Modern health care must reconcile evidence-based scientific medicine with person-centered clinical medicine, to develop “evidence-informed individualized care.”1 Within this context, clinical guidelines are developed at some expense through synthesizing scientific evidence and establishing expert consensus. This study examines the role of guidelines for the primary care management of low back pain (LBP), which eludes definitive treatment and is the leading global cause of years lived with disability.2–7 In 2009, the English National Institute for Health and Care Excellence (NICE) published clinical guidelines on managing persistent, nonspecific LBP (PNS-LBP) in primary care.8,9 These guidelines sparked debate,10–16 recommended previously contested treatments (eg, acupuncture),17–22 and are currently being updated. They recommended keeping diagnosis under review and using a combination of front-line treatments while considering patients’ preferences. They are broadly similar to European23 and American24 recommendations25 (Supplemental Digital Content 1, http://links.lww.com/BRS/B40 compares these recommendations).
Research suggests that following recommendations based on best evidence improves patient outcomes.26–31 For example, physiotherapists using recommended active rather than passive treatments for acute LBP achieved better clinical outcomes more cheaply.26 However, clinical practice often diverges from guidelines.28,32–42 Clinicians unfamiliar with guidelines are unlikely to implement them.43 Controversial guidelines, those with indirect or vague wording, and/or those requiring major changes are less likely to be implemented.44,45 Clinicians may diverge from guidelines when they (1) individualize treatment according to their perceptions of patients’ characteristics, treatment histories, and/or treatment preferences, (2) hold biomedically oriented pain cognitions, or (3) prioritize therapeutic relationships.46–53 Whatever individual clinicians believe, the fundamentally social nature of clinical practice can further marginalize guidelines.54
Merely publishing clinical guidelines is insufficient to ensure their implementation54–56 and guidelines should be viewed in the context of clinical practice.54 LBP studies have explored implementation of physiotherapy guidelines33 and specific treatment recommendations28,40 but not the NICE guidelines. Therefore, we aimed to (1) clarify the decision-making processes that lead primary care clinicians to deliver particular treatments to LBP patients, and (2) examine clinicians’ perspectives on the NICE clinical guidelines for LBP in primary care.
MATERIALS AND METHODS
Qualitative Data Collection
We identified potential participants in South-West England in 2011 via the Primary Care Research Network South-West and professional registers. Primary care clinicians consulted by at least 1 patient with PNS-LBP within 6 months received written invitations. We selected a maximum variation sample from 83 replies on the basis of characteristics in Table 1.
Four interviewers conducted semi-structured telephone (48) or face-to-face (5) interviews to elicit clinicians’ accounts of decision-making and views on clinical guidelines for LBP in primary care (mean duration 43 minutes, range 19–109 minutes). To reduce social desirability bias, interviewers were nonclinicians, recruitment materials did not emphasize guidelines, and interview introductions were neutral: “We are interested in finding out all about how you manage patients with LBP and what you think about the various treatment options.” Informed consent was obtained before digitally audio-recording interviews, subsequently transcribed verbatim, and anonymized. Interviews and analysis proceeded iteratively.
We used thematic analysis57 with open coding and constant comparison58 in NVivo9.59 Three authors collaboratively conducted the analysis. We listened to audio-recordings and repeatedly read transcripts before categorizing meaning units (utterances that express a single meaning) into PNS-LBP definitions, clinical management, decision-making, NICE guidelines, NICE-recommended treatments/referrals, and other treatments. We reviewed the categorized meaning units within the context of the original interviews and coded them inductively, generating descriptive labels. Coded data were compared within and across codes and categories, very similar codes were merged, and disjointed codes were split. We wrote memos58 describing analytic decisions. We diagrammed codes, grouped together codes related to the same processes, and reviewed these to identify and name emerging themes. These emerging themes were discussed with other team members with diverse backgrounds to aid interpretation (eg, health psychology, physiotherapy, complementary alternative medicine—CAM, general practice). We reviewed themes against transcripts to ensure fit and explored inter-professional similarities and differences. Finally, we mapped themes related to the NICE guidelines against decision-making themes. Illustrative anonymized quotes were selected to provide typical examples of themes; some atypical quotes are presented to demonstrate diversity. Below, “CAM practitioners” refer to osteopaths, chiropractors, and acupuncturists, although many physiotherapists also deliver manual therapy and acupuncture.
