Ansgar Espeland

General practitioners often diverge from clinical guidelines regarding spine radiography. This study aimed to identify and describe A) factors general practitioners consider may affect their decisions about ordering plain radiography for back pain and B) barriers to guideline adherence suggested by such factors. Focus group interviews regarding factors affecting ordering decisions were carried out on a diverse sample of Norwegian general practitioners and were analysed qualitatively. Results of this study and two qualitative studies from the Netherlands and USA on use of spine radiography were interpreted for barriers to guideline adherence. These were compared with an existing barrier classification system described by Dr Cabana's group. The factors which Norwegian general practitioners considered might affect their decisions about ordering plain radiography for back pain concerned the following broader issues: clinical ordering criteria, patients' wishes for radiography and the general practitioner's response, uncertainty, professional dignity, access to radiology services, perception of whether the patient really was ill, sense of pressure from other health care providers/social security, and expectations about the consequences of ordering radiography. The three studies suggested several attitude-related and external barriers as classified in a previously reported system described by Dr Cabana in another study. Identified barriers not listed in this system were: lack of expectancy that guideline adherence will lead to desired health care process, emotional difficulty with adherence, improper access to actual/alternative health care services, and pressure from health care providers/organisations. Our findings may help implement spine radiography guidelines. They also indicate that Cabana et al.'s barrier classification system needs extending. A revised system is proposed.

Quantitative and qualitative cross-sectional interview study. To investigate how patients who are referred for plain radiography because of low back pain perceive the importance and usefulness of the examination. Up to 50% of plain radiography examinations for low back pain may be unnecessary based on clinical criteria. However, many patients have great confidence in these examinations. A further exploration of the patients’ views may indicate how their needs can be met without unnecessary use of radiography. Ninety-nine patients (65 women, 34 men) 14–91 years of age who were referred from Norwegian general practitioners for plain radiography of the lumbosacral spine were asked to rate the examination as slightly/fairly or very important (93 responded). Chi-squared tests were used to evaluate differences in rating according to age, gender, clinical history, and clinical appropriateness of the examination, as determined by comparing information in the referral form with Norwegian (NR) and British (BR) recommendations for use of radiography. Each of the 99 patients also underwent a semistructured interview that was based on questions about importance, usefulness, and reasons for the radiography referral. Answers were categorized and described using a qualitative method (template analysis). Seventy-two percent (68 of 93) of patients rated radiography as very important. The proportion was higher for men than women (85%vs. 65%, P = 0.04), higher for those with worsening than those with improving/unchanged symptoms (86%vs. 65%, P = 0.03), and higher for inappropriately than appropriately referred patients (NR: 76%vs. 61%, P = 0.17; BR: 81%vs. 56%, P = 0.01). The qualitative analysis showed that the patients related their views on the importance and usefulness of receiving radiography to seven different issues: symptoms and clinical history, information and advice (especially from health care providers), need for emotional support from the physician, need for certainty and reassurance, need for symptom explanation and diagnosis, reliability of radiography compared with clinical evaluation, and expected practical consequences of the radiologic examination. The finding that inappropriately referred patients tended to rate their radiography referral as more important than appropriately referred patients indicates that the patient’s view may be a substantial barrier to appropriate use of radiography. The study identified seven issues underlying the patients’ views on importance and usefulness of receiving radiography. Strategies to prevent unnecessary use of plain radiography for low back pain that address these issues are suggested.