Facilitators and barriers to deferring imaging for acute low back pain: a qualitative study

Early imaging for uncomplicated acute low back pain has no diagnostic benefit yet is completed after nearly one-quarter of primary care visits for acute back pain. This qualitative study examined patient and clinician perspectives on facilitators and barriers to deferring imaging for acute low back pain, including potential messages regarding a watchful waiting strategy without early imaging.

Qualitative data derived from six patient focus groups (N = 30 patients with recent visits for acute low back pain) in Sacramento, CA and nine semi-structured physician interviews in 2020. Patients were asked about expectations regarding imaging, perceptions of care received for acute low back pain, and perspectives about potential messages encouraging a watchful waiting approach without early imaging. Clinicians were asked about facilitators and barriers to deferring low-value imaging. We used thematic analysis guided by grounded theory to identify and integrate themes.

Over half of patients had received early imaging during their recent back pain episode. Patients expected physicians to provide a detailed rationale for ordering imaging or not. Patients were typically not persuaded by information on potential harms of imaging and sometimes thought discussion of imaging harms would undermine their trust in the clinician. Patients would be more willing to defer imaging if provided detailed and empathic guidance on pain management. Physicians expressed confidence in advocating a watchful waiting approach without imaging but acknowledged challenges in building patient trust during time-pressed visits, particularly when seeing patients for the first time.

This qualitative study highlights several challenges to deferring early imaging in acute low back pain, as patients typically expect early imaging and were skeptical of clinician messaging about imaging harms. Physicians highlighted lack of a previously established, trustful relationship as a common structural barrier to deferring low-value spinal imaging.