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

The gap between evidence and practice is the one of the “most important challenges for public health in this century” p. 1 [1]. In the case of low back pain (LBP) there is increasing awareness that the tremendous burden of LBP would be reduced if health care was more concordant with evidence [2, 3]. Three significant evidence-practice gaps are inappropriate radiological imaging for LBP, addressing the psychosocial aspects of the pain experience, and providing patients with evidence based information [4, 5]. Current guidelines suggest that radiological imaging for LBP such as x-rays, Computerised Tomography (CT) or Magnetic Resonance Imaging (MRI) should only be ordered when there is suspicion of serious (e.g. cancer, fracture) or a specific pathology (severe or progressive neurological deficits), or the patient is a candidate for interventions such as surgery [6]. However, between 25–50 % of people with LBP receive an x-ray [7, 8] and this unwarranted imaging is costly, exposes the patient to radiation unnecessarily and may make patients worse by increasing their worry and inducing fear avoidance behaviours when common structural changes are reported without adequate explanation [6, 9, 10]. Psychosocial issues are amongst the strongest predictors of outcome in LBP [11]. Despite this, psychological distress, including anxiety and depression, is poorly recognised and then enacted upon by practitioners [4, 8]. A critical element of LBP care is providing patients with information that encourages self-management such as keeping physically active [12]. Despite this only 20 % of Australian patients with LBP are advised to remain active and avoid bed rest [13]. Gaps between evidence and practice such as these results in increased disability, burden, and cost.

Many different interventions have been applied to reduce evidence-practice gaps, but there is no consensus on what is most effective. Educational workshops directed toward practitioners are a common strategy. Psychosocial oriented educational workshops are reported to improve practitioner beliefs and self-reported behaviours [14, 15]. However the effect on actual practice is unclear, and is reported to have no impact or only modest improvements [16‐18]. A Cochrane review that investigated interventions to improve the appropriateness of LBP radiological imaging concluded that dissemination of educational materials or clinical guidelines to clinicians resulted in minimal changes [19]. The effect of audit and feedback, whereby practitioners are provided with feedback about the number of imaging requests for LBP, is variable with some studies reporting no influence on imaging referral practices and others reporting improvements [19]. Across a broad array of health conditions, audit and feedback has been reported to result in small but potentially important improvements to professional practice, and is most effective when there are low levels of performance at baseline and when verbal and written feedback is provided [20]. Alternatively attaching education messages to lumbar spine radiological reports is reported to reduce imaging requests by doctors by 20 % [21]. ‘Passive strategies’ such as disseminating guidelines to practitioners is reported to result in modest improvements to their beliefs and intentions to practice in an evidence-based way measured via self-report questionnaire [22]. However a study that measured practitioner behaviours from patient records demonstrated poorer results [23]. Therefore more research is needed to understand which interventions, in which settings and with which populations are effective in improving the quality of LBP care.

This was a single cohort pragmatic mixed methods pilot study. Mixed methods approaches can produce greater insights than quantitative or qualitative methods alone [28] and health service case studies such as this, in which a problem is studied in depth, are useful in exploring complex, multi-faceted health issues in real life settings [29].

Our aim, to improve LBP care in an Australian Aboriginal Primary Health Service provided by GPs in this pilot investigation, was partially achieved. There was a reduction in inappropriate imaging referrals amongst participating GPs. There were no changes in psychosocially oriented LBP assessments or the provision of LBP information; although in qualitative interviews GPs suggested that they were performing more of these practice behaviours than was being recorded. However an unforeseen issue was the practices of locum GPs.

Guideline inconsistent LBP imaging referrals amongst participating GPs reduced from 18/44 patients to 2/46 patients during the project. The primary interventions used to influence this behaviour (and TDF behavioural domain) were three educational workshops. The determinants of change were; improved knowledge of LBP imaging guidelines (knowledge), an awareness of the negative consequences of inappropriate imaging (beliefs about consequences), and education delivered by a trusted source (social influence). In our initial analysis we identified the availability of clinical tools, including imaging guidelines (environmental context and resources) and practitioner skills in explaining to patients why imaging was not needed (skills) however these were less prominent determinants of practice change. GPs continued to identify the expectations of insurance companies for imaging, and to a lesser degree patients, as social influences. A novel approach in our study was that in education workshops for GPs we focussed on the negative consequences of inappropriate radiological imaging, in particular the potential negative effects on patient beliefs and iatrogenic LBP disability [9]. Other studies, including the IMPLEMENT trial have focussed on the consequences of missing an underlying pathology by not imaging, radiation exposure, cost, or for imaging to guide treatment [26, 40]. Our findings suggest that to improve LBP imaging referral practices, educational workshops should focus on evidence based recommendations for radiological imaging, practitioner knowledge and beliefs about the consequences in relation to the potential negative effects of imaging to the patient within a biopsychosocial model of LBP, and delivered by someone who is identified as a trusted source of information.

There were no changes to psychosocial oriented assessments reflected in audit results. However GPs indicated qualitatively that they understood more about psychosocial factors (knowledge) and were providing more psychosocially oriented assessments than was reflected by clinical audit data. In our study we implemented the STarT Back tool [37] to aid memory, attention and decision processes for GPs to deliver psychosocially oriented care. GPs felt the STarT Back was useful however there was poor uptake/recording. On reflection, to improve the uptake of STarT Back and recording of psychosocial care we needed greater attention to the environment context. This includes embedding STarT Back within the clinic management software or introducing a “tick box” within electronic patient records when psychosocial assessment and care has been provided. As has been noted with other online clinical aids, to increase uptake tools need to be integrated into existing systems and routine workflow [42]. This would also allow reliable recording of practice for future research.

There was a modest increase in the provision of self-management information amongst participating and GPs indicated qualitatively that they were providing more self-management advice to patients than was reflected in audit results. The potential mismatch between GP reports and self-management advice measured via clinical audit means that future work needs to develop a more reliable system for recording self-management advice that is integrated into usual clinical systems [5]. One planned intervention to increase the delivery of LBP self-management information was the development of culturally appropriate LBP information. This was not developed in time for GPs to utilise however GPs did make use of a printed patient information leaflet provided during one education session. This suggests that the availability of patient information resources, in addition to knowledge of what information to provide to patients, is again, a key environmental and contextual enabler to this behaviour.

A significant unforeseen issue that emerged during the project were the practices of locum GPs (environment context & resources) that was not identified in our initial analysis. During the project, imaging rates increased from 5/33 guideline inconsistent imaging referrals per patient to 18/44 for locum/part-time staff with no changes in psychosocially oriented LBP assessments or the provision of LBP information. During informal discussion about this study, one locum GP revealed to IL how he considered himself experienced in musculoskeletal medicine and was confident managing patients with LBP. Influencing the practices of short term locum staff will, without doubt, be a substantial challenge, and more research examining the beliefs and attitudes of this group about LBP and the determinants of their practices would be valuable. Research has highlighted the challenges of maintaining the quality of care in the rural context where there are higher numbers of locum staff and greater workforce turnover [43, 44] however little research has reported interventions aiming to improve the quality of care in this context. Participating GPs were very aware of this issue, and identified environmental and contextual factors, including better orientation processes and protocols for LBP care and focussing on consistent staffing levels, as priorities. Other strategies may need to be at a systems level within the organisation, such as professional leadership and focussing on a ‘culture’ of evidence based practice [45]. More broadly, influencing medical practices in LBP care such as during medical training, or via well-resourced social marketing campaigns [46] may be needed.

The gap between LBP evidence and practice is a tremendous issue facing health care systems and systematic approaches to improve care are needed. Systematic LBP research translation is in its infancy. Our pilot study contributes by describing the process used to understand, plan and implement change in one primary care service. Our interventions resulted in improvements in two of our desired behaviours. A recent trial, the IMPLEMENT study, resulted in modest improvements in practitioner intentions to practice in an evidence based manner and no change in measured behaviour; lumbar spine imaging referrals [5]. Both our study and the IMPLEMENT study used a systematic, step-by-step approach including the TDF. Comparing both studies must be done with caution as they are different in their scope and context, and observational research may have inflated outcomes compared to experimental studies. Nevertheless there is value in contrasting the findings and discussing the implications for future LBP implementation endeavours.

Firstly, we found improvements in imaging behaviours and self-management advice amongst participating GPs to be generally coherent with our analysis of barriers and enablers and the interventions we developed in response to these, providing support for this approach. However although this approach has theoretical support, to date there is a dearth of research and hence little evidence that there are superior better outcomes in LBP care when a systematic, theory directed approach is taken [5]. More research utilising systematic, theory-informed approaches are needed. Secondly, in our behavioural analysis, with the exception of intentions and reinforcement, we identified the same behavioural domains as the IMPLEMENT study (knowledge, physical skills, beliefs about consequences, social influences, memory, attention and decision processes, environmental context & resources, social professional role/identity, and reinforcement) but different barriers and enablers. For example as previously discussed, we identified the domain “beliefs about consequences” with respect to GPs who were unaware of the negative consequence of inappropriate imaging practices on patient outcomes, whereas this was not a primary focus in the IMPLEMENT study [26]. Differences in the barriers and enablers between the two studies may be because of the different study contexts or different methods employed to investigate barriers and enablers. The authors of IMPLEMENT postulated that a lack of change in GPs behaviours may have been due to a biomedical or structural orientation toward LBP [5], suggesting that this was a barrier that may have been missed in their initial behavioural analysis. In contrast this was a barrier we identified and aimed to address in our interventions. Both studies used qualitative methods in the analysis of behaviour however different findings may reflect a different perspective of researchers. Improving the identification of modifiable barriers to LBP practice is important if they are to be addressed. We suggest that LBP implementation researchers who are targeting similar behaviours consider the barriers and enablers that our study, the IMPLEMENT trial [26] and other studies have identified [40, 47] and examine these factors for relevancy within their populations. We anticipate that as the field of LBP implementation research develops the modifiable determinants of LBP behaviours will become more refined (e.g. knowledge, memory) and their applicability for which target populations in which contexts understood so as to guide practice improvement initiatives.

Lastly our study differed significantly to the IMPLEMENT study because it was a led a by service ‘insider’. Data suggests that IL’s position within the health service may have been a positive influence on outcomes. Project ‘champions’ can improve implementation success by increasing motivation and act as a positive social influence for change within their organisation [24]. However it may be difficult to identify and engage change champions in a large multisite study. Also, intensive systematic approaches such as in our study are resource intensive, intellectually and financially [48], and may be challenging to replicate across a number of settings.

This was a pilot investigation and there is a tension between smaller service level implementation initiatives and the need to scale-up interventions so that practice improvements may be applied across broader populations. Our findings suggest several avenues that could contribute to the issue of broader change and that warrant further exploration. Firstly and as we have discussed, while the outcomes of practitioner education on improving LBP radiological imaging referral practices is equivocal [19], we recommend education that incorporates the negative consequences of inappropriate imaging on patient outcomes [9]. Secondly, reducing environmental contextual barriers to evidence based practice by integrating evidence based tools into usual clinical systems warrants investigation. In our study a future priority is the STarT Back tool. Electronic clinical decision making tools integrated into usual care processes have been trialled successfully in other areas of primary care [49] however the potential application to LBP care is in its infancy.

The strengths of this pilot project were the application of a careful systematic approach and the use of quantitative and qualitative methods to provide an in-depth analysis. The limitations are that it is in one health care service involving a small number of GP’s and the transferability of the findings elsewhere are unknown. One planned intervention strategy was the development of culturally appropriate LBP information (Lin et al- submitted) which was aiming to increase the amount of patients receiving LBP information. Unfortunately this was not developed and tested in a time to include within the project and is the focus of ongoing work. Another potential factor was that IL was a service ‘insider’ and responsible for implementation of interventions and data collection, potentially introducing the element of bias. We attempted to minimise bias by having clear criteria for the clinical audits and in the qualitative analysis by ensuring there are steps to ensure rigour. Although during interviews participants were very forthcoming, it is possible that IL’s role may have influenced disclosure or the perspectives of interviewees, including viewing IL as a “trusted source of information”. Alternatively it is also possible that, as an insider, IL was also uniquely positioned to understand the context of the service, and this may have positively influenced disclosure. Other methods exist to understand the determinants of change, for example to quantitatively measure participants knowledge, skills and beliefs about their capabilities to undertake the desired behaviours before and following the interventions. This could be considered in future work to compliment qualitative perspectives. There was a two year time period for the project and it is possible that other factors external to the project may be responsible for changes. One activity was a one-day interprofessional symposium for health practitioners coordinated by IL and PO, and that also included a pain medicine specialist and clinical psychologist. The symposium focussed on assessing and managing persistent pain conditions and held in the town in which the study was conducted. There were no known state or national campaigns targeting better LBP care. It is possible that the interprofessional symposium may have reinforced information presented to GP participants within the educational workshops as the content was very similar and thus contributed to change. However although this is possible, we believe it is unlikely to have been a major influence as participants discussed project interventions during interviews, linking these to changes. A significant advantage of the approach is that it has provided insight into the determinants of change, and therefore enabled us to prioritise areas to address in the future improvement of care.

The application of a systematic research translation approach resulted in partial improvements in LBP care. Determinants of practice change amongst GPs in relation to radiological imaging referrals 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. The effect on other behaviours was less clear. We have identified issues that we need to address to improve LBP care further; the practices of locum staff and improved integration of clinical tools into clinical software are two priorities. Our approach and findings are applicable to other health services interested in improving LBP care and contributes to the cumulative evidence base in LBP implementation research.