We observed significant changes in the primary care physician’s clinical management of patients with low back pain following his involvement in an interprofessional model of collaborative care. The physician prescribed fewer medications to study patients compared to pre-study patients, yet the patients had similar pain severity. This difference may have been related to the physician’s participation in the collaborative model of care that facilitated patient access and choice to an alternative treatment modality, as well as to the educational sessions that highlighted evidence based care and LBP guidelines.
A study conducted by Bishop et al. provides some support for the use of a multi-modal guidelines-based plan in treating low back pain
. They compared the outcomes of multi-modal guidelines-based care, which included a chiropractor delivering manipulative care, to that of primary care physician-directed usual care. Interestingly, the use of narcotic analgesic medications was 78% in the usual care group, compared to 0% in the multi-modal group. Despite this difference in medication use, improvement in bodily pain was comparable between the two groups. However, they found the guideline-based multi-modal treatment to be associated with significantly greater improvement in condition-specific functioning. This appears to support our results that patients seeing both a chiropractor and a primary care physician in an evidence based collaborative-like setting use less medication.
The study group patients who were referred by the physician for chiropractic care had fewer physician visits than non-referred patients, the latter having the same average number of visits as the pre-study group. However, the non-referred study patients tended to have more radiating pain and neurological deficits, suggesting a more complicated condition that could possibly explain the greater number of physician visits. It is possible that the physician was pre-selecting patients for chiropractic referral based on his experience participating in the study or applying evidence based care.
Patients in the study group, who were referred, had fewer subsequent primary care physician visits suggesting a possible opportunity for primary care physicians to see other patients, thus decreasing their wait lists. The visits to the chiropractor were not tracked and hence the overall impact of the referral on the health care system was not considered.
Previous studies have suggested that socioeconomic factors, such as employment, play a significant role in the use of prescription medications and alternative treatments
[15, 16]. Recently, opioid use among socioeconomically disadvantaged patients in Ontario has increased substantially
. Similarly, patients using opioids were more likely to be unemployed, implying economic disadvantage
. As well, higher socioeconomic status was found to be related to decreased use of analgesics and sedatives
. The authors suggested that a reason for the difference in medication use was that such patients could afford paying for alternative therapies. Participating in a collaborative model of care with access to no cost alternative therapy appeared to decrease the frequency of prescribing regardless of whether the patient was referred. This decrease could have been attributed to increased primary care physician choice to access alternative care, more discriminating prescription use of medications by the primary care physician, or simply primary care physician involvement in the study, which allowed patient referral without considering ability to pay for chiropractic services.
The decreased use of medications in patients referred for chiropractic services has been reported previously
[19–21]. Rhee et al. conducted a retrospective study using administrative claims data from a sample of 13,670 LBP patients
. They reported patients seeing a chiropractor were found to be less likely to use narcotic medications, supporting a previous finding that chiropractic care could be used as “a substitute treatment to pain medication and other health care services in patients with LBP” [20: 2610].
Finally, studies have reported that patients with chronic musculoskeletal conditions tend to visit physicians and chiropractors, and take more medications than patients seeing only a chiropractor
[3, 4]. It may be that such visits to both providers occurred with limited interprofessional collaboration. The findings reported herein suggest that patients with musculoskeletal conditions whose physician participated in a collaborative model of care were prescribed fewer medications, frequently referred to another health care provider, and had fewer physician visits. Also, fewer patients were prescribed two and three medications for low back pain, thus decreasing potential drug-drug interactions. This is important because approximately one third of patients taking opioids for chronic low back pain are at an increased risk of an adverse drug-drug interaction
. Furthermore, this enhanced level of interprofessional collaboration led to greater communication between providers and improved continuity of care, i.e. care delivered in a coordinated and timely manner
. These findings raise interesting questions about how interprofessional collaborative care can change provider behaviour and influence the overall utilization of health care resources and quality of care.
Evidence suggests improving patient care depends partly on the ability of health care providers to change their behaviour
. The application of a particular behaviour change theory may provide understanding of the array of factors that influence such change. The theory of planned-behaviour hypothesizes that an individuals’ perceived control over, and their intention to perform a behaviour are determining factors to its engagement
. The strength of this intention is influenced by the attitudes and beliefs towards a particular behaviour, the normative beliefs, and motivation to comply. The physician in our study was a site champion, involved in planned site administrative and education meetings, and had previous interprofessional experience, variable factors that could influence intention and behaviour change. Further work may help inform how behavioural theory can influence interprofessional collaboration and enhance the delivery of quality patient-centred care.
There are significant limitations to an uncontrolled before-after study. In our study, the data were extracted from a consecutive sample of patients from the EMRs of a single primary care physician who may have been biased due to his involvement in the study. As such, the results noted could also have been favourably confounded by the Hawthorne effect
, where the physician’s behaviour was modified by their participation. Although this is a fundamental concern with our selected study design, the noted observed changes in the number of medication prescriptions and the referral patterns of study patients suggests that the implementation of the collaborative model did have some influence upon the physician’s management of low back pain patients. In addition, coding bias or recording errors of various aspects of the patients’ visit and medication used may have occurred. However, the frequency of medication prescription and trend to decreased drug use are similar to previously reported larger studies.