Implementing high value back pain care in private physiotherapy in Australia: A qualitative evaluation of physiotherapists who participated in an “implementation to innovation” system

Figures & data

Table 1. Core components of PRISM

PRISM component	Description
1. Education and training	Contemporary educational strategies to optimize biological and clinical science pain knowledge and skills in pain care
2. Clinical pathways and collaborative innovation	Refinement and implementation of a high-value care patient pathway, including detection of sinister pathology, risk stratification, avoiding unnecessary imaging and medication (e.g., opioids), pain education, distress management training via brief cognitive behavioral therapy, refinement and implementation of clinical tools (see Table 2), and practical coaching for graded reactivation and self-management^Citation17
3. High reliability management and learning system	Establishing a community of practice, electronic clinical decision-making systems, an agreed-upon clinical protocol, audit and feedback, simulation and structured observation, mentoring and shared problem solving, data feedback, and suggestions on innovation

Table 2. Tools for the high-value care pathway

Tool	Features
Subjective patient questionnaire (Appendix B)	Patient questionnaire including data on patient demographics, back pain history, pain assessment, understanding of pain biology, catastrophizing, coping strategies, depression assessment, work status, recovery appraisal, and recovery expectations. Aggregated and de-identified comparative results from the questionnaire were fed back to participants
MyBack^Citation31	An electronic tool with an embedded algorithm to assist health professionals in understanding the level of risk associated with a patient’s signs and symptoms and triaging patients into management pathways based on risk
Explain Pain^Citation32	A patient resource providing content knowledge important for reassurance and pain science education. The book can be lent to patients to read through with carers/significant others
Explain Pain Supercharged^Citation33	A clinician’s guide for the content presented in the patient resource. Includes a guide to a pain assessment “cheat sheet”; planning conceptual change strategies; multiple examples of how to offer new concepts, engineer new experiences consistent with new concepts, and use resources that corroborate new concepts
GLITtER patient resources^Citation34,Citation35	A 4-week patient guide that includes a framework for talking about common radiological findings in a manner that aims to reassure patients and promote activity
The Explain Pain Handbook: Protectometer^Citation36	A patient workbook integrated into care according to the cheat sheet findings
BackTracker	A bespoke tool to assist clinicians and patients to determine “normal” or “average” expected recovery rates. Can be used to guide reassurance and evidence-based escalation
Tamethebeast.org	An online resource that patients can read in their own time. It presents common pain-related target concepts and includes patient interviews in the form of podcasts
Painful Yarns^Citation37	A patient handbook that presents common target concepts

GLITtER = Green Light Imaging Interpretation to Enhance Recovery.

Figure 1. PRISM conceptual model

Table 3. Participant characteristics

Gender	Male	Female	Other
	4	2
Age (years)	< 30	31–40	41–50	50–60	61+
	1	3	2
Years in profession	< 10	11–20	21–30	31–40	41+
	1	3	2
Average number of acute LBP patients presenting per month	<5	6–10	11–15	15–20	21+
	3	2	1

LBP = low back pain.

