Explaining variation in GP referral rates for x-rays for back pain

Patterns of knee osteoarthritis management in general practice: a retrospective cohort study using electronic health records

OBJECTIVE

This study determined patterns of knee osteoarthritis (OA) management by general practitioners (GPs) using routine healthcare data from Dutch general practices from 2011 to 2019.

DESIGN

A retrospective cohort study was conducted using the Integrated Primary Care Information database between 2011 and 2019. Electronic health records (EHRs) of n = 750 randomly selected knee OA patients (with either codified or narrative diagnosis) were reviewed against eligibility criteria and n = 503 patients were included. Recorded information was extracted on GPs' management from six months before to three years after diagnosis and patterns of management were analysed.

RESULTS

An X-ray referral was the most widely recorded management modality (63.2%). The next most widely recorded management modalities were a referral to secondary care (56.1%) and medication prescription or advice (48.3%). Records of recommendation of/referral to other primary care practitioners (e.g. physiotherapists) were found in only one third of the patients. Advice to lose weight was least common (1.2%). Records of medication prescriptions or recommendation of/referral to other primary care practitioners were found more frequently in patients with an X-ray referral compared to patients without, while records of secondary care referrals were found less frequently. Records of an X-ray referral were often found in narratively diagnosed knee OA patients before GPs recorded a code for knee OA in their EHR.

CONCLUSION

These findings emphasize the importance of better implementing non-surgical management of knee OA in general practice and on initiatives for reducing the overuse of X-rays for diagnosing knee OA in general practice.

Patient requests for radiological services: An Australian study of patient agency and the impact of online health information

ISSUE ADDRESSED

The Internet has been instrumental in patients' knowledge about health and medicine through increasing consultation of online sources that advocate self-management. For example, those patients who request referrals from their doctors for tests and procedures in radiology. Such patient-initiated referral requests can devolutionise the traditional model of health care. This study aimed to understand individuals who sought online health information (OHI) and whether requests for radiological referrals were the result of OHI seeking.

METHODS

The individuals targeted were those who have had a radiological procedure in the past 5 years. Using an online survey tool, individuals completed a 20-min anonymous survey. Included in the survey was a validated digital health literacy measurement scale, eHEALS.

RESULTS

Those who scored higher on the eHEALS measure were likely to be under 55 years of age and were more inclined to request radiological referrals. Though they were not concerned with the credibility of sourced websites, most secured the desired outcome from their requests.

CONCLUSION

Overall, this study indicates that patients are consulting online sites for health information, and individuals with higher digital literacy scores are asking doctors for referrals for radiological tests and procedures. These findings confirm our anecdotal experience in radiology departments. So what?: In conducting this study, we hope to better inform radiology and other health practitioners of the way OHI is impacting clinical practice.

Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing

BACKGROUND

How contextual factors may influence GP decisions in real life practice is poorly understood. The authors have undertaken a scoping review of antibiotic prescribing in primary care, with a focus on the interaction between context and GP decision-making, and what it means for the decisions made.

METHOD

The authors searched Medline, Embase and Cinahl databases for English language articles published between 1946 and 2019, focusing on general practitioner prescribing of antibiotics. Articles discussing decision-making, reasoning, judgement, or uncertainty in relation to antibiotic prescribing were assessed. As no universal definition of context has been agreed, any papers discussing terms synonymous with context were reviewed. Terms encountered included contextual factors, non-medical factors, and non-clinical factors.

RESULTS

Three hundred seventy-seven full text articles were assessed for eligibility, resulting in the inclusion of 47. This article documented the experiences of general practitioners from over 18 countries, collected in 47 papers, over the course of 3 decades. Contextual factors fell under 7 themes that emerged in the process of analysis. These were space and place, time, stress and emotion, patient characteristics, therapeutic relationship, negotiating decisions and practice style, managing uncertainty, and clinical experience. Contextual presence was in every part of the consultation process, was vital to management, and often resulted in prescribing.

CONCLUSION

Context is essential in real life decision-making, and yet it does not feature in current representations of clinical decision-making. With an incomplete picture of how doctors make decisions in real life practice, we risk missing important opportunities to improve decision-making, such as antibiotic prescribing.

Determinants of clinical practice guidelines' utilization for the management of musculoskeletal disorders: a scoping review

Context

Many clinical practice guidelines have been developed for the management of musculoskeletal disorders (MSDs). However, there is a gap between evidence-based knowledge and clinical practice, and reasons are poorly understood. Understanding why healthcare providers use clinical practice guidelines is essential to improve their implementation, dissemination, and adherence.

Aim

To identify determinants of clinical practice guidelines’ utilization by health care providers involved in the assessment and management of MSDs.

