Clinically relevant contextual factors for enrolling patients in a pain intervention across multiple health care centers.

BACKGROUND: Low back pain (LBP) negatively impacts public health and places a significant burden on healthcare systems. Non-pharmacologic interventions are recommended as first-line treatments for LBP, yet their uptake remains low due to implementation challenges. This study examined clinically relevant contextual factors that influenced implementation of two care pathways for LBP. METHODS: We applied the Basel Approach for Contextual Analysis (BANANA) to examine 10 contextual factors across 17 sites implementing two low back pain care pathways: a sequenced care pathway integrating physical therapy with psychologically informed treatment via telehealth, and a navigator pathway facilitating access to non-pharmacologic pain treatments. A parallel mixed-methods design (QUAN + qual) evaluated contextual influences on enrollment. Quantitative analysis used a clustered Cox proportional hazards model with robust variance to assess time to minimum enrollment. Qualitative interviews with 12 high- and low-referring providers, guided by the Consolidated Framework for Implementation Research, explored organizational context, implementation conditions, and pathway impact. CLINICALTRIALS: gov ID: NCT04411420. RESULTS: Sites in both pathways reached enrollment targets in a similar timeframe (~16 months), though navigator sites showed less variability and enrolled their first patient faster (17.2 vs. 47.5 days). In the clustered survival analysis, urban community-based outpatient clinics demonstrated faster time to minimum enrollment (HR = 3.07, 95% CI 1.31-7.18) compared with medical centers for both pathways. The number (HR = 1.50, 95% CI 1.39-1.63) and years of experience (HR = 1.06 per year, 95% CI 1.02-1.10) of physical therapists in the sequenced care pathway were associated with faster time to minimal enrollment but navigator pathway-related factors were not associated with enrollment speed. Qualitative themes included provider comfort with referring, perceived benefits of holistic care, the role of leadership support, and importance of patient feedback. Barriers identified included communication gaps, site-level variability, and logistical challenges for specific populations. CONCLUSIONS: This analysis highlights the role of contextual factors in shaping enrollment within embedded care pathways for LBP. Tailoring implementation strategies to local contexts, care pathway characteristics, strengthening provider engagement, and enhancing feedback mechanisms may improve the reach and scalability of non-pharmacologic interventions in real-world healthcare settings.

Duke Scholars

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