Background
Methods
Overview of development and preliminary testing of the implementation intervention
Stage 1: Development of an implementation intervention using the behaviour change wheel
Stage 2: Development and preliminary testing of a clinical resource to be used in the implementation intervention
Final implementation intervention to reduce imaging for LBP in general medical practice
Results
Stage 1: Development of a draft implementation intervention using the behaviour change wheel
Step 1: Understanding the behaviour
Changes required to reduce referral for non-indicated imaging for low back pain | Barriers and facilitators (identified through literature review) that will be influenced by the identified change | Theoretical Domains Framework component | COM-B component (Behaviour Change Wheel) |
---|---|---|---|
General practitioner (GP) changes required: | |||
- GPs need to have the skills to: 1. 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: 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. Limitations of imaging in the diagnosis and management of low back pain 3. Risks of imaging 4. Key concepts required in patient explanations explain why imaging isn’t necessary | Barriers: 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: 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: 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. | Memory, attention, and decision process | Psychological capability |
- GPs need to have: 1. Increased time for patient education 2. 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: 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 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. Reassure patients without imaging | Barriers: GPs feel that patients often want or expect imaging, and that they don’t understand the limited usefulness of imaging to manage low back pain; Fear that patients will be upset if they don’t receive imaging or may devalue the GP | Beliefs about capabilities | Reflective motivation |
- GPs need to be aware of the risks and benefits of referring for imaging, and the likely consequences of referring for imaging when it isn’t indicated | Barriers: - Perceived usefulness of imaging and negative consequences to following guidelines [30, 46, 47, 49‐52, 55] GPs feel that imaging will be useful – provide diagnosis, help to reassure the patient, help to facilitate patient management, build patient relationships; They feel there are more negative consequences associated with following guideline advice not to refer for imaging GPs report that they receive direct pressure from patients to refer for imaging; They feel that if they don’t comply with the request patients will devalue them and go elsewhere to obtain imaging GPs perceive that imaging will help to reassure anxious patients that their condition is not serious and will increase compliance with advice GPs feel that they may open themselves to possible litigation if they don’t refer for imaging Specific patient characteristics more likely to lead to increased imaging (i.e. elderly, workers compensation claims, etc.) Facilitators: GPs are in agreement with the guidelines and feel that more positive consequences are associated with following guideline advice not to refer for imaging | Beliefs about consequences | Reflective motivation |
Patient changes required: | |||
- Patients need to have knowledge of: 1. Limitations of imaging in the management of low back pain 2. Risks of imaging 3. Signs to be aware of that may indicate the need for imaging | Barriers: Patients feel that imaging will provide reassurance to them by excluding pathological causes of low back pain and providing a diagnosis, particularly when pain levels are high or not resolving - Lack of awareness of risks of imaging [19] Patients report being unaware of potential risks of imaging, and even where some risks are recognised report that potential benefits outweigh these risks. | Knowledge | Psychological capability |
- Patients need to be aware of the decision process that was used to determine that they don’t need imaging | Barriers: Patients feel that imaging will provide reassurance to them by excluding pathological causes of low back pain and providing a diagnosis, particularly when pain levels are high or not resolving Facilitators - Communication with patients [46] Patients whose GPs communicate with them adequately are more likely to be reassured without the use of imaging | Memory, attention, and decision process | Psychological capability |
- Patients need to receive educational resources focusing on patient reassurance, appropriate management and why imaging isn’t required | Barriers: Patients feel that imaging will provide reassurance to them by excluding pathological causes of low back pain and providing a diagnosis, particularly when pain levels are high or not resolving - Lack of awareness of risks of imaging [19] Patients report being unaware of potential risks of imaging, and even where some risks are recognised report that potential benefits outweigh these risks | Environmental context and resources | Physical opportunity |
- Patients need to have less access to contradictory information sources, or more access to evidence-based information sources | Barriers: - Influences from friends, family, or other healthcare practitioners, and previous experience that imaging is important [19] Advice from friends, family, or other healthcare practitioners, and previous experience of referral for imaging for low back pain likely to increase perceived need for imaging | Social influences | Social opportunity |
- Patients need to be aware of possible outcomes of the suggested management plan, and possible consequences of being referred for imaging when not indicated | Barriers: Patients feel that imaging will provide reassurance to them by excluding pathological causes of low back pain and providing a diagnosis, particularly when pain levels are high or not resolving | Beliefs about consequences | Reflective motivation |