Decisions about which treatment to prescribe, refer, or deliver to an individual patient were made within local social and organizational structures. National clinical guidelines were merely one relatively peripheral influence. Clinicians’ views of their professional identity and expertise led different professional groups to focus on slightly different clinical decisions (Table 2). Regardless of which decisions clinicians focused on, 4 overarching themes captured their accounts. Each theme suggests why clinical guidelines and the practice of clinical work can diverge and identifies opportunities for better connecting evidence-based guidelines and practice.
Identifying the Problem: Terminology and Diagnosis
NICE define PNS-LBP as tension, soreness, and/or stiffness in the lower back region, not caused by malignancy, infection, fracture, inflammatory disorders, nerve root compression, and recurrent or persistent for at least 6 weeks but not longer than 12 months.8,9 Participants generally understood that “non-specific LBP” refers to musculoskeletal LBP with no serious underlying pathology or nerve root pain; many equated it with “simple” or “mechanical” LBP. The term “PNS-LBP” was perceived differently.
As summarized in Table 3, some aspects of “PNS-LBP” were perceived as helpful, but overall, this term was not perceived as particularly relevant by clinicians. Some GPs and nurses saw “PNS-LBP” as honest but of limited use for communicating with patients and/or colleagues. GPs and nurses also considered the timeframe useful for prompting more intensive interventions aiming to prevent progression to chronic pain. However, almost all clinicians struggled with the idea of pain being positively diagnosed as “non-specific.” GPs and nurses typically relied on history-taking and rarely undertook the clinical examinations or investigations they perceived valuable to rule out serious pathology or nerve root pain. Many also felt that “non-specific LBP” was an unfamiliar term that lacked information and was thus unsatisfactory for patients.
Physiotherapists and CAM practitioners saw “PNS-LBP” as an inferior diagnosis encompassing excessive clinical variation and insufficient precision rendering it incapable of informing treatment. Indeed, physiotherapists and CAM practitioners described performing comprehensive clinical examinations and taking detailed histories, ascertaining specific anatomical and physiological features (eg, muscle spasm), pain intensity, impact on patient's activities and sleep, likely cause(s), and duration. Further investigations (eg, diagnostic ultrasound, X-ray) were used sparingly to exclude suspected serious pathologies. Physiotherapists and CAM practitioners used their professional theoretical frameworks to develop a detailed etiological model of a patient's LBP and formulate an individualized treatment plan; the term “PNS-LBP” was not perceived as facilitating this.
Overall, many clinicians found that the label “PNS-LBP” had little relevance to their clinical practice. A fundamental disconnect thus exists between the terminology on the front cover of the NICE guidelines and clinicians’ preferred ways of working. However, participants did not suggest a preferable alternative title.
Knowing The Patient
Clinicians described taking individual and/or family histories, performing clinical examinations, attending to patients’ age and gender, and exploring patients’ working life (eg, profession/job, economic situation), lifestyle (eg, sports-player, sedentary), and mental health (eg, anxiety, depression). This knowledge was used to tailor clinical management.
“The way I might treat a 20 year old rugby player would be very different to the way I would treat an 80 year old lady, very different.” (WH, female chiropractor, private practice)
“Certainly if someone wants to see a physiotherapist and is keen to be part of that process then I would refer early to physio[therapist].” (TA, female GP, NHS)
Thus, clinicians were broadly consistent with the guideline's recommendation to consider patient preferences. However, they did not recognize this convergence because they mistakenly perceived the guidelines as a rigid treatment pathway that was inconsistent with individually tailored care.
“I think every treatment plan needs to be tailored really to the patient, and in spite of NICE, in spite of everyone's efforts, there isn’t a single pathway or plan that suits everyone.” (RO, male GP, NHS)
Knowing The Treatment
Clinicians not only viewed treatments primarily in terms of perceived effectiveness but also discussed mechanisms of action, adverse effects, and contraindications. When delivering treatment, knowledge was primarily based on professional clinical experience and/or training. When making referrals or recommendations, knowledge was based on more diverse sources. Sources of perceived “abstract” information (eg, theoretical literature, “evidence-base,” guidelines) appeared to have little influence.
