in Newfoundland and Labrador (NL). Methods This was an exploratory, qualitative study describing family doctors’ experiences and practices related to diagnostic imaging for non-specific LBP in NL, guided by the Theoretical Domains Framework (TDF). Data were collected using in-depth, semi-structured interviews. Transcripts were analyzed deductively (assigning text to one or more domains) and inductively (generating themes at each of the domains) before the results were examined to determine which domains should be targeted to reduce imaging. Results Nine family doctors (four males; five females) working in community (n = 4) and academic (n = 5) clinics in both rural (n = 6) and urban (n = 3) settings participated in this study. We found five barriers to reducing imaging for patients with NSLBP: 1) negative consequences, 2) patient demand 3) health system organization, 4) time, and 5) access to resources. These were related to the following domains: 1) beliefs about consequences, 2) beliefs about capabilities, 3) emotion, 4) reinforcement, 5) environmental context and resources, 6) social influences, and 7) behavioural regulation. Conclusions Family physicians a) fear that if they do not image they may miss something serious, b) face significant patient demand for imaging, c) are working in a system that encourages unnecessary imaging, d) don’t have enough time to counsel patients about why they don’t need imaging, and e) lack access to appropriate practitioners, community programs, and treatment modalities to prescribe to their patients. These barriers were related to seven TDF domains. Successfully reducing inappropriate imaging requires a comprehensive intervention that addresses these barriers using established behaviour change techniques. These techniques should be matched directly to relevant TDF domains. The results of our study represent the important first step of this process – identifying the contextual barriers and the domains to which they are related.

Telemedical Interdisciplinary Care Team Evaluation and Treatment of People With Low Back Pain: A Retrospective Observational Study

“… 38 Recent work has identified that fear of negative consequences, low counseling time, and lack of access to appropriate practitioners act as barriers to following evidence-based imaging guidelines in primary care physicians treating LBP. 39 Built into our model is access to health coaching, physical therapy, and other ancillary needs which may be helpful to provide care, potentially lessening the impetus for imaging.…”

A qualitative study exploring perceived barriers and enablers to fidelity of training and delivery for an intervention to reduce non-indicated imaging for low back pain

“…One coder (DT) identified the domains representing key barriers and enablers to enhancing fidelity to provider training or intervention delivery of the proposed intervention. The domains most likely representing perceived barriers and enablers were identified through considering the frequency of the belief statements, the presence of conflicting beliefs (i.e., participants reporting mixed views for a particular strategy to enhance fidelity to provider training or intervention delivery), and the perceived strength of the impact a belief may have on enhancing fidelity to provider training and intervention delivery (i.e., participants expressing beliefs they were particularly vocal about determined by length of participant quote or the use of emphatic or emotional speech) [ 31 , 32 ]. Using these criteria, the research team decided to take a more conservative approach to considering domains as non-relevant.…”

Factors influencing imaging clinical decision‐making in low back pain management. A scoping review

“…External drivers: (dis)incentives (Bussières et al, 2012;Pike et al, 2022), referral requirements (Nevedal et al, 2020;Pike et al, 2022), insurance/compensation claims (Blokzijl et al, 2021;Pike et al, 2022), surgical candidacy, colleague requests (Pike et al, 2022). Behavioural regulators: Access to other clinicians, patient education material, decision support tools (Pike et al, 2022), previous imaging . Knowledge (Un)familiarity/(un)awareness of CPG's (Bussières et al, 2012;Ganesh et al, 2022;Nevedal et al, 2020;Pike et al, 2022;, (dis)agreement with CPG (Bussières et al, 2012;Nevedal et al, 2020; or formal education (Bussières et al, 2012), CPG quality/conflicting messages (Bussières et al, 2012;Pike et al, 2022), LBP aetiology (Grimshaw et al, 2011)/clinical course (Nevedal et al, 2020;, awareness of LBP assessment/imaging indications , reliance on formal education/ongoing education , purpose of imaging (Bussières et al, 2012;Nevedal et al, 2020), purpose of CPG (Bussières et al, 2012) Social Patient pressure (Blokzijl et al, 2021;Bussières et al, 2012;Nevedal et al, 2020); ability to resist pressure (Blokzijl et al, 2021;Nevedal et al, 2020); patient retaliation (Nevedal et al, 2020).…”