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Canada has the fourth highest per capita rate of opioid prescriptions in the world, contributing to the country's opioid crisis. Due to both their pain-relieving and euphoric properties, opioids can be highly addictive, leading to potential overdose and death. Deprescription is an endorsed and organized method of discontinuing a drug but very little is known about the barriers that Canadian physicians face when attempting to deprescribe opioids, particularly those who practice in rural areas (which have some of the highest rates of opioid users). This was an explorative, qualitative study describing rural family doctors' experiences and practices regarding opioid deprescription in primary care. A convenience sample of family doctors who had experience working with patients taking opioid medications was recruited from the professional networks of study team members. After consenting to participate, data was collected using semi-structured telephone interviews and analyzed by researchers experienced in applying the Theoretical Domains Framework to assess barriers and enablers of behavior change. 10 physicians participated in this study. Our analysis revealed four barriers and five enablers related to opioid deprescription in rural primary care. Barriers include a lack of knowledge and skills related to deprescribing, discomfort initiating deprescription, patient pressure to continue prescribing opioids, and a lack of foundational support required to deprescribe. Enablers include working with colleagues who share common views on overuse of opioids and deprescription; access to other healthcare providers, community-based resources, and clinical tools; using a systematic approach to deprescription; previous experience successfully deprescribing opioids; and practicing in a rural setting. Opioid dependence and over-prescription continue to be a problem for our health system. Deprescription is necessary but challenging for family physicians. Rural physicians are keenly aware of the importance of preserving the physician-patient therapeutic relationship and open and clear communication about opioid medications and deprescription but feel unprepared to manage this in the face of difficult issues surrounding deprescription. They also feel unprepared to deal with deprescription effectively without access to other resources, healthcare professionals, patient education materials and time. Rural physicians would benefit most from added foundational supports for deprescription.

Background 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. Methods 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. Results 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 — fr om 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). Conclusions 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. Registration PROSPERO 2017, CRD42017070703

Evidence-based guidelines for managing LBP exist but their recommendations are often not used by health professionals in primary care. A key challenge to address this issue is understanding how people understand LBP, how they feel about it, and cope with it - particularly with regard to why they visit their doctors and their treatment expectations. This is important to understand, particularly since physician barriers to following LBP treatment guidelines have centered on patient issues (such as patient demand for imaging). This was a qualitative, exploratory study using semi-structured interviews to explore patient perceptions of LBP and their coping strategies, paying particular attention to why patients with LBP in Newfoundland and Labrador (NL) seek care from family physicians and their treatment expectations, especially with regard to imaging. Eligible patients included adults aged 18 + years or older, living in both rural and urban settings in NL, Canada, who had visited their family physician about low back pain within the year prior to the interview. Researchers experienced in applying the Common-sense Model of Self-regulation (CSM), used the model to inform the development of our question guide and as a framework for the data analysis. We found that new onset, severity, or persistent pain prompted patients to visit their family doctor, primarily to seek advice and/or a diagnosis, or for a referral to imaging or other providers. While patients believed that imaging was essential to understanding the underlying cause of their symptoms or informing their treatment, they were divided about its effectiveness - some felt it was beneficial to their treatment while others reported that it had no effect. We found that patients were unified in their largely negative views regarding prognosis and all experienced a range of negative emotions surrounding their LBP such as fear, stress, frustration, and guilt. We also found wide variation in understanding of cause and use of coping strategies. Patients posited several causes for the pain including injury, overexertion, comorbid conditions, and issues related to posture and sitting, and were split on their thoughts regarding prevention - about half thought it could be prevented, half did not. We found that patients coped with their LBP using a variety of strategies but were often disappointed in the results. Most reported no benefit to visiting their family doctors for their LBP. Some were pleased with their experiences with allied HCPs, noting small, but steady, improvements using recommended exercises but others were generally dissatisfied. Our exploration of patient views and expectations for low back pain care indicates a mismatch between the care they are looking for and the care they receive. It also suggested a general lack of knowledge about the cause of LBP, the value and usefulness of imaging for its diagnosis and treatment, and poor physician-patient communication.