Method

A scoping review of the literature was conducted. Three databases were searched from inception to March 2021. Article identification, study design, methodological quality, type of healthcare providers, MSDs, barriers and facilitators associated with guidelines’ utilization were extracted from selected articles.

RESULTS: 8671 citations were retrieved, and 43 articles were selected. 51% of studies were from Europe, and most were quantitative studies (64%) following a cross-sectional design (88%). Almost 80% of articles dealt with low back pain guidelines, and the most studied healthcare providers were general practitioners or physiotherapists. Five main barriers to guideline utilization were expressed by providers: 1) disagreement between recommendations and patient expectations; 2) guidelines not specific to individual patients; 3) unfamiliarity with “non-specific” term, or with the bio psychosocial model of MSDs; 4) time consuming; and 5) heterogeneity in guideline methods. Four main facilitators to guideline utilization were cited: 1) clinician’s interest in evidence-based practice; 2) perception from clinicians that the guideline will improve triage, diagnosis and management; 3) time efficiency; and 4) standardized language.

Conclusion

Identifying modifiable determinants is the first step in developing implementation strategies to improve guideline utilization in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04204-w.

Axial spondyloarthritis 10 years on: still looking for the lost tribe

Despite the publication of various recommendations, quality standards and referral strategies to promote early diagnosis in axial SpA (axSpA) over the last decade, there remains a significant delay to diagnosis, leading to a lost tribe of undiagnosed, untreated patients with persistent back pain and axSpA symptoms. This review discusses the various factors contributing to diagnostic delay in axSpA, while providing recommendations to improve the diagnostic pathway, for example use of the online Spondyloarthritis Diagnosis Evaluation (SPADE) tool (http://www.spadetool.co.uk/). Significant shortcomings exist at both the primary and secondary care level, with healthcare professionals often lacking knowledge and awareness of axSpA. Myths regarding the classical signs and symptoms still prevail, including the perception of axSpA as a male disease, only occurring in individuals who are HLA-B27 positive with raised inflammatory markers. Individuals within this lost tribe of undiagnosed patients are likely lacking adequate treatment and are thereby at risk of worse clinical outcomes. It is therefore vital that public health initiatives are implemented to improve education of healthcare professionals and to ensure early specialist referral, to ultimately improve the lives of patients with axSpA.

Quality of Referral Letters Written by Family Physicians to Otologists -A Peer Assessment

Introduction

Otolaryngology is a field with a high referral rate; however, there is a dearth of research on the quality of referral letters written in this field. This study was carried out to explicitly assess the quality of referral letters, more specifically in the field of otology.

Materials and Methods

Two otologists assessed referral letters written by general practitioners or primary care physicians working as family physicians. They were asked to make independent assessment on different variables related to the quality of referral letters and their appropriateness. A "qualified referral letter" in the current study is defined as a letter with standard items, including, description of chief complaint, description of associated symptoms, relevant physical findings, past medical history, drug history, family history, and reasons for referral.

Results

A total of 1000 referral letters written by 652 primary care physicians were investigated in the current study. The obtained results indicated that 74% of referral letters to otologists contained inadequate information regarding various items in the referral letters. Symptoms, diagnosis, and signs were only reported in 28.3%, 28.9%, and 3.6% of the letters, respectively. The findings showed that most common reasons for referrals were uncertainty in diagnosis (52.4%), persistence of the patient (32.6%), and failed therapy (32%). With regards to case-specific conditions, the highest referral rates were related to external otitis, otitis media with effusion, and acute otitis media.

Conclusion

According to the obtained results of the current study, the content of referral letters were insufficient or inappropriate. Therefore, it is recommended to improve otolaryngology syllabus and provide suitable courses for undergraduate students in order to become familiar with the importance of referral letter writing.

Does the implementation of a care pathway for patients with hip or knee osteoarthritis lead to fewer diagnostic imaging and referrals by general practitioners? A pre-post-implementation study of claims data

Background

The Dutch care for hip and knee osteoarthritis (OA) is of good quality, but there is room for improvement regarding the efficient use of diagnostic imaging and conservative treatment. Therefore a stepped-care approach, in the shape of the care pathway ‘Better exercise in osteoarthritis’, was implemented to reduce the number of diagnostic imaging requested by GPs and referrals of GPs to orthopaedic care.

Methods

In 2015, the pathway is implemented with the use of educational meetings, distributing guidelines and incorporating reminders in the GPs’ referral application. To evaluate the effect of the pathway on the diagnostic and referral behaviour of GPs, hip and knee related health insurance claims are used together with claims of other joints and of a control region for comparison. The average number of claims and the percentage change in the post-implementation period are described. Binary logistic regression analysis is used to examine the interaction between region (intervention and control) and period (pre- and post-implementation). Using random sampling of patient records, information about the practical application of the pathway and the number of hip or knee arthroplasties is added.

