Table 1

Health-system barriers to following guideline recommendations on care for low back pain, and potential policy solutions
Guideline recommendationHealth-system barrierDetailsPotential policy solutions (suitability for health systemsa)
Conduct a focused history and physical examination to determine patients’ risk of having a serious underlying cause of painLack of time and trainingClinicians may lack adequate training in musculoskeletal assessment and managementDelivery arrangements
• Increase training in history and examination procedures for low back pain and include the topics of unnecessary care and shared decision-making in curricula for trainee clinicians (all health systems)
• Provide easy access to training courses for clinicianson shared decision-making for low back pain care (all health systems)37
• Provide locally relevant care pathways for low back pain e.g. the National Low Back and Radicular Pain Pathway 2017 in the United Kingdom (fee-for-service systems, capitation systems)38
• Build audit and feedback mechanisms on low back pain care, e.g. feedback on referral rates for diagnostic imaging tests (all health systems)39
Clinicians may be under time pressure during consultations for low back painDelivery arrangements
• Enhance the role of nurse practitioners and physiotherapists in primary care as they may be less likely to prescribe unnecessary care for low back pain, e.g. imaging tests (all health systems)40
• Assess the cost–effectiveness of using allied health staff who could provide equivalent low back pain care as physicians (all health systems)41
• Encourage evaluations, embedded in routine care, of the cost–effectiveness of any new model of low back pain care (all health systems)
• Allow patients to self-refer to physical and psychological therapies care for low back pain (capitation systems)
Financial arrangements
• Provide reimbursement for clinicians needing extra time for patients with complex low back pain problems (fee-for-service systems, hybrid systems)

Screen patients using a prognostic model; arrange early referral to non-pharmacological treatment for those at risk of a poor outcomeVested interests and funding arrangementsSome clinicians, companies and professional associations market ineffective early interventions for low back painGovernance
• Impose fines for clinicians, companies and professional associations who make false claims about efficacy of services (all health systems)
Prohibit direct-to-consumer advertising of non-evidence-based tests and treatments (all health systems)
Limited access to evidence-based information and health careThe prognosis of low back pain and the role of self-care is poorly understood by the publicDelivery arrangements
•      Create mass-media campaigns informing the public about self-management of low back pain, when to seek health care and how to identify false treatment claims (all health systems)42
•      Create health literacy programmes about low back pain, e.g. school and podcast programmes targeting parents and their school-aged children (all health systems)43
•      Encourage shared decision-making between clinician and patient on low back pain care, which can also increase informed decision-making for other health conditions

Prioritize non-pharmacological treatment for initial managementLimited access to coordinated, evidence-based health carePhysical, psychological and complementary therapies for low back pain may be unaffordable for patientsDelivery arrangements
• Invest in existing eHealth programmes for low back pain care, e.g. clinician-guided, remotely delivered, cognitive behavioural therapy-based pain management programmes (all health systems)44
Evidence-based non-pharmacological treatment for low back pain is poorly integrated with general practitioner care.Financial arrangements
• Fund programmes of guideline-adherent non-pharmacological treatment for selected patients with low back pain, e.g. those at risk of chronic pain (all health systems)
• Limit or remove expensive, non-evidence-based treatments for low back pain from funding schedules (all health systems)
Set up bundled payment systems for low back pain care, e.g. comprehensive care for joint replacement programme which “coordinates care over the full continuum of services and eliminates spending that doesn't benefit patients” (all health systems45
Lack of time and trainingQuality cognitive-behavioural therapy for low back pain is hampered by shortages of health workers, e.g. clinical psychologistsGovernance
• Provide government subsidies for university training positions on for low back pain care in needed health professions (all health systems)

If medication is needed, begin with simple analgesics such as nonsteroidal anti-inflammatory drugsVested interests and funding arrangementsComplex medicines for low back pain that lack evidence of lack of efficacy are aggressively marketedGovernance
• Impose fines for pharmaceutical companies who make false claims about efficacy and safety of products (all health systems)
• Require post-marketing evaluation to measure impact of use of medicine outside of the indications where efficacy has been demonstrated (all health systems)
Medicines and procedures that are ineffective for low back pain are funded by public or private insurance schemesFinancial arrangements
• Tighten or restrict indications for financial coverage of low back pain care, e.g. only fund treatment when there is evidence for clear benefit or in the context of a randomized trial to gather evidence (fee-for-service systems, capitation systems)
• Ensure agreements between all stakeholders involved in funding, provision and evaluation of therapies for low back pain and that evaluations are only done in the context of a clinical trial (all health systems)
• All clinical trials for low back pain treatment should pre-specify what outcomes constitute positive and negative results (all health systems)
• Require regular health technology assessments and reassessments of health services for low back pain46 (all health systems)
Over-the-counter medicines that are either ineffective (paracetamol) or untested (codeine combinations) in low back pain are cheap and easy to access from community pharmaciesGovernance
• Change opioid drugs, e.g. codeine combinations, from over-the-counter to prescription-only medicine (all health systems)

Avoid the following:
(i) prescribing opioid drugs;
(ii) referral for routine diagnostic imaging tests;
(iii) prescribing steroid injections for patients with chronic low back pain; and
(iv) referral for surgery for patients with chronic non-specific low back pain, outside of a randomized trial
Vested interests and funding arrangementsProviders (physicians, radiologists and surgeons), device manufacturers and pharmaceutical companies profit from low back pain careGovernance
• Compulsory review of all new drugs, equipment and practices for low back pain care, e.g. standard health technology assessment and reassessment (all health systems)46
Limited access to coordinated, evidence-based health carePatients, clinicians and the public believe that that opioid drugs, imaging tests and surgery are necessary care for low back painDelivery arrangements
• Create mass-media campaigns to warn health providers and the public about unnecessary care for low back pain (all health systems)
Vested interests and funding arrangementsPublic or private insurance schemes reimburse patients for low back pain care that is not concordant with guidelines, e.g. opioid drugs, imaging tests and surgeryFinancial arrangements
• Tighten or remove indications for health-care coverage, e.g. only fund treatments for low back pain where there is evidence for clear benefit or, if there is absence of evidence, in the context of a randomized trial (fee-for-service systems, capitation systems)
a We indicate which types of health-care funding systems are most suitable for interventions: all health systems (including low- and middle-income countries); fee-for-service systems (e.g. Australia); capitation systems (e.g. United Kingdom of Great Britain and Northern Ireland); hybrid systems, i.e. combination of fee-for-service and capitation (e.g. United Sates of America).