Primary Healthcare Research Unit (PHRU), Faculty of Medicine, Memorial University, Room 417 | Janeway Hostel, Health Sciences Centre, 300 Prince Philip Parkway, St. John's, NL, A1B 3V6, Canada.
Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, UK.
Implement Sci. 2019 May 7;14(1):49. doi: 10.1186/s13012-019-0884-4.
Adoption of low back pain guidelines is a well-documented problem. Information to guide the development of behaviour change interventions is needed. The review is the first to synthesise the evidence regarding physicians' barriers to providing evidence-based care for LBP using the Theoretical Domains Framework (TDF). Using the TDF allowed us to map specific physician-reported barriers to individual guideline recommendations. Therefore, the results can provide direction to future interventions to increase physician compliance with evidence-based care for LBP.
We searched the literature for qualitative studies from inception to July 2018. Two authors independently screened titles, abstracts, and full texts for eligibility and extracted data on study characteristics, reporting quality, and methodological rigour. Guided by a TDF coding manual, two reviewers independently coded the individual study themes using NVivo. After coding, we assessed confidence in the findings using the GRADE-CERQual approach.
Fourteen studies (n = 318 physicians) from 9 countries reported barriers to adopting one of the 5 guideline-recommended behaviours regarding in-clinic diagnostic assessments (9 studies, n = 198), advice on activity (7 studies, n = 194), medication prescription (2 studies, n = 39), imaging referrals (11 studies, n = 270), and treatment/specialist referrals (8 studies, n = 193). Imaging behaviour is influenced by (1) social influence-from patients requesting an image or wanting a diagnosis (n = 252, 9 studies), (2) beliefs about consequence-physicians believe that providing a scan will reassure patients (n = 175, 6 studies), and (3) environmental context and resources-physicians report a lack of time to have a conversation with patients about diagnosis and why a scan is not needed (n = 179, 6 studies). Referrals to conservative care is influenced by environmental context and resources-long wait-times or a complete lack of access to adjunct services prevented physicians from referring to these services (n = 82, 5 studies).
Physicians face numerous barriers to providing evidence-based LBP care which we have mapped onto 7 TDF domains. Two to five TDF domains are involved in determining physician behaviour, confirming the complexity of this problem. This is important as interventions often target a single domain where multiple domains are involved. Interventions designed to address all the domains involved while considering context-specific factors may prove most successful in increasing guideline adoption.
PROSPERO 2017, CRD42017070703.
采用腰痛指南是一个有据可查的问题。需要信息来指导行为改变干预措施的制定。本综述是首次使用理论领域框架（TDF）综合关于医生为腰痛提供循证护理的障碍的证据。使用 TDF 使我们能够将医生报告的具体障碍映射到个别指南建议上。因此，这些结果可以为未来增加医生对腰痛循证护理的依从性的干预措施提供方向。
我们从最初开始搜索文献，直到 2018 年 7 月，以获取定性研究。两位作者独立筛选标题、摘要和全文的资格，并提取有关研究特征、报告质量和方法严谨性的数据。在 TDF 编码手册的指导下，两位审稿人使用 NVivo 独立对个别研究主题进行编码。编码后，我们使用 GRADE-CERQual 方法评估研究结果的可信度。
来自 9 个国家的 14 项研究（n=318 名医生）报告了与以下 5 项指南推荐行为之一有关的障碍：（9 项研究，n=198）在诊所进行诊断评估，（7 项研究，n=194）关于活动的建议，（2 项研究，n=39）药物处方，（11 项研究，n=270）影像学转诊，（8 项研究，n=193）治疗/专科转诊。影像学行为受到（1）来自患者的社会影响，他们要求进行影像检查或寻求诊断（n=252，9 项研究），（2）信念的影响，医生认为提供扫描将使患者安心（n=175，6 项研究），（3）环境背景和资源的影响，医生报告缺乏与患者就诊断和不需要扫描进行对话的时间（n=179，6 项研究）。转诊到保守治疗受到环境背景和资源的影响-较长的等待时间或完全缺乏辅助服务的机会，使医生无法转诊到这些服务（n=82，5 项研究）。
医生在提供腰痛循证护理方面面临着许多障碍，我们已经将这些障碍映射到了 7 个 TDF 领域。有 2 到 5 个 TDF 领域参与决定医生的行为，这证实了这个问题的复杂性。这很重要，因为干预措施通常针对单个领域，而多个领域都涉及其中。设计干预措施以解决所有涉及的领域，并考虑具体的背景因素，可能会在增加指南的采用方面最成功。
PROSPERO 2017，CRD42017070703。