Results

In both regions, the number of diagnostic imaging decreased and the number of initial orthopaedic consultations increased during the post-implementation period. Significant interaction effects were found in knee-related diagnostics (p ≤ 0.001) and diagnostics of other joints (p = 0.039). No significant interaction effects were found in hip-related diagnostics (p = 0.060) and in initial orthopaedic consultation claims of hip (p = 0.979), knee (p = 0.281), and other joints (p = 0.464). Being referred according to the pathway had no significant effect on the probability of undergoing arthroplasty.

Conclusion

The implementation of the pathway had a positive effect on GPs diagnostic behaviour related to the knee, but not to the hip. The referral behaviour of GPs to orthopaedic care needs attention for future interventions and research, since an increase (instead of a desired decrease) in the number of initial orthopaedic consultations was found. Focusing on the entire width of care for hip and knee OA could be helpful.

Health professionals' referral practice and related healthcare utilization for people with low back pain in Singapore: A retrospective study

Background

Low back pain is a common musculoskeletal disorder that can incur high financial burden. A significant proportion of this burden may be incurred from referrals to health services and subsequent healthcare usages. Patients' overall experience of pain and its related life interferences may also have some relevance to this usage.

Objective

This study aimed to examine the referral practices and subsequent health service utilization of patients with LBP within a tertiary specialist clinic setting. A secondary objective was to explore potential associations between primary independent variables of pain and life interferences with health service utilization.

Methods

Participants were patients with low back pain, who completed a set of self-reported low back pain measures. These included measures for pain intensity, pain interference, disability and quality of life. The participants' back pain-related referral and health service utilization in the subsequent 12 months were recorded.

Results

A total of 282 patients completed the full measures. Of these, 59.9% were referred for physiotherapy, 26.3% for diagnostic imaging and 9.2% for interventional procedures. Compared to patients who were referred from tertiary care, those from primary care had lower pain intensity ( p = 0 . 001 ), pain interference ( p = 0 . 002 ), disability ( p = 0 . 001 ), but better physical and mental quality of life ( p < 0 . 001 , p = 0 . 017 ). High pain interference was a common factor among patients who were referred on to other services after first consultation. Levels of medical utilization and physiotherapy utilization were both associated with pain intensity ( F = 2 . 39 , p = 0 . 027 vs F = 3 . 87 , p = 0 . 001 ), pain interference ( F = 5 . 56 , p = 0 . 007 vs F = 4 . 12 , 0.01) and disability ( F = 5 . 89 , p = 0 . 001 vs F = 3 . 40 , p = 0 . 016 ). Regression analysis showed that the source of referral contributed to 6% of the variance in medical utilization and 3% of the variance in physiotherapy utilization. After controlling the demographic variables and referral sources, none of the independent variables added any significant variance to medical utilization. Only pain intensity contributed an additional 2% variance to physiotherapy utilization.

Conclusion

Referral patterns and practices appear similar to those reported in other studies. Higher levels of pain intensity, interference, disability and quality of life appear to influence the referral to different health services and subsequent treatment utilization.

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

BACKGROUND

Imaging is overused in the management of low back pain (LBP). Interventions designed to decrease non-indicated imaging have predominantly targeted practitioner education alone; however, these are typically ineffective. Barriers to reducing imaging have been identified for both patients and practitioners. Interventions aimed at addressing barriers in both these groups concurrently may be more effective. The Behaviour Change Wheel provides a structured framework for developing implementation interventions to facilitate behavioural change. The aim of this study was to develop an implementation intervention aiming to reduce non-indicated imaging for LBP, by targeting both general medical practitioner (GP) and patient barriers concurrently.

METHODS

The Behaviour Change Wheel was used to identify the behaviours requiring change, and guide initial development of an implementation intervention. Preliminary testing of the intervention was performed with: 1) content review by experts in the field; and 2) qualitative analysis of semi-structured interviews with 10 GPs and 10 healthcare consumers, to determine barriers and facilitators to successful implementation of the intervention in clinical practice. Results informed further development of the implementation intervention.

RESULTS

Patient pressure on the GP to order imaging, and the inability of the GP to manage a clinical consult for LBP without imaging, were determined to be the primary behaviours leading to referral for non-indicated imaging. The developed implementation intervention consisted of a purpose-developed clinical resource for GPs to use with patients during a LBP consult, and a GP training session. The implementation intervention was designed to provide GP and patient education, remind GPs of preferred behaviour, provide clinical decision support, and facilitate GP-patient communication. Preliminary testing found experts, GPs, and healthcare consumers were supportive of most aspects of the developed resource, and thought use would likely decrease non-indicated imaging for LBP. Suggestions for improvement of the implementation intervention were incorporated into a final version.