- Patients need to feel that they are receiving emotional support from the GP without imaging | Barriers: - Emotional support and validation of pain from GP referring for imaging [21] Patients feel that GPs who comply with their wishes to refer for imaging are providing necessary emotional support and validating their pain | Emotion | Automatic motivation |
Step 2: Identify intervention options
Step 3: Identify content and implementation options
Intervention function (targeted to GP/Patient) | Behavioural change technique | Implementation intervention: content | Policy category | Implementation intervention: mode of delivery |
---|---|---|---|---|
Education (GP) | Information about health consequences | Guidelines for appropriate diagnosis and management of low back pain | 1. Communication/marketing 2. Service provision | 1. Providing GP with educational material 2. Training session with GP - Verbal discussion of guidelines |
Information regarding the appropriate diagnosis and management of low back pain | 1. Communication/marketing | 1. Providing GP with educational material - Copies of developed clinical resource provided to GPs to read | ||
Prompts/cues | Decision tree for appropriate imaging for low back pain (clinical decision support) | 1. Environmental/social planning | 1. Providing GP with clinical resources - Copies of developed clinical resource provided to GPs to use during a consult, includes decision tree for clinical decision support | |
Management plan | 1. Environmental/social planning | 1. Providing GP with clinical resources - Copies of developed clinical resource provided to GPs to use during a consult, includes customisable management plan | ||
Training (GP) | Feedback on the behaviour | Explanation of the goals of using the clinical resource to reduce imaging for low back pain | 1. Communication/marketing 2. Service provision | 1. Providing GP with training material - Information sheet about the developed clinical resource provided to GPs to read 2. Training session with GP - Verbal discussion of goals |
Instruction on how to perform a behaviour | Instruction on how the developed clinical resource can be used: - as clinical decision support - as a checklist or reminder of correct management - to provide key educational messages to patients - to provide individualised management advice - in a time-efficient manner | 1. Communication/marketing 2. Service provision | 1. Providing GP with training material - Information sheet about the developed patient education booklet provided to GPs to read 2. Training session with GP - Verbal discussion of how to use the developed clinical resource | |
Modelling (GP) | Demonstration of a behaviour | Modelling of appropriate information to be given to the patient during a consult | 1. Environmental/social planning 2. Service provision | 1. Providing GP with clinical resources - Copies of developed clinical resource provided to GPs to use during a consult, includes key messages to be delivered to patient 2. Training session with GP - Demonstration by training facilitator of how to use the developed clinical resource |
Environmental restructuring and Enablement (GP) | Adding objects to the environment | Developed clinical resource for use during a consult - Facilitate GP-patient communication - Provide a tool to help educate and reassure patients during a consult, in a time-efficient manner - Provide clinical decision support, and a reminder of appropriate imaging use and management advice to give to patient | 1. Environmental/social planning | 1. Providing GP with clinical resources - Copies of developed clinical resource provided to GPs to use during a consult |
Education (Patient) | Information about health outcomes | Information to: - Address common misconceptions around low back pain, with a particular focus on imaging - Reassure the patient that their low back pain is not serious - Explain why imaging is not necessary - Provide suitable management advice - Provide information regarding symptoms associated with more serious pathology | 1. Communication/marketing | 1. Providing patient with educational material - GP delivers the developed clinical resource to the patient during a consult, providing key messages and individualising the management plan - Patient can use the resource as an ongoing resource of information and individualised management advice |
Persuasion (Patient) | Credible source | Clinical resource delivered by GP and developed by a reputable university research team | 1. Environmental/social planning | 1. Providing patient with clinical resources - GP delivers the developed clinical resource to the patient during a consult, providing key messages and personalising the management plan |
Information about health consequences | Decision tree for appropriate imaging for low back pain (clinical decision support) | 1. Service provision | 1. GP-Patient consult - GP uses the decision tree in the clinical resource during the consult to explain to the patient why they don’t need imaging, facilitates shared decision making | |
Environmental restructuring and Enablement (Patient) | Adding objects to the environment | Customisable clinical resource given to patient in consult - Facilitate GP-patient communication - Short, appealing and easy to read with limited text and clear information - Reinforce or remind of information provided within the consult - Provide appropriate, individualised management advice - Provide links to other resources with guideline consistent messages | 1. Environmental/social planning | 1. Providing patient with clinical resources - GP delivers the developed clinical resource to the patient during a consult, providing key messages and personalising the management plan - Patient can use the booklet as an ongoing resource of information and individualised management advice |
Stage 2: Development and testing of the clinical resource
