Abstract
Background: Moving towards more appropriate and comprehensive care for low back pain (LBP) is an important health services research issue globally. There continues to be health services overuse and continued poor uptake of best practices in this area. LBP management and outcomes have changed little over the past three decades, and there have been calls for more interdisciplinary work to address this issue. The central research questions asks, What factors enable or constrain the implementation of best practices by primary care providers managing low back pain? This project uses the Consolidated Framework for Implementation Research (CFIR) to identify barriers and facilitators to the uptake of best practices.
Approach: This study involved a multi-phased, mixed methods approach that was used to understand the social and practice environments of primary care, which is the level in which much care is coordinated amongst LBP patients. There were multiple benefits to using mixed methods including comprehensiveness, convergence and triangulation, and elaboration and expansion. The first phase of the study involved a literature review to provide a current understanding of what is known about the implementation of best practices in LBP management. The second phase then used quantitative surveys to sample a group of 240 LBP primary care providers to understand barriers and facilitators to the implementation of best practices. The third phase involved quantitative interviews to understand the perspectives of 2 primary care providers and why specific barriers and facilitators were important to the implementation process.
Results: After synthesizing the results, CFIR was adapted for use in low back pain management. Findings suggest that implementation strategies will have to focus on specific areas to bring more best practices into low back pain management. This includes considering: high-quality evidence; understanding patient needs; access to knowledge that fits into provider workflows; having high self-efficacy; and drawing on content champions and execution plans to drive action. In addition, LBP management implementation efforts need to draw on multiple providers including physiotherapists, chiropractors and nurses. As well, it will be important to optimize the use of virtual care for integrating best practices. Important demographic characteristics including gender, level of experience and geography should also be considered in implementation efforts as they have shown to have important influences on best practice uptake.
Implications: There are several important implications for LBP management and practice including: using the CFIR as adapted to LBP; increasing health team models; establishing virtual care guidelines; increasing targeted training sessions; expanding LBP focused programs; increasing electronic medical record integration; increasing patient health record integration; and integrating more champions and plans in the area of LBP management. As well, there are several implications for policy including: promoting team models and collaborative care; evaluating funding for physiotherapy; increasing support to underserved geographies; and providing more educational tools for LBP management. This study is relevant to several key stakeholders including primary care providers, policy-decision makers, implementation scientists, and patients themselves, all of whom may benefit from these recommendations. This study addressed an important know-dogap in LBP management and helps to improve a longstanding issue that impacts most people along their life course.