Facilitators and Barriers to Deferring Low-Value Imaging for Low Back Pain: A Qualitative Study

Context: Early imaging for uncomplicated low back pain, occurring within 28 days of onset of pain, has no diagnostic benefit and is a marker of low-value care, yet is completed after nearly one-quarter of U.S. back pain visits.

Objective: This qualitative study examined facilitators and barriers to deferring low-value imaging for acute low back pain.

Study Design and Analysis: Patient focus groups and semi-structured physician interviews were conducted and transcribed, with thematic analysis used to identify themes from the resultant data.

Setting or Dataset: Six virtual patient focus groups with a total of 30 patients and nine telephone physician interviews conducted in 2020.

Population Studied: Patients were aged < 65 years and had seen a physician for acute low back pain in the last two years. Physicians were active in clinical practice and several had expertise in either low-value care or patient-doctor communication.

Intervention/Instrument: Trained coders applied open coding and analytical memoing to the focus group and interview transcripts. Once consensus on broad coding categories was obtained, a codebook was developed to independently code the transcripts using Dedoose software. Upon completion of coding, themes were identified from the transcripts.

Outcome Measures: Patients’ expectations regarding imaging and perceptions of care received for acute low back pain, along with physicians’ beliefs on facilitators and barriers to deferring low-value imaging.

Results: Patients expected physicians to provide a rationale for ordering imaging or not, as they often considered imaging to be an indicator of high-quality care and desired imaging to relieve anxiety. Patients were typically not persuaded by potential downsides of imaging, but conveyed willingness to defer imaging if provided expert and empathic guidance on pain management. Physicians expressed confidence in advocating for deferred imaging, highlighted the importance of managing patients’ expectations, and acknowledged challenges in building patient trust during time-pressed visits, particularly when seeing patients for the first time.

Conclusions: This qualitative study suggests patients may be receptive to deferring imaging for acute low back pain when the rationale is explained and when a pain management strategy is provided. Physicians highlighted lack of a previously established, trustful relationship as a common structural barrier to deferring low-value spinal imaging.