Initial Management of Acute and Chronic Low Back Pain: Responses from Brief Interviews of Primary Care Providers

Eric J. Roseen; Frank Garrett Conyers; Steven J. Atlas; Darshan H. Mehta

doi:10.1089/acm.2020.0391

Table 4.

Summary Themes and Representative Quotes of Barriers to Referring Patients with Chronic Low Back Pain to Nonpharmacologic Treatments

Barrier^a PCP responses^b
Clinic A (high-income) Clinics B and C (low-income)
Not familiar with evidence-base 1 —

“To be honest, I do not really know the efficacy data for most of those treatments. I should take a look, but anecdotally I haven't heard of too many success stories [A-1].”

Not convinced by evidence-base 3 14

“I know people recommend these things, but I just don't really buy the data. If a patient has really been struggling with pain and all else has failed, I will often suggest it, but it isn't my go to solution [A-18].”
“There have been a good number of trials that looked at this question, but I am not totally sold on the pain score reduction as it relates to clinical significance. I think the question of if these therapies make a meaningful difference is still unanswered [B-24].”
“It's tough. I am not a strong believer in the few trials that are out there. Unless a patient has failed multiple interventions, I usually don't go that route until much later, if at all [C-23].”

NPTs not effective in practice/past experiences 2 1

“I have sent patients in to acupuncture and massage therapy over the years. They didn't really have much improvement, so I don't have a ton of faith in these services as a primary modality [A-16].”
“I have a hard time buying the evidence that these things work. I use PM&R given the right scenario, but even those people tend to not improve much over time [B-21].”

Limited NPT availability and/or no established relationship w/providers 1 3

“We don't really have any of those services locally that I am aware of. I also have a hard time referring to specialists that require physical skills without having heard positive reviews. In the same way that I try to recommend a certain surgeon that I know is good when a patient is in need of a procedure. I am not familiar with any local providers that I would trust in the same way [A-13].”
“Maybe I should be using more, but I am not strikingly convinced by the evidence that there is much utility. And in practice, there are not that many places here in Roxbury and the ones that are present are pretty expensive [C-4].”

Not covered by insurance and/or too expensive 1 13

“I've found that these things are rarely covered by insurance, so I use them as an end of the line option [A-26].”
“They usually are not covered by public insurance. Most of my panel is resource limiting so it's a balance of selecting therapies that are likely to have meaningful benefit with reasonable price points [B-2].”
“It's hard because I think there is a role for integrative therapies in pain management. However, given insurance usually does not cover and the out of cost expense is not negligible, I rarely turn to these services at initial presentation. I revisit if other therapies have failed [B-10].”
“My panel is mostly uninsured. Typically, these procedures and classes have relatively high copays and upfront cost [C-15].”

^aSome participants shared more than one barrier.
^bResponses are from 35 PCPs who indicated they were not comfortable referring to nonpharmacologic treatments and offered at least one barrier to making referrals. Eight PCPs were from a clinic A (high-income). The other 27 PCPs were from clinics B and C (low-income). Values in column correspond to the number of PCPs who made statements assigned to each theme.
NPT, nonpharmacologic treatment;
PCP, primary care provider;
PM&R, physical medicine and rehabilitation.

Barrier^a	PCP responses^b
Barrier^a	Clinic A (high-income)	Clinics B and C (low-income)
Not familiar with evidence-base	1	—

“To be honest, I do not really know the efficacy data for most of those treatments. I should take a look, but anecdotally I haven't heard of too many success stories [A-1].”

Not convinced by evidence-base	3	14

“I know people recommend these things, but I just don't really buy the data. If a patient has really been struggling with pain and all else has failed, I will often suggest it, but it isn't my go to solution [A-18].”
“There have been a good number of trials that looked at this question, but I am not totally sold on the pain score reduction as it relates to clinical significance. I think the question of if these therapies make a meaningful difference is still unanswered [B-24].”
“It's tough. I am not a strong believer in the few trials that are out there. Unless a patient has failed multiple interventions, I usually don't go that route until much later, if at all [C-23].”

NPTs not effective in practice/past experiences	2	1

“I have sent patients in to acupuncture and massage therapy over the years. They didn't really have much improvement, so I don't have a ton of faith in these services as a primary modality [A-16].”
“I have a hard time buying the evidence that these things work. I use PM&R given the right scenario, but even those people tend to not improve much over time [B-21].”

Limited NPT availability and/or no established relationship w/providers	1	3

“We don't really have any of those services locally that I am aware of. I also have a hard time referring to specialists that require physical skills without having heard positive reviews. In the same way that I try to recommend a certain surgeon that I know is good when a patient is in need of a procedure. I am not familiar with any local providers that I would trust in the same way [A-13].”
“Maybe I should be using more, but I am not strikingly convinced by the evidence that there is much utility. And in practice, there are not that many places here in Roxbury and the ones that are present are pretty expensive [C-4].”

Not covered by insurance and/or too expensive	1	13

“I've found that these things are rarely covered by insurance, so I use them as an end of the line option [A-26].”
“They usually are not covered by public insurance. Most of my panel is resource limiting so it's a balance of selecting therapies that are likely to have meaningful benefit with reasonable price points [B-2].”
“It's hard because I think there is a role for integrative therapies in pain management. However, given insurance usually does not cover and the out of cost expense is not negligible, I rarely turn to these services at initial presentation. I revisit if other therapies have failed [B-10].”
“My panel is mostly uninsured. Typically, these procedures and classes have relatively high copays and upfront cost [C-15].”