CONCLUSIONS

The developed implementation intervention, aiming to reduce non-indicated imaging for LBP, was informed by behaviour change theory and preliminary testing. Further testing is required to assess feasibility of use in clinical practice, and the effectiveness of the implementation intervention in reducing imaging for LBP, before large-scale implementation can be considered.

Barriers and facilitators for guideline adherence in diagnostic imaging: an explorative study of GPs' and radiologists' perspectives

Background

Diagnostic imaging has been a part of medicine for the last century. It has been difficult to implement guidelines in this field, and unwarranted imaging has been a frequent problem. Some work has been done to explain these phenomena separately. Identifying the barriers to and facilitators of guideline use has been one strategy. The aim of this study is to offer a more comprehensive explanation of deviations from the guideline by studying the two phenomena together.

Methods

Eight general practitioners and 10 radiologists from two counties in Norway agreed to semi-structured interviews. Topics covered in the interviews were knowledge of the guideline, barriers to and facilitators of guideline use, implementation of guidelines and factors that influence unwarranted imaging.

Results

Several barriers to and facilitators of guideline use were identified. Among these are lack of time, pressure from patients, and guidelines being too long, rigid or unclear. Facilitators of guideline use were easy accessibility and having the guidelines adapted to the target group. Some of the factors that influence unwarranted imaging are lack of time, pressure from patients and availability of imaging services.

Conclusion

There are similarities between the perceived barriers for guideline adherence and the perceived factors that influence unwarranted imaging. There may be a few reasons that explains the deviation from guidelines, and the amount of unwarranted imaging.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3372-7) contains supplementary material, which is available to authorized users.

Lumbar Spine X-Ray as a Standard Investigation for all Low back Pain in Ghana: Is It Evidence Based?

BACKGROUND

Low back pain (LBP) has a prevalence of 84% in Africa. The commonest form of imaging is plain lumbar spine x-ray. It gives a radiation dose equivalent to 65 times a chest x-ray dose and sends one of the highest doses to the human reproductive organs. The commonest cause of LBP in Africa is degenerative disease. X-ray findings do not change mode of treatment yet most physicians still routinely request for x-rays.

METHODS

This is a systematic review of databases including The Cochrane, CINAHL plus, AMED, and MEDLINE. Key evidence was clinical guidelines on x-ray use for low back pain. Key search terms included low back pain, x-rays, guidelines, Ghana.

RESULTS

Four clinical guidelines on LBP emerged from two Systematic Reviews rated excellent and four good Randomized Controlled Trials: The European guidelines for acute and sub-acute non-specific Low Back Pain, The American College of Physicians and the American Pain Society guideline for diagnostic imaging for Low Back Pain, The NICE guidelines for persistent non-specific Low Back Pain and the Ghana Standard Treatment Guidelines (GSTG). All the guidelines agree that a good history and clinical examination for all LBP patients helps in diagnosing. Only GSTG recommends routine plain spinal x-rays.

CONCLUSION

There is strong evidence indicating very little benefit from routine lumbar spine x-rays for all LBP. The GSTG needs to be revised considering the increased risks of radiation exposure and the x-ray costs.

FUNDING

None declared.

Attitudes and diagnostic practice in low back pain: A qualitative study amongst Greek and British physiotherapists

AIM

To explore current diagnostic practice and attitudes of Greek and United Kingdom physiotherapists (PTs) on assessing low back pain (LBP) patients.

METHODS

Three focus groups were undertaken, followed by a structured questionnaire-type survey comprising 23 health professionals and a random stratified sample of 150 PTs, respectively. Twenty-nine themes relating to LBP diagnostic practice emerged. These were then given to 30 British PTs assessing their level of agreement with their Greek counterparts. Analysis was performed by percentage agreements and χ² tests.

RESULTS

The survey was divided into three subsections; PTs’ attitudes on LBP assessment, patients’ attitudes and diagnostic/healthcare issues, each constituting 14, 7 and 8 statements, respectively. Over half of the statements fell within the 30%-80% agreement between Greece and United Kingdom whereas, 5 statements reported low (< 10%) and 8 statements demonstrated high (> 90%) PT percentage agreement. Similarities across British and Greek PTs were detected in history taking methods and in the way PTs feel patients perceive physiotherapy practice whereas, re-assessment was undertaken less frequently in Greece. Diagnosis according to 91% of the Greek PTs is considered a “privilege” which is exclusive for doctors in Greece (only 17% British PTs agreed) and is accompanied with a great overuse of medical investigations. Forty percent of Greek PTs (compared to 0% of British) consider themselves as “executers”, being unable to interfere with treatment plan, possibly implying lack of autonomy.

