Using theory to improve low back pain care in Australian Aboriginal primary care: a mixed method single cohort pilot study

Abstract

BackgroundLow back pain (LBP) care is frequently discordant with research evidence. This pilot study evaluated changes in LBP care following a systematic, theory informed intervention in a rural Australian Aboriginal Health Service. We aimed to improve three aspects of care; reduce inappropriate LBP radiological imaging referrals, increase psychosocial oriented patient assessment and, increase the provision of LBP self-management information to patients.MethodsThree interventions to improve care were developed using a four-step systematic implementation approach. A mixed methods pre/post cohort design evaluated changes in the three behaviours using a clinical audit of LBP care in a six month period prior to the intervention and then following implementation. In-depth interviews elicited the perspectives of involved General Practitioners (GPs). Qualitative analysis was guided by the theoretical domains framework.ResultsThe proportion of patients who received guideline inconsistent imaging referrals (GICI) improved from 4.1 GICI per 10 patients to 0.4 (95 % CI for decrease in rate: 1.6 to 5.6) amongst GPs involved in the intervention. Amongst non-participating GPs (locum/part-time GPs who commenced post-interventions) the rate of GICI increased from 1.5 to 4.4 GICI per 10 patients (95 % CI for increase in rate: .5 to 5.3). There was a modest increase in the number of patients who received LBP self-management information from participating GPs and no substantial changes to psychosocial oriented patient assessments by any participants; however GPs qualitatively reported that their behaviours had changed. Knowledge and beliefs about consequences were important behavioural domains related to changes. Environmental and resource factors including protocols for locum staff and clinical tools embedded in patient management software were future strategies identified.ConclusionsA systematic intervention model resulted in partial improvements in LBP care. Determinants of practice change amongst GPs were increased knowledge of clinical guidelines, education delivered by someone considered a trusted source of information, and awareness of the negative consequences of inappropriate practices, especially radiological imaging on patient outcomes. Inconsistent and non-evidence based practices amongst locum GPs was an issue that emerged and will be a significant future challenge. The systematic approach utilised is applicable to other services interested in improving LBP care.

Using behaviour change theory and preliminary testing to develop an implementation intervention to reduce imaging for low back pain

“…Screen for clinical suspicion of underlying pathology to determine if imaging is necessary 2. Communicate with patients to explain their diagnosis and advise them that they don’t need imaging Barriers: - Diagnostic uncertainty [ 30 , 46 , 54 , 55 ] GPs uncertain in their skills in adequately diagnosing low back pain without imaging; Fear of missing a diagnosis of underlying pathology - Unsure how to advise patients that imaging is not needed [ 52 ] GPs uncertain how to convincingly explain to patients that imaging is not needed Facilitators: - Communication with patients [ 46 ] GPs confident in communicating with patients, to educate and reassure them Skills Physical capability - GPs need to have knowledge of: 1. Guidelines and appropriate indications for imaging 2.…”

“…Risks of imaging 4. Key concepts required in patient explanations explain why imaging isn’t necessary Barriers: - Lack of guideline awareness [ 30 , 46 , 52 , 55 ] GPs lack knowledge and awareness of current guidelines recommending appropriate use of imaging for low back pain - Unsure how to advise patients that imaging is not needed [ 52 ] GPs uncertain how to convincingly explain to patients that imaging is not needed Facilitators: - Guideline awareness [ 51 , 52 ] GPs display knowledge of current guidelines recommending appropriate use of imaging for low back pain - Awareness of limitations of imaging [ 51 ] GPs aware of limitations of imaging in providing diagnoses, directing management, or reassuring patients. - Awareness of danger of radiation exposure [ 51 ] GP aware that x-rays and CT scans add to radiation exposure and may be harmful Knowledge Psychological capability - GPs need to use a decision-making process which incorporates the appropriate use of imaging Barriers: - Diagnostic uncertainty [ 30 , 46 , 54 , 55 ] GPs uncertain in their skills in adequately diagnosing low back pain without imaging; Fear of missing a diagnosis of underlying pathology Facilitators: - Availability of guidelines [ 51 ] Guidelines act as a memory-aid and are more likely to be followed if they are accessible, concise and user-friendly.…”

“…Cues to remind them of imaging appropriateness 3. Resources to give to patient to improve ability to educate and reassure the patient in a limited time Barriers: - Time constraints [ 30 , 48 – 50 , 54 , 55 ] GPs don’t have enough time with patients to provide explanations and reassurance; Imaging seen as a quick way to reassure the patient and increase patient compliance - Diagnostic uncertainty [ 30 , 46 , 54 , 55 ] GPs uncertain in their skills in adequately diagnosing low back pain without imaging; Fear of missing a diagnosis of underlying pathology - Perceived need to give the patient something to take home [ 30 ] GPs feel that patients expect to receive something from the consult and an imaging referral is often used to achieve this Environmental context and resources Physical opportunity - GPs need to use their role as a trusted source of information provision to educate patients Facilitators: - Communication with patients [ 46 ] GPs confident in communicating with patients, to educate and reassure them - Senior GP who adheres to guidelines [ 52 ] Having a senior GP to model correct behaviour and act as a potential opinion leader to the other GPs Social influences Social opportunity - GPs need to be confident in their ability to: 1. Screen for clinical suspicion of underlying pathology to determine feel that imaging Ps feel that imaging if imaging is necessary 2.…”

Unmet Needs of Aboriginal Australians With Musculoskeletal Pain: A Mixed‐Method Systematic Review

“…One is investigation of the quality of MSP health care, such as the quality of communication, and practices with the potential to cause iatrogenic harm, such as opioid prescribing, the provision of non–evidence‐based and potentially harmful health information, and unwarranted radiologic imaging. Implementation‐oriented research aiming to identify disparities in health care practice behaviors and their determinants could then link to health service interventions to reduce evidence‐to‐practice gaps . While several articles report Aboriginal peoples’ experiences of low back pain, more qualitative research investigating the lived and health care experiences of other MSP conditions, especially OA, would be useful in further understanding disparities in access to care and informing health care delivery.…”

Non‐traumatic musculoskeletal pain in Western Australian hospital emergency departments: A clinical audit of the prevalence, management practices and evidence‐to‐practice gaps

“…A NTMSP audit tool was developed for data collection (Table S1), which was based on a synthesis of high‐quality MSP clinical guidelines and a LBP audit tool used previously in primary care . Working definitions were developed in accordance with guideline recommendations for audit items (summarised in Table S2).…”