Appendix A. Consolidated criteria for reporting qualitative research checklist

Item	Guide questions/description	Reported in section or page no.^a
Domain 1: Research team and reflexivity
Personal characteristics
1. Interviewer/facilitator	Which author/s conducted the interview or focus group?	See Methods → Data collection and analysis
2. Credentials	What were the researcher’s credentials? For example, Ph.D., M.D.	See affiliations and titles
3. Occupation	What was the researcher’s occupation at the time of the study?	All researchers were researchers
4. Gender	Was the researcher male or female?	LM, PH: male; CM, EK, LW: female
5. Experience and training	What experience or training did the researcher have?	CG has experience in qualitative research methods that capture people’s perspectives on and experiences with a range of effects, including health professional training, evaluation of programs, and consumer input into and feedback on resources. She has actively engaged with developing interview guides, facilitating focus group and interview discussions with children and adults, thematic analysis and syntheses of qualitative data for reports, and, more recently, scientific publications. PH has undertaken semistructured interviews and focus groups with health care professionals, managers, and executives mainly in relation to patient safety and quality improvement over the last 15 years for the purposes of research and evaluation. He is the author of 14 peer-reviewed papers that undertook qualitative analysis of patient safety incident reports. EK has had relevant research experience in planning, conducting, and reporting feasibility studies of clinical interventions for low back pain and knee osteoarthritis. EK is also a registered physiotherapist. Over the last 7 years, LW’s primary qualitative research activities have centered around leading and analyzing data from focus groups and semistructured interviews with diverse stakeholder groups (e.g., health care professionals, researchers, policymakers, tertiary educators, consumers, and journal editors) to seek their perspectives on a range of topics. These include exploring their experiences of referral and triage processes for patients with spinal complaints, the use of clinical practice guidelines and their understanding of the underlying development processes, recommendations for defining roles and credentialing requirements for extended scope physiotherapy practitioners in Australia, the meaning of consumer engagement, the application of person-centered care principles in residential aged care, and journal publication practices and trends. In addition, Louise has coauthored several metasyntheses, which have facilitated skills in critical appraisal, analysis, and aggregation of data from primary qualitative studies. LW is also a registered physiotherapist. GLM is the professor of neuroscience and foundation chair in physiotherapy at the University of South Australia.
Relationship with participants
6. Relationship established	Was a relationship established prior to study commencement?	There was no relationship between the study participants and the researchers prior to the commencement of the study.
7. Participant knowledge of the interviewer	What did the participants know about the researcher? For example, personal goals, reasons for doing the research	The participant information form that was provided with the consent form signed by the participant was explicit in its description of the purpose of the research and the professional qualifications of the researchers (CG, PH, LM). This information was provided to participants in more detail in the workshops.
8. Interviewer characteristics	What characteristics were reported about the interviewer/facilitator? For example, bias, assumptions, reasons, and interests in the research topic	One of the researchers (PH) was a facilitator who had worked in the same profession as the participants, meaning that he had shared experience of the clinical context in which the participants were applying their new knowledge. CG, who was not from the same profession, may have acted to mitigate bias from PH being from the same profession as the participants.
Domain 2: Study design
Theoretical framework
9. Methodological orientation and theory	What methodological orientation was stated to underpin the study? For example, grounded theory, discourse analysis, ethnography, phenomenology, content analysis	See Methods → Study design: Interpretive description
Participant selection
10. Sampling	How were participants selected? For example, purposive, convenience, consecutive, snowball	See Methods → Sampling strategy
11. Method of approach	How were participants approached? For example, face-to-face, telephone, mail, e-mail	Participants were initially approached by e-mail and then a follow-up telephone when they were invited to participate in the study.
12. Sample size	How many participants were in the study?	See Methods → Sampling strategy: 6
13. Nonparticipation	How many people refused to participate or dropped out? Reasons?	No people refused to participate or dropped out
14. Setting of data collection	Where was the data collected? For example, home, clinic, workplace	See Methods → Data collection and analysis: Clinic, over the telephone.
15. Presence of nonparticipants	Was anyone else present besides the participants and researchers?	There was no one else present during data collection besides the participants and researchers.
16. Description of sample	What are the important characteristics of the sample? For example, demographic data, date	See Table 3
Data collection
17. Interview guide	Were questions, prompts, and guides provided by the authors? Was it pilot tested?	See Methods → Data collection and analysis and Appendices C and D
18. Repeat interviews	Were repeat interviews carried out? If yes, how many?	Data were collected at multiple time points, including seven discussion forums, a semistructured interview, and an electronic questionnaire.
19. Audio/visual recording	Did the research use audio or visual recording to collect the data?	See Methods → Data collection and analysis
20. Field notes	Were field notes made during and/or after the interview or focus group?	See Methods → Data collection and analysis
21. Duration	What was the duration of the interviews or focus group?	See Results
22. Data saturation	Was data saturation discussed?	Given the small number of participants, data saturation was not discussed.
23. Transcripts returned	Were transcripts returned to participants for comment and/or correction?	See Methods → Data collection and analysis
Domain 3: Analysis and findings
Data analysis
24. Number of data coders	How many data coders coded the data?	See Methods → Data collection and analysis
25. Description of the coding tree	Did authors provide a description of the coding tree?	Not applicable
26. Derivation of themes	Were themes identified in advance or derived from the data?	Themes were derived from the data (inductive)
27. Software	What software, if applicable, was used to manage the data?	Software was not used to manage the data
28. Participant checking	Did participants provide feedback on the findings?	See Methods → Data collection and analysis
Reporting
29. Quotations presented	Were participant quotations presented to illustrate the themes/findings? Was each quotation identified? For example, participant number	Yes, see text
30. Data and findings consistent	Was there consistency between the data presented and the findings?	See themes in the results compared to the quotations in text
31. Clarity of major themes	Were major themes clearly presented in the findings?	See Results
32. Clarity of minor themes	Is there a description of diverse cases or discussion of minor themes?	No diverse cases (other than the spectrum of quotes presented in Results) or minor themes were discussed

^aThe third column either reports the section in the manuscript where the information is found or, if the information is not in the manuscript, a summary is provided.

Table

		True	False	Unknown
1	It is possible to have pain and not know about it.
2	When part of your body is injured, special pain receptors convey the pain message to your brain.
3	Pain only occurs when you are injured or at risk of being injured.
4	When you are injured, special receptors convey the danger message to your spinal cord.
5	Special nerves in your spinal cord convey “danger” messages to your brain.
6	Nerves adapt by increasing their resting level of excitement.
7	Chronic pain means that an injury hasn’t healed properly.
8	Worse injuries always result in worse pain
9	Descending neurons are always inhibitory.
10	Pain occurs whenever you are injured.
11	When you injure yourself, the environment that you are in will not affect the amount of pain you experience, as long as the injury is exactly the same.
12	The brain decides when you will experience pain.

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