CONCLUSION

Although similarities on history taking methods and on patients’ attitudes were detected across both groups, gross differences were found in re-assessment procedures and diagnostic issues between Greek and British physiotherapists, highlighting differences in service delivery and professional autonomy.

Healthcare provider and patient perspectives on diagnostic imaging investigations

BACKGROUND

Much has been written about the patient-centred approach in doctor-patient consultations. Little is known about interactions and communication processes regarding healthcare providers' and patients' perspectives on expectations and experiences of diagnostic imaging investigations within the medical encounter. Patients journey through the health system from the point of referral to the imaging investigation itself and then to the post-imaging consultation. AIM AND SETTING: To explore healthcare provider and patient perspectives on interaction and communication processes during diagnostic imaging investigations as part of their clinical journey through a healthcare complex.

METHODS

A qualitative study was conducted, with two phases of data collection. Twenty-four patients were conveniently selected at a public district hospital complex and were followed throughout their journey in the hospital system, from admission to discharge. The second phase entailed focus group interviews conducted with providers in the district hospital and adjacent academic hospital (medical officers and family physicians, nurses, radiographers, radiology consultants and registrars).

RESULTS

Two main themes guided our analysis: (1) provider perspectives; and (2) patient dispositions and reactions. Golden threads that cut across these themes are interactions and communication processes in the context of expectations, experiences of the imaging investigations and the outcomes thereof.

CONCLUSION

Insights from this study provide a better understanding of the complexity of the processes and interactions between providers and patients during the imaging investigations conducted as part of their clinical pathway. The interactions and communication processes are provider-patient centred when a referral for a diagnostic imaging investigation is included.

What is the evidence on interventions to manage referral from primary to specialist non-emergency care? A systematic review and logic model synthesis

Background

Demand management describes any method used to monitor, direct or regulate patient referrals. Several strategies have been developed to manage the referral of patients to secondary care, with interventions targeting primary care, specialist services, or infrastructure.

Objective

This research aimed to conduct an inclusive systematic review and logic model synthesis in order to better understand factors impacting on the effectiveness of interventions targeting referral between primary and secondary medical health care.

Design

The approach combined systematic review with logic modelling synthesis techniques to develop an evidence-based framework of factors influencing the pathway between interventions and system-wide changes.

Setting

Primary health care.

Main outcome measures

Referral from primary to secondary care.

Review methods

Systematic searches were undertaken to identify recent, relevant studies. Quality of individual studies was appraised, with consideration of overall strength of evidence. A narrative synthesis and logic model summary of the data was completed.

Results

From a database of 8327 unique papers, 290 were included in the review. The intervention studies were grouped into four categories of education interventions (n = 50); process change interventions (n = 49); system change interventions (n = 38); and patient-focused interventions (n = 3). Effectiveness was assessed variously in these papers; however, there was a gap regarding the mechanisms whereby these interventions lead to demand management impacts. The findings suggest that, although individual-level interventions may be popular, the stronger evidence relates only to peer-review and feedback interventions. Process change interventions appeared to be more effective when the change resulted in the specialist being provided with more or better quality information about the patient. System changes including the community provision of specialist services by general practitioners, outreach provision by specialists and the return of inappropriate referrals appeared to have evidence of effect. The pathway whereby interventions might lead to service-wide impact was complex, with multiple factors potentially acting as barriers or facilitators to the change process. Factors related, first, to the doctor (including knowledge, attitudes and beliefs, and previous experiences of a service), second, to the patient (including condition and social factors) and, third, to the influence of the doctor–patient relationship. We also identified a number of potentially influential factors at a local level, such as perceived waiting times and the availability of a specialist. These elements are key factors in the pathway between an intervention and intended demand management outcomes influencing both applicability and effectiveness.

Conclusions

The findings highlight the complexity of the referral process and multiple elements that will impact on intervention outcomes and applicability to a local area. Any interventions seeking to change referral practice need to address factors relating to the individual practitioner, the patient and also the situation in which the referral is taking place. These conclusions apply especially to referral management in a UK context where this whole range of factors/issues lies well within the remit of the NHS. This work highlights that intermediate outcomes are important in the referral pathway. It is recommended that researchers include measure of these intermediate outcomes in their evaluation of intervention effectiveness in order to determine where blocks to or facilitators of system-wide impact may be occurring.

Study registration

The study is registered as PROSPERO CRD42013004037.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Non-surgical care in patients with hip or knee osteoarthritis is modestly consistent with a stepped care strategy after its implementation

OBJECTIVE

To improve the management of hip or knee osteoarthritis (OA), a stepped care strategy (SCS) has been developed that presents the optimal sequence for care in three steps. This study evaluates the extent to which clinical practice is consistent with the strategy after implementation and identifies determinants of SCS-consistent care.

