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.
Highlights
Low back pain (LBP) care is frequently discordant with research evidence
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 or a specific pathology, or the patient is a candidate for interventions such as surgery [6]
Practice outcomes Imaging Participating General Practitioner (GP) were consulted by 44 LBP patients in the pre-intervention period, 18 of which were referred for imaging inconsistently with guidelines (4.1 guideline inconsistent imaging referrals (GICI) per 10 pts) (Table 3)
Summary
Low 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. Three significant evidencepractice gaps are inappropriate radiological imaging for LBP, addressing the psychosocial aspects of the pain experience, and providing patients with evidence based information [4, 5]. 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
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