Objectives Imaging of the back is not recommended for patients with non-specific low back pain (LBP). Imaging does not improve clinical outcomes and can lead to unnecessary treatment, harms and costs. Non-specific LBP accounts for about 90% of all LBP in primary care yet Australian data suggests over 25% of patients with new LBP are referred for imaging. This is despite many GPs being aware of the limited role of imaging in LBP. This suggests that knowledge of guideline recommendations on imaging in LBP is not enough to influence practice.
Factors such as desire to identify a pathoanatomical cause of pain, under-recognition of the biopsychosocial model of pain, fear of missing a serious diagnosis and patient expectations are well-recognised barriers to following guideline recommendations.
The aim of this program was to align physician behaviour with guideline recommendations and reduce inappropriate imaging for patients with LBP by addressing these barriers.
Method We developed a national educational visiting program on the management of patients with acute LBP in primary care. The program was delivered by 60 clinical service specialists (CSS; field force) across Australia to GPs between October 2018 and May 2019. Education sessions were delivered face-to-face or using virtual visit technology as either 1:1 or small group sessions.
The program was designed using principles of academic detailing and behavioral psychology, and informed by literature reviews, stakeholder consultation, interviews with clinicians, and specialist review. CSS were upskilled on commonly cited barriers to implementing guideline recommendations in clinical practice and how to employ specific enablers to overcome these challenges.
A retrospective pre-test survey with a control group will be administered in May 2019 to measure changes in GP knowledge, attitudes and practice following the education program. A program feedback form was administered one week after the educational visit to obtain short-term feedback.
Results Over 6000 GPs participated in the educational visiting program and discussion focused on three key messages: diagnosis of non-specific LBP without the need for imaging; identification and management of patients at risk of developing chronic disabling pain; and return to normal activities and work. Preliminary process evaluation data suggests the program was well received. A total of 751 health professionals, including 671 GPs, have completed the program feedback form. A total of 93% of responders report having their learning needs entirely met, 94% report the activity was entirely relevant to their practice and 94% report being entirely satisfied with the activity. Longer-term impacts of the program will be evaluated later in 2019 by assessing changes in GPs’ self-reported knowledge, attitudes and practice. These data will be presented at the conference.
Conclusions There are many barriers to implementing guideline recommendations in clinical practice. These barriers are potent drivers of inappropriate imaging in LBP and can be challenging to address. Preliminary process evaluation demonstrates that education programs that encourage discussion of barriers to implementing guideline recommendations and methods to address these are well received and relevant for GPs. Program evaluation of longer-term impacts will demonstrate the impact of this program on GPs knowledge, attitudes and practice in managing patients with LBP.
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