DESIGN

A 2-year observational prospective cohort study.

SETTING

General practices in the region of Nijmegen in the Netherlands.

PARTICIPANTS

Three hundred and thirteen patients with hip or knee OA and their general practitioner (GP).

INTERVENTIONS

Multifaceted interventions were developed to implement the strategy.

MAIN OUTCOME MEASURES

Consistency between clinical practice and the strategy was examined regarding three aspects of care: (i) timing of radiological assessment, (ii) sequence of non-surgical treatment options and (iii) making follow-up appointments.

RESULTS

Out of the 212 patients who reported to have had an X-ray, 92 (44%) received it in line with the SCS. The sequence of treatment was inconsistent with the SCS in 58% of the patients, which was mainly caused by the underuse of lifestyle advice and dietary therapy. In 57% of the consultations, the patient reported to have been advised to make a follow-up appointment. No determinants that influenced all three aspects of care were identified.

CONCLUSIONS

Consistency with the SCS was found in about half of the patients for each of the three aspects of care. Health care can be further optimized by encouraging GP s to use X-rays more appropriately and to make more use of lifestyle advice, dietary therapy and follow-up appointments.

Psychological factors explaining the referral behavior of Iranian family physicians

BACKGROUND

The recently developed policy of the family practice program in rural regions of Iran faced some challenges such as inefficient referral system. The health insurance organizations (purchaser) and health policy makers are concerned about the high rate of patient referrals from family physicians to specialists due to imposing unnecessary services and costs.

OBJECTIVES

This study examined utility of the theory of planned behavior to explain intention of Iranian family physicians to reduce referral rate of patients with respiratory diseases to medical specialist.

PATIENTS AND METHODS

An exploratory cross-sectional study, employing a correlational design directed by the theory of planned behavior was conducted. A questionnaire was developed based on an eliciting study and review of literature. One hundred and seventy-four family physicians working at primary care centers in two provinces of Iran completed the questionnaire (response rate of 86%).

RESULTS

The finding revealed that intention of family physicians to reduce referral rate of patients to specialists was significantly related to two theory-based variables of subjective norms (r = 0.38, P < 0.001) and perceived behavioral control (r = 0.43, P < 0.001), and not to attitudes. A stepwise regression entering direct measures of the theory variables explained 35% of the variance on the intention, with perceived behavioral control being the strongest predictor. Adding background variables to the model achieved further 5% by variables of practice size and past referral rate behavior.

CONCLUSIONS

The results indicated that psychological variables of the theory of planned behavior could explain a noticeable proportion of variance in family physician's intention to decrease the rate of referring patients with respiratory diseases to medical specialists. The intention is primarily influenced by normative and control considerations. These findings contribute to a better understanding of referral decisions by family physicians and are of great value in developing interventions to reduce the variation in referral rate of patients to medical specialists at primary care health centers.

Met or matched expectations: what accounts for a successful back pain consultation in primary care?

BACKGROUND

Patients' as well as doctors' expectations might be key elements for improving the quality of health care; however, previous conceptual and theoretical frameworks related to expectations often overlook such complex and complementary relationship between patients' and doctors' expectations. The concept of 'matched patient-doctor expectations' is not properly investigated, and there is lack of literature exploring such aspect of the consultation.

AIM

The paper presents a preliminary conceptual model for the relationship between patients' and doctors' expectations with specific reference to back pain management in primary care.

METHODS

The methods employed in this study are integrative literature review, examination of previous theoretical frameworks, identification of conceptual issues in existing literature, and synthesis and development of a preliminary pragmatic conceptual framework.

OUTCOME

A simple preliminary model explaining the formation of expectations in relation to specific antecedents and consequences was developed; the model incorporates several stages and filters (influencing factors, underlying reactions, judgement, formed reactions, outcome and significance) to explain the development and anticipated influence of expectations on the consultation outcome.

CONCLUSION

The newly developed model takes into account several important dynamics that might be key elements for more successful back pain consultation in primary care, mainly the importance of matching patients' and doctors' expectations as well as the importance of addressing unmet expectations.

Agreement of general practitioners with the guideline-based stepped-care strategy for patients with osteoarthritis of the hip or knee: a cross-sectional study

Background

To improve the management of hip or knee osteoarthritis (OA), a multidisciplinary guideline-based stepped-care strategy (SCS) with recommendations regarding the appropriate non-surgical treatment modalities and optimal sequence for care has been developed. Implementation of this SCS in the general practice may be hampered by the negative attitude of general practitioners (GPs) towards the strategy. In order to develop a tailored implementation plan, we assessed the GPs’ views regarding specific recommendations in the SCS and their working procedures with regard to OA.