Clinicians oriented to but did not universally accept the pervasive discourse of evidence-based health care. Some appeared to embrace evidence-based health care while others resisted it, portraying the evidence base as shifting and inconsistent and therefore of limited practical use (Table 4 presents quotes). The latter clinicians explicitly reflected on how constructs such as “evidence,” as communicated through guidelines, were less important than experiential learning for clinical practice. Indeed, experiential sources of knowledge, including personal experience, colleague's experiences, and patients’ experiences, were generally highly valued and influential.
Feeling knowledgeable allowed clinicians to deliver a treatment or refer a patient on. Perceived lack of knowledge meant that a treatment was not considered, even if it was guideline-recommended. However, some practitioners thought that the NICE guidelines might enhance awareness of effective and ineffective treatments, validating and/or slightly extending existing practices. The guidelines’ coverage of diverse treatments was thought to encourage patients and practitioners to consider diverse options and to help practitioners explain why certain treatments (eg, TENS) were not prescribed. CAM practitioners felt the guidelines helped to legitimize their practices for mainstream medical and public audiences.
Even if clinicians perceived the NICE guidelines as novel and potentially helpful, they did not describe changing practice in response to them. This seemed to be primarily due to constraints on National Health Service (NHS) service provision.
Working Within Organizational Constraints
Clinicians discussed the challenges of working within organizational constraints including limited NHS resources (Table 5 summarizes illustrative quotes). These constraints seemed particularly important when usually effective initial pain management and education was unsuccessful. Referrals for physiotherapy were described as routinely available (although waiting times varied) and clinicians valued and praised those services that were available, helpful, and accessible to their patients. However, others highlighted disparities between the NICE-recommended care pathway and the real-world situation of short consultation times, difficult-to-access specialist services, and long waiting lists. Furthermore, GPs and nurses were deterred from referring patients to services such as pain management (incorporating CBT), acupuncture, chiropractic and osteopathy, by a perceived lack of NHS services, and/or a lack of familiarity with local providers. Few were aware that patients might receive manual therapy and/or acupuncture from physiotherapists. For many, the only NHS-funded option after physiotherapy was to refer to a pain management clinic, which could be associated with high NHS costs, long waiting lists, and resource implications for patients (eg, travel).
When considering referring to CAM practitioners, many clinicians emphasized variability between practitioners and the importance of referring to a known clinician of good repute. Clinicians with multi-disciplinary networks of local colleagues referred patients to trusted individuals within those networks. Without such networks, clinicians were reluctant to advise patients.
“I think a lot of the problem here is the practitioner you see, isn’t it, how qualified they are and so on, and patients have to judge that for themselves, which is why I don’t refer actively or recommend anybody.” (GO, female GP, NHS)
Our analysis illustrated how clinicians select treatments on the basis of knowing the individual patient, knowing about their patient's back pain, and knowing about common treatment options; these processes can be facilitated and constrained by organizational factors. The NICE guidelines for PNS-LBP were a peripheral influence on these decision-making processes and we found 4 key explanations for this. One, the terminology in the guidelines (PNS-LBP) does not resonate with clinical practice. Many clinicians did not value or use the adjective “non-specific” and instead sought a more nuanced understanding to guide treatment. Physiotherapists and CAM practitioners described trying to identify more specific cause(s) of a patient's LBP before formulating treatment plans. Two, clinicians strive to tailor treatment to individuals and often attend to patients’ preferences. However, some clinicians mistakenly perceived this as guideline-inconsistent because they believed that guidelines impose rigid treatment pathways. Three, the NICE guidelines are a useful source of abstract information about treatments, but without opportunities to experience recommended treatments (personally or vicariously) and/or to make personal contact with individual practitioners clinicians seem unlikely to refer patients to CAM practitioners for NICE-recommended frontline treatments of acupuncture or manual therapy. Four, a perceived lack of NHS services, long waiting lists, and lack of trusted interdisciplinary networks impede referrals for physiotherapy, manual therapy (in particular manipulation), combined psychological and physical programs, and acupuncture.
Other studies have described separately individualized and patient-centered care in LBP,46–51 clinicians’ understandings of LBP,49,52,53 the clinical relevance of experiential learning,54 and the challenges of producing and implementing multidisciplinary guidelines to help reduce the fragmentation of LBP care.60 Unsatisfactory labels that provide no diagnostic information have also been discussed for Medically Unexplained Symptoms.61 A meta-synthesis on GPs’ attitudes toward guidelines in primary care suggests some common issues, for example, perceived tensions between guideline-based care and individualized care and perceived relevance of guidelines, but the issues we identified around interdisciplinary networks and structural constraints appear to be far less commonly discussed.62 Reflecting and extending studies in other conditions,28,32–39 our clinicians varied in how much they were aware of, were influenced by, and acted in accordance with guidelines.
