Physician-reported barriers to using evidence-based recommendations for low back pain in clinical practice: a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework

Abstract

Background Adoption of low back pain guidelines is a well-documented problem. Information to guide the development of behaviour change interventions is needed. The review is the first to synthesise the evidence regarding physicians’ barriers to providing evidence-based care for LBP using the Theoretical Domains Framework (TDF). Using the TDF allowed us to map specific physician-reported barriers to individual guideline recommendations. Therefore, the results can provide direction to future interventions to increase physician compliance with evidence-based care for LBP. Methods We searched the literature for qualitative studies from inception to July 2018. Two authors independently screened titles, abstracts, and full texts for eligibility and extracted data on study characteristics, reporting quality, and methodological rigour. Guided by a TDF coding manual, two reviewers independently coded the individual study themes using NVivo. After coding, we assessed confidence in the findings using the GRADE-CERQual approach. Results Fourteen studies ( n = 318 physicians) from 9 countries reported barriers to adopting one of the 5 guideline-recommended behaviours regarding in-clinic diagnostic assessments (9 studies, n = 198), advice on activity (7 studies, n = 194), medication prescription (2 studies, n = 39), imaging referrals (11 studies, n = 270), and treatment/specialist referrals (8 studies, n = 193). Imaging behaviour is influenced by (1) social influence — fr om patients requesting an image or wanting a diagnosis ( n = 252, 9 studies), (2) beliefs about consequence— physicians believe that providing a scan will reassure patients ( n = 175, 6 studies), and (3) environmental context and resources— physicians report a lack of time to have a conversation with patients about diagnosis and why a scan is not needed ( n = 179, 6 studies). Referrals to conservative care is influenced by environmental context and resources —long wait-times or a complete lack of access to adjunct services prevented physicians from referring to these services ( n = 82, 5 studies). Conclusions Physicians face numerous barriers to providing evidence-based LBP care which we have mapped onto 7 TDF domains. Two to five TDF domains are involved in determining physician behaviour, confirming the complexity of this problem. This is important as interventions often target a single domain where multiple domains are involved. Interventions designed to address all the domains involved while considerin...

Clinician and patient beliefs about diagnostic imaging for low back pain: a systematic qualitative evidence synthesis

“…Similar to a review by Hall et al, we found clinicians believed an absence of serious pathology on imaging provides reassurance to some patients. 95 We have shown that this was not always true from the patient's perspective; some patients with chronic low back pain seemed relieved by the presence of pathology on their imaging results-that is, the diagnostic grail. Indeed, a mega-ethnography by Toye et al found that patients with chronic musculoskeletal pain value having visual 'proof' in the form of imaging results to legitimise their invisible pain.…”

“…Patients, on the other hand, did not appear to be aware of such harms. Previous reviews have suggested a clinician's decision to ultimately pursue imaging is influenced by several complex factors including a belief that imaging is reassuring, 95 misconceptions about clinical guidelines, 12 and a desire to satisfy the patient. 96 Our review suggests that a mismatch in beliefs and understanding about the harms of imaging could be an important new target for intervention.…”

Data-driven versus theory-driven methods to understand health service implementation problems: A case study of childhood vaccination barriers

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What do the General Public Believe About the Causes, Prognosis and Best Management Strategies for Low Back Pain? A Cross Sectional Study

“…[12] Although evidence for what is driving many of these behaviours is sparse, a recent systematic review of qualitative studies found that overuse of imaging may be in part due to patient beliefs and expectations. [13] For example, GPs reported that their patients believe an image will provide the best diagnosis for their back pain and it is easier to order an image than to try and explain otherwise. [13] Therefore, understanding the nature of patient beliefs and expectations regarding treatment will help coordinate efforts to improve consistency and quality of care.…”

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