Methods

A survey was conducted among a random sample of Dutch GPs. Questions included the GP’s demographical characteristics and the practice setting as well as how the management of OA was organized and whether the GPs supported the SCS recommendations. In particular, we assessed GP’s views regarding the effectiveness of 14 recommended and non-recommended treatment modalities. Furthermore, we calculated their agreement with 7 statements based on the SCS recommendations regarding the sequence for care. With a linear regression model, we identified factors that seemed to influence the GPs’ agreement with the SCS recommendations.

Results

Four hundred fifty-six GPs (37%) aged 30–65 years, of whom 278 males (61%), responded. Seven of the 11 recommended modalities (i.e. oral Non-Steroidal Anti-Inflammatory Drugs, physical therapy, glucocorticoid intra-articular injections, education, lifestyle advice, acetaminophen, and tramadol) were considered effective by the majority of the GPs (varying between 95-60%). The mean agreement score, based on a 5-point scale, with the recommendations regarding the sequence for care was 2.8 (SD = 0.5). Ten percent of the variance in GPs’ agreement could be explained by the GPs’ attitudes regarding the effectiveness of the recommended and non-recommended non-surgical treatment modalities and the type of practice.

Conclusion

In general, GPs support the recommendations in the SCS. Therefore, we expect that their attitudes will not impede a successful implementation in general practice. Our results provide several starting points on which to focus implementation activities for specific SCS recommendations; those related to the prescription of pain medication and the use of X-rays. We could not identify factors that contribute substantially to GPs’ attitudes regarding the SCS recommendations regarding the sequence for care.

Evidence-based imaging and effective utilization: lessons in neuroradiology

Expensive advanced imaging, such as magnetic resonance (MR) imaging, contributes to the unsustainable growth of health care costs in the United States. Evidence-based imaging decreases costs and improves outcomes by guiding appropriate utilization of imaging. Low back pain is an important case illustration. Despite strong evidence that early advanced imaging with MR imaging for uncomplicated low back pain leads to increased costs without significant clinical benefit, MR imaging utilization for acute low back pain has increased. Barriers to evidence-based imaging can be traced to patient- and physician-related factors. Radiologists have a critical role in addressing some of these barriers.

Identifying factors likely to influence compliance with diagnostic imaging guideline recommendations for spine disorders among chiropractors in North America: a focus group study using the Theoretical Domains Framework

Background

The Theoretical Domains Framework (TDF) was developed to investigate determinants of specific clinical behaviors and inform the design of interventions to change professional behavior. This framework was used to explore the beliefs of chiropractors in an American Provider Network and two Canadian provinces about their adherence to evidence-based recommendations for spine radiography for uncomplicated back pain. The primary objective of the study was to identify chiropractors’ beliefs about managing uncomplicated back pain without x-rays and to explore barriers and facilitators to implementing evidence-based recommendations on lumbar spine x-rays. A secondary objective was to compare chiropractors in the United States and Canada on their beliefs regarding the use of spine x-rays.

Methods

Six focus groups exploring beliefs about managing back pain without x-rays were conducted with a purposive sample. The interview guide was based upon the TDF. Focus groups were digitally recorded, transcribed verbatim, and analyzed by two independent assessors using thematic content analysis based on the TDF.

Results

Five domains were identified as likely relevant. Key beliefs within these domains included the following: conflicting comments about the potential consequences of not ordering x-rays (risk of missing a pathology, avoiding adverse treatment effects, risks of litigation, determining the treatment plan, and using x-ray-driven techniques contrasted with perceived benefits of minimizing patient radiation exposure and reducing costs; beliefs about consequences); beliefs regarding professional autonomy, professional credibility, lack of standardization, and agreement with guidelines widely varied ( social/professional role & identity); the influence of formal training, colleagues, and patients also appeared to be important factors ( social influences); conflicting comments regarding levels of confidence and comfort in managing patients without x-rays ( belief about capabilities); and guideline awareness and agreements ( knowledge).

Conclusions

Chiropractors’ use of diagnostic imaging appears to be influenced by a number of factors. Five key domains may be important considering the presence of conflicting beliefs, evidence of strong beliefs likely to impact the behavior of interest, and high frequency of beliefs. The results will inform the development of a theory-based survey to help identify potential targets for behavioral-change strategies.

Evaluation of a radiographic technique: one dimension of critical thinking

Background:

Previous articles in this series (July 2010 and April 2011) have looked at examples of how undergraduate students can demonstrate their ability to interpret data and generate new ideas as part of developing their critical thinking skills. As a final example, the evaluation component of critical thinking is explored that requires students to recognize arguments, separate fact from opinion and verify the value of evidence. In this way they can fully engage with evidence-based practice.