Guidelines recommend patient education materials (PEMs) for low back pain (LBP), but no systematic review has assessed PEMs on their own. We investigated the effectiveness of PEMs on process, clinical, and health system outcomes for LBP and sciatica. Systematic searches were performed in MEDLINE, EMBASE, CINAHL, PsycINFO, SPORTDiscus, trial registries and grey literature through OpenGrey. We included randomized controlled trials of PEMs for LBP. Data extraction, risk of bias, and quality of evidence gradings were performed independently by two reviewers. Standardized mean differences or risk ratios and 95% confidence intervals were calculated, and effect sizes pooled using random-effects models. Analyses of acute/subacute LBP were performed separately from chronic LBP at immediate, short, medium, and long-term (6, 12, 24, and 52 weeks, respectively). 27 studies were identified. Compared to usual care for chronic LBP, we found moderate to low-quality evidence that PEMs improved pain intensity at immediate (SMD = -0.16 [95% CI: -0.29, -0.03]), short (SMD = -0.44 [95% CI: -0.88, 0.00]), medium (SMD = -0.53 [95% CI: -1.01, -0.05]), and long-term (SMD = -0.21 [95% CI: -0.41, -0.01]), medium-term disability (SMD = -0.32 [95% CI: -0.61, -0.03]), quality of life at short (SMD = -0.17 [95% CI: -0.30, -0.04]) and medium-term (SMD = -0.23 [95% CI: -0.41, -0.04]) and very low-quality evidence that PEMs improved global improvement ratings at immediate (SMD = -0.40 [95% CI: -0.58, -0.21]), short (SMD = -0.42 [95% CI: -0.60, -0.24]), medium (SMD = -0.46 [95% CI: -0.65, -0.28]), and long-term (SMD = -0.43 [95% CI: -0.61, -0.24]). We found very low-quality evidence that PEMs improved pain self-efficacy at immediate (SMD = -0.21 [95% CI: -0.39, -0.03]), short (SMD = -0.25 [95% CI: -0.43, -0.06]), medium (SMD = -0.23 [95% CI: -0.41, -0.05]), and long-term (SMD = -0.32 [95% CI: -0.50, -0.13]), and reduced medium-term fear-avoidance beliefs (SMD = -0.24 [95% CI: -0.43, -0.06]) and long-term stress (SMD = -0.21 [95% CI: -0.39, -0.03]). Compared to usual care for acute LBP, we found high to moderate-quality evidence that PEMs improved short-term pain intensity (SMD = -0.24 [95% CI: -0.42, -0.06]) and immediate-term quality of life (SMD = -0.24 [95% CI: -0.42, -0.07]). We found low to very low-quality evidence that PEMs increased knowledge at immediate (SMD = -0.51 [95% CI: -0.72, -0.31]), short (SMD = -0.48 [95% CI: -0.90, -0.05]), and long-term (RR = 1.28 [95% CI: 1.10, 1.49]) and pain self-efficacy at short (SMD = -0.78 [95% CI: -0.98, -0.58]) and long-term (SMD = -0.32 [95% CI: -0.52, -0.12]). We found moderate to very low-quality evidence that PEMs reduced short-term days off work (SMD = -0.35 [95% CI: -0.63, -0.08]), long-term imaging referrals (RR = 0.60 [95% CI: 0.41, 0.89]), and long-term physician visits (SMD = -0.16 [95% CI: -0.26, -0.05]). Compared to other interventions (e.g., yoga, Pilates), PEMs had no effect or were less effective for acute/subacute and chronic LBP. There was a high degree of variability across outcomes and time points, but providing PEMs appears favorable to usual care as we observed many small, positive patient and system impacts for acute/subacute and chronic LBP. PEMs were generally less effective than other interventions; however, no cost effectiveness analyses were performed to weigh the relative benefits of these interventions to the likely less costly PEMs.

[This corrects the article DOI: 10.1371/journal.pone.0274527.].

While numerous guidelines do not recommend preoperative tests for low risk patients undergoing low risk surgeries, they are often routinely performed. Canadian data suggests preoperative tests (e.g. ECGs and chest x-rays) preceded 17.9%-35.5% of low-risk procedures. Translating guidelines into clinical practice can be challenging and it is important to understand what is driving behaviour when developing interventions to change it. Thus, we completed a theory-based investigation of the perceived barriers and enablers to reducing unnecessary preoperative tests for low-risk surgical procedures in Newfoundland, Canada. We used snowball sampling to recruit surgeons, anaesthesiologists, or preoperative clinic nurses. Interviews were conducted by two researchers using an interview guide with 31 questions based on the theoretical domains framework. Data was transcribed and coded into the 14 theoretical domains and then themes were identified for each domain. We interviewed 17 surgeons, anaesthesiologists, or preoperative clinic nurses with 1 to 34 years' experience. Overall, while respondents agreed with the guidelines they described several factors, across seven relevant theoretical domains, that influence whether tests are ordered. The most common included uncertainty about who is responsible for test ordering, inability to access patient records or to consult/communicate with colleagues about ordering decisions and worry about surgery delays/cancellation if tests are not ordered. Other factors included workplace norms that conflicted with guidelines and concerns about missing something serious or litigation. In terms of enablers, respondents believed that clear institutional guidelines including who is responsible for test ordering and information about the risk of missing something serious, supported by improved communication between those involved in the ordering process and periodic evaluation will reduce any unnecessary preoperative testing. These findings suggest that both health system and health provider factors need to be addressed in an intervention to reduce pre-operative testing.