Interviewing clinicians produced deeper insights than would be possible using questionnaires. Our findings reflect how clinicians understand their work but, without ethnographic observations, we were unable to describe clinical practice directly. We interviewed members of 6 relevant professions: GPs, physiotherapists, chiropractors, osteopaths, acupuncturists, and nurses. Only a small number of nurses volunteered to participate; that may reflect that practice nurses are rarely involved in caring for patients with LBP in primary care, but this small subsample should be viewed as a limitation—interviewing more nurses may have resulted in a more nuanced understanding of their views. Organizational constraints might be less in other locales where private-sector CAM practitioners are commissioned to provide NHS services.63
It is well known that merely publishing clinical guidelines and evidence is insufficient to ensure their implementation.54–56 Our findings suggest specific novel actions that address key elements of clinical decision-making and could thus increase the relevance of LBP guidelines for clinical practice. In relation to “knowing the patient,” guidelines could emphasize the need to attend to patients’ preferences; a clear example might help shift misperceptions that guidelines are rigid.62,64 In relation to “identifying the problem,” scientifically developing broad consensus around terminology (eg, using a Delphi process), clearly communicating the relevance of general terminology to all professional groups, and/or including recent evidence about stratified care65,66 could improve on the inadequate umbrella term PNS-LBP.67–71 In relation to “knowing the treatment,” medical schools and professional bodies could do more to follow GMC guidelines and educate clinicians about the evidence-base and professional regulation of acupuncture, osteopathy, and chiropractic72; encouraging local inter-professional networks could facilitate communication and relationship-building between individual practitioners. These changes would help to increase GPs’ and nurses’ familiarity with and self-efficacy for referring to CAM practitioners. To address “organizational constraints,” commissioners need to understand better the need to purchase recommended treatments (particularly acupuncture, osteopathy, chiropractic, and combined psychological and physical programs) to enable clinicians to implement recommended pathways. While purchasing decisions are increasingly challenging given the broader economic context, commissioners appear to have impeded clinical implementation of the LBP guidelines in England by failing to fund recommended treatments. This not only prevents patients receiving recommended treatments but also represents an unfortunate waste of resources invested in guideline development.73 Developments in NHS commissioning (eg, national clinical directors, clinical commissioning groups) provide opportunities for improved implementation of guidelines. For example, the Any Qualified Provider policy encourages commissioners to look beyond the NHS for providers. Implementing recent developments in stratified care, which enable sub-grouping of patients (based on prognosis) for targeted treatments,65,66 might also increase the efficiency and cost-effectiveness of care.69
Qualitative research on patients’ noncompliance to medical regimes prompted a radical shift by demonstrating that noncompliance should be re-conceptualized as rational nonadherence.74 Similarly, qualitative work around clinical decision-making offers deeper insights into the role of guidelines in clinical practice, particularly for more complex multidisciplinary guidelines. Future studies should consider studying not only clinicians but also commissioners. Our recommendations could increase the relevance of LBP and possibly other guidelines for practice, and further research is needed to implement and test them.
- This study shows how the NICE guidelines for managing LBP in primary care are one, relatively peripheral, influence on clinical decision-making among GPs, chiropractors, acupuncturists, physiotherapists, osteopaths, and nurses.
- We suggest that the NICE guidelines are such a peripheral influence because they do not resonate with clinicians’ day-to-day experience of providing care for individual patients within organizational constraints.
- When they are revised, the NICE guidelines for LBP could be made more relevant to clinicians by ensuring terminology reflects that used in clinical practice; dispelling the image of guidelines as rigid and prohibiting patient-centered care; providing opportunities for clinicians to engage in experiential learning about guideline-recommended therapies; and better ensuring commissioning of guideline-recommended treatments for NHS patients.
We thank the participants for sharing their experiences, the Primary Care Research Network who helped to recruit the participants, and Clare McDermott and Saima Ali for undertaking some of the interviews.
Supplemental digital content is available for this article. Direct URL citations appearing in the printed text are provided in the HTML and PDF version of this article on the journal's Web site (www.spinejournal.com).
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