Contents:

The evaluation component of critical thinking encourages students to ask the right questions when considering research data and dig deeper into the motives, expertise and assumptions underlying the evidence presented. The worked example is for an evaluation of the effectiveness of X-ray imaging of the lumbar spine in patients presenting with persistent nonspecific low back pain (LBP). The structure of the evaluation includes clinical indications, diagnostic yield, effectiveness of current practice and comparison with other diagnostic imaging options.

Conclusions:

Since critical thinking is not a single entity, understanding the key components that contribute to the whole is important if undergraduate students are to be encouraged and supported in developing their critical thinking skills. The example of an evaluation of a radiographic technique illustrates how students are expected to go about demonstrating their understanding of the intentions and motivations behind judgements, protocols and guidelines that are aimed at improving the delivery of health care.

The effectiveness of a posted information package on the beliefs and behavior of musculoskeletal practitioners: the UK Chiropractors, Osteopaths, and Musculoskeletal Physiotherapists Low Back Pain ManagemENT (COMPLeMENT) randomized trial

STUDY DESIGN

Randomized controlled trial.

OBJECTIVE

To investigate the effect of a printed information package on the low back pain (LBP)-related beliefs and reported behavior of musculoskeletal practitioners (chiropractors, osteopaths, and musculoskeletal physiotherapists) across the United Kingdom.

SUMMARY OF BACKGROUND DATA

A substantial proportion of musculoskeletal practitioners in United Kingdom does not follow current LBP guideline recommendations.

METHODS

In total, 1758 practitioners were randomly allocated to either of the 2 study arms. One arm was posted a printed information package containing guideline recommendations for the management of LBP (n = 876) and the other received no intervention (n = 882). The primary outcome measure consisted of 3 "quality indicators" (activity, work, and bed-rest) relating to a vignette of a patient with LBP, in which responses were dichotomized into either "guideline-inconsistent" or "guideline-consistent." The secondary outcome was the practitioners' LBP-related beliefs, measured using the Health Care Providers Pain and Impairment Relationship Scale. Outcomes were measured at baseline and at 6 months.

RESULTS

Follow-up at 6 months was 89%. The changes in reported behavior on the quality indicators were as follows: activity, odds ratio (OR) 1.29 (95% confidence interval, 1.03-1.61) and number needed to be treated (NNT), 19 (15-28); work, OR 1.35 (1.07-1.70) and NNT 19 (14-29); and bed-rest, OR 1.31 (0.97-1.76) and NNT 47 (33-103). The composite NNT for a change from guideline-inconsistent to guideline-consistent behavior on at least 1 of the 3 quality indicators was 10 (9-14). LBP-related beliefs were significantly improved in those who were sent the information package (P = 0.002), but only to a small degree (mean difference, 0.884 scale points; 95% confidence interval, 0.319-1.448).

CONCLUSION

Printed educational material can shift LBP-related beliefs and reported behaviors of musculoskeletal practitioners, toward practice that is more in line with guideline recommendations.

Referral patterns to renal services: what has changed in the past 4 years?

BACKGROUND

Awareness of chronic kidney disease (CKD) has been prompted by the publication of several large epidemiological studies since 2002. This has led to various initiatives for the early identification and management of CKD, including the introduction of automated glomerular filtration rate (GFR) reporting and renal indicators in the primary care quality and outcomes framework (QOF) since April 2006. These initiatives were intended to promote identification of CKD and have had an impact on referral patterns to renal services. The aim of this study was to understand the nature of this impact in a catchment population of 1.2 million people.

METHODS

Data were collected and recorded from all written referrals from primary care between 1 April 2004 and 31 March 2008. Referral patterns for each postcode sector were mapped using Microsoft MapPoint 2004. The effect of chance on referral patterns was modelled by using small area analysis techniques. The association between the CKD prevalence reported from QOF data and the estimated CKD prevalence was examined at post-code district level.

RESULTS

There were 1461 referrals in 2 years prior to the introduction of the initiatives and 2890 referrals in the 2 years post-introduction. The main reason for referral in both groups was impaired renal function or previously established renal disease. Reported comorbidity was similar between the groups. Mapping showed that there was wide heterogeneity in referral behaviour in the first 2 years of the study, which was less in the second period. Small area analysis suggested that the variation that led to the extremal quotients observed in both of the study periods was not due to random variation in referral pattern alone. There was no correlation between the reported CKD prevalence and the referral rates.

CONCLUSION

Referral patterns have changed between 1 April 2004 and 31 March 2008. The main findings were an increase in referral rate and in the age at referral without a significant change in reported comorbidity of the people referred. The main increase in referral rates was seen in more advanced CKD suggesting more targeted referral of patients with CKD to renal services.