Overutilisation of imaging in the management of low back pain

Low back pain is one of the leading causes of disability globally and is associated with significant costs to the health care system. Improving the management of low back pain is necessary to optimise patient outcomes while minimising associated costs. For the majority of people with low back pain their pain cannot be attributed to a specific cause and the use of medical imaging does not improve management of these patients. Imaging is only indicated infrequently, in cases where serious pathology (e.g. malignancy or infection) is suspected. Overuse of imaging has been associated with increased healthcare costs and risks such as overdiagnosis, with the potential for further inappropriate investigations and treatments, increased rates of surgery, and radiation exposure. Effective interventions to reduce the use of non-indicated imaging would help improve patient management and reduce associated healthcare costs. The work presented in this thesis details the development of an intervention to reduce the use of non-indicated imaging for low back pain. Systematic reviews were performed to assess the extent of overuse of imaging for low back pain (Chapter 2) and the effectiveness of previously tested interventions to reduce imaging (Chapter 3), followed by a survey to establish whether patients believe imaging to be important in the management of low back pain (Chapter 4). The results of these studies indicated the need for a novel intervention to reduce imaging for low back pain, addressing both practitioner and patient related barriers. Chapters 5 and 6 describe the development and preliminary testing of this intervention. The development of the intervention was systematically performed using the Behaviour Change Wheel and the Theoretical Domains Framework. Development of the intervention was informed by experts in the field of low back pain and key stakeholders, including general practitioners and healthcare consumers (Chapter 5). Finally, a qualitative study was performed to assess general practitioners' experiences using the intervention in clinical practice. Barriers and facilitators to using the intervention in clinical practice were identified and used to inform implementation strategies of the final intervention (Chapter 6). The developed intervention incorporates a low back pain education and management booklet, designed to be used by general practitioners with patients during a clinical consult, and a training session to instruct practitioners in the use of the booklet. The booklet can be used by general practitioners to screen patients for the need for imaging, reassure and educate patients about their low back pain (and where appropriate why imaging isn't required), and provide customised management advice to the patient. The intervention was found to be useful by general practitioners, likely to reduce non-indicated imaging as designed, and suitable for future effectiveness testing.