Low-value care in musculoskeletal health care: is there a way forward?

Key points

1. 01Low-value care is defined as services that confer little or no benefit to patients or where risk of harm exceeds probable benefit
2. 02Most patients with back pain, neck pain, or osteoarthritis receive care inconsistent with clinical guidelines across all professional groups including GPs, physiotherapists, and chiropractors
3. 03Drivers include clinician financial incentives, knowledge gaps, patient-clinician relationship dynamics, and perverse health-system incentives such as reimbursement structures
4. 04Reversing low-value care requires coordinated behaviour change by patients, clinicians, professional organisations, funders, and health-system administrators
5. 05Implementation interventions grounded in theoretical frameworks appear more effective at changing clinician behaviour, but convincing evidence that they improve patient outcomes is still lacking

How it was conducted

Design

Narrative review prepared as an invited keynote presentation at the Pain in Motion IV conference, Maastricht, Holland, May 2022

Scope