Residents of rural areas have poorer health status, less healthy behaviours and higher mortality than urban dwellers, issues which are commonly addressed in primary care. Strengthening primary care may be an important tool to improve the health status of rural populations. Synthesize and categorize studies that examine interventions to improve rural primary care. Experimental or observational studies published between January 1, 1996 and December 2022 that include an historical or concurrent control comparison. Pubmed, CINAHL, Cochrane Library, Embase. We extracted and charted data by broad category (quality, access and efficiency), study design, country of origin, publication year, aim, health condition and type of intervention studied. We assigned multiple categories to a study where relevant. 372 papers met our inclusion criteria, divided among quality (82%), access (20%) and efficiency (13%) categories. A majority of papers were completed in the USA (40%), Australia (15%), China (7%) or Canada (6%). 35 (9%) papers came from countries in Africa. The most common study design was an uncontrolled before-and-after comparison (32%) and only 24% of studies used randomized designs. The number of publications each year has increased markedly over the study period from 1-2/year in 1997-99 to a peak of 49 papers in 2017. Despite substantial inequity in health outcomes associated with rural living, very little attention is paid to rural primary care in the scientific literature. Very few studies of rural primary care use randomized designs.

Introduction While numerous guidelines do not recommend preoperative tests for low risk patients undergoing low risk surgeries, they are often routinely performed. Canadian data suggests preoperative tests (e.g. ECGs and chest x-rays) preceded 17.9%-35.5% of low-risk procedures. Translating guidelines into clinical practice can be challenging and it is important to understand what is driving behaviour when developing interventions to change it. Aim Thus, we completed a theory-based investigation of the perceived barriers and enablers to reducing unnecessary preoperative tests for low-risk surgical procedures in Newfoundland, Canada. Method We used snowball sampling to recruit surgeons, anaesthesiologists, or preoperative clinic nurses. Interviews were conducted by two researchers using an interview guide with 31 questions based on the theoretical domains framework. Data was transcribed and coded into the 14 theoretical domains and then themes were identified for each domain. Results We interviewed 17 surgeons, anaesthesiologists, or preoperative clinic nurses with 1 to 34 years’ experience. Overall, while respondents agreed with the guidelines they described several factors, across seven relevant theoretical domains, that influence whether tests are ordered. The most common included uncertainty about who is responsible for test ordering, inability to access patient records or to consult/communicate with colleagues about ordering decisions and worry about surgery delays/cancellation if tests are not ordered. Other factors included workplace norms that conflicted with guidelines and concerns about missing something serious or litigation. In terms of enablers, respondents believed that clear institutional guidelines including who is responsible for test ordering and information about the risk of missing something serious, supported by improved communication between those involved in the ordering process and periodic evaluation will reduce any unnecessary preoperative testing. Conclusion These findings suggest that both health system and health provider factors need to be addressed in an intervention to reduce pre-operative testing.