Development of the clinical resource content and format
Expert review of the first iteration of the clinical resource
Resultant changes to the first iteration of the clinical resource
Stakeholder feedback on the second iteration of the clinical resource
General practitioner | |
Booklet would help to decrease imaging pressure from patients “Yeah [help decrease pressure felt to refer patients for imaging] because I mean it’s got the resources, the references at the back and the websites that they can look up for more information to see why it’s not necessary, rather than just coming from my word of mouth” (GP10) Booklet provides a reminder of correct imaging decisions for the GP “…[algorithm] also helpful for the doctor as a reminder maybe for someone who doesn’t, just as a reminder you know, think of those sort of red flags that need to be screened for” (GP8) Potential negative consequences of not referring for imaging when a patient really wants it “if people are hell-bent on getting imaging you’re pretty dumb not to give it to them, because it’ll be the one that you don’t that’ll be the one that has some bizarre weird tumour or something” (GP5) “I think if someone was adamant that they wanted an x-ray I think that they would be unhappy leaving the room without an x-ray request form, whether you give them this paperwork or not” (GP10) | |
Health consumers | |
Information in the booklet is reassuring “I found it quite reassuring you know that quite a lot of people who have imaging might show up you know some kind of change which isn’t actually going to be problematic in terms of effect to their life” (MoP2) “I guess it’s reassuring to know that everyone will get back pain, or most people will get back pain, but the what you can do to decrease it is super helpful” (MoP6) Useful to receive the booklet from the GP to give appropriate information and management “I think it would be helpful [to receive the booklet from the GP] because I think different people approach GPs with a different pace of knowledge and different set of expectations” (MoP1) “it [having the GP go through the booklet] highlights that you are going through and thinking about it and that you’ve got a booklet telling you the same thing and a GP telling you the same thing which sort of reinforces the message” (MoP1) “I should think so [feel reassured]. I know I mean again a lot of people are different but I think the fact that you’re getting it through the GP I think for a lot of people that gives it extra credibility” (MoP3) Booklet demonstrates why the GP made their decision not to refer for imaging “that little the thing on page 2 [flowchart] makes it very clear on which way, which pathway you need to go basically” (MoP8) Booklet provides a reminder of management advice “I think it’s good that GPs told me things but I might get distracted by other things happening in life as well, so if I had a booklet I could always refer back and so it’s like a dictionary – if I need to look up something I can always refer to this booklet” (MoP5) Booklet can be used to by patients to monitor their progress and when they need to go back to the GP “If you haven’t been to the doctor for a while and you think hang on what should I do again, like what should I do, should I go back - that whole when should I return for further medical advice [in the booklet] that I think that’s really good” (MoP4) “Yes [would feel reassured back pain being managed correctly]; that sort of makes you feel that you know what to do if it gets worse. So you know it’s been managed at the level it’s at and then if it gets any worse you can look here and go, oh yeah, that happens, probably should go get that checked” (MoP7) Reading booklet changed beliefs on the importance of imaging “I think a lot of people believe, and I certainly believed, that this [imaging] would give you that answer” (MoP1) “[the booklet states] that you should always look to solve pain with the least amount of surgery, doctors, x-rays, things as possible first” (MoP4) “I do think it [the booklet] would have changed the way I thought about imaging at first” (MoP2) “Yeah, yeah for sure [booklet change beliefs]. Now I know that imaging won’t necessarily show anything or it will only show something that most people will also have but not necessarily have pain for. I didn’t know that at all” (MoP7) Booklet unlikely to change beliefs on the importance of imaging “Not to me [booklet help change beliefs], I think, I would still, I would still get an x-ray or something at the start just to make sure” (MoP9) “I believe in a pain threshold if it’s really painful then generally it’s a sign something serious is wrong so that then you should probably consider getting imaging more strongly” (MoP1) |
Resultant changes to the second iteration of the clinical resource
Resultant changes to the implementation intervention
Final implementation intervention to reduce GP referral for non-indicated imaging for LBP
-
Provide clinical decision support to the GPs
-
Provide a reminder to GPs of appropriate clinical indicators for imaging of the low back
-
Facilitate communication between GPs and patients to provide reassurance and explain why imaging isn’t required in their case
-
Provide the GP with a useful clinical resource that they can give the patient to take home instead of a non-indicated imaging referral
-
Provide the patient with a resource, individualised for them by the GP, to include information on: why the GP determined they didn’t need imaging, what management strategies they should undertake, and what to do if their LBP does not resolve
-
Provide the patient with educational resources they can continue to refer to, and share with friends or family
-
Be quick, easy, and appealing to read
-
Explain why the clinical resource was developed and how it is intended to be used through discussion, provision of an information sheet (available in Additional file 5), and demonstration of how to use the clinical resource in clinical practice