IntroductionGuidelines recommend patient education materials (PEMs) for low back pain (LBP), but no systematic review has assessed PEMs on their own. We investigated the effectiveness of PEMs on process, clinical, and health system outcomes for LBP and sciatica.MethodsSystematic searches were performed in MEDLINE, EMBASE, CINAHL, PsycINFO, SPORTDiscus, trial registries and grey literature through OpenGrey. We included randomized controlled trials of PEMs for LBP. Data extraction, risk of bias, and quality of evidence gradings were performed independently by two reviewers. Standardized mean differences or risk ratios and 95% confidence intervals were calculated, and effect sizes pooled using random-effects models. Analyses of acute/subacute LBP were performed separately from chronic LBP at immediate, short, medium, and long-term (6, 12, 24, and 52 weeks, respectively).Results27 studies were identified. Compared to usual care for chronic LBP, we found moderate to low-quality evidence that PEMs improved pain intensity at immediate (SMD = -0.16 [95% CI: -0.29, -0.03]), short (SMD = -0.44 [95% CI: -0.88, 0.00]), medium (SMD = -0.53 [95% CI: -1.01, -0.05]), and long-term (SMD = -0.21 [95% CI: -0.41, -0.01]), medium-term disability (SMD = -0.32 [95% CI: -0.61, -0.03]), quality of life at short (SMD = -0.17 [95% CI: -0.30, -0.04]) and medium-term (SMD = -0.23 [95% CI: -0.41, -0.04]) and very low-quality evidence that PEMs improved global improvement ratings at immediate (SMD = -0.40 [95% CI: -0.58, -0.21]), short (SMD = -0.42 [95% CI: -0.60, -0.24]), medium (SMD = -0.46 [95% CI: -0.65, -0.28]), and long-term (SMD = -0.43 [95% CI: -0.61, -0.24]). We found very low-quality evidence that PEMs improved pain self-efficacy at immediate (SMD = -0.21 [95% CI: -0.39, -0.03]), short (SMD = -0.25 [95% CI: -0.43, -0.06]), medium (SMD = -0.23 [95% CI: -0.41, -0.05]), and long-term (SMD = -0.32 [95% CI: -0.50, -0.13]), and reduced medium-term fear-avoidance beliefs (SMD = -0.24 [95% CI: -0.43, -0.06]) and long-term stress (SMD = -0.21 [95% CI: -0.39, -0.03]). Compared to usual care for acute LBP, we found high to moderate-quality evidence that PEMs improved short-term pain intensity (SMD = -0.24 [95% CI: -0.42, -0.06]) and immediate-term quality of life (SMD = -0.24 [95% CI: -0.42, -0.07]). We found low to very low-quality evidence that PEMs increased knowledge at immediate (SMD = -0.51 [95% CI: -0.72, -0.31]), short (SMD = -0.48 [95% CI: -0.90, -0.05]), and long-term (RR = 1.28 [95% CI: 1.10, 1.49]) and pain self-efficacy at short (SMD = -0.78 [95% CI: -0.98, -0.58]) and long-term (SMD = -0.32 [95% CI: -0.52, -0.12]). We found moderate to very low-quality evidence that PEMs reduced short-term days off work (SMD = -0.35 [95% CI: -0.63, -0.08]), long-term imaging referrals (RR = 0.60 [95% CI: 0.41, 0.89]), and long-term physician visits (SMD = -0.16 [95% CI: -0.26, -0.05]). Compared to other interventions (e.g., yoga, Pilates), PEMs had no effect or were less effective for acute/subacute and chronic LBP.ConclusionsThere was a high degree of variability across outcomes and time points, but providing PEMs appears favorable to usual care as we observed many small, positive patient and system impacts for acute/subacute and chronic LBP. PEMs were generally less effective than other interventions; however, no cost effectiveness analyses were performed to weigh the relative benefits of these interventions to the likely less costly PEMs.

Introduction Engaging with patients about their lived experience of health and illness and their experience within the healthcare system can help inform the provision of care, health policies and health research. In the context of health research, however, operationalizing the levels of patient engagement is not straightforward. We suggest that a key challenge to the routine inclusion of patients as partners in health research is a lack of tangible guidance regarding how this can be accomplished. Methods In this article, we provide guidance on how to codesign and operationalize a concrete patient engagement plan for any health research project. Results We illustrate a seven‐step approach using the example of a national clinical trial in Canada and provide a patient engagement planning template for use in any health research project. Conclusion Such concrete guidance should improve the design and reporting of patient engagement in health research. Patient or Public Contribution The De‐Implementing Wisely Research group is informed by a national 9‐member patient partner council (PPC). The research team includes three lead patient partners who are coinvestigators on the grant that funds the program of research. Members of the council advise on all aspects of the study design and implementation. The ideas presented in this paper were informed by regular communication and planning with the PPC; specific contributions of lead patient partner authors are outlined as follows: Brian Johnston, Susan Goold and Vanessa Francis are patient partners with a wide breadth of experience in the healthcare system and health research projects. The guidance in this article draws on their lived and professional expertise. All patient partner authors contributed to the planning of the manuscript, participated in meetings to develop content and provided critical manuscript edits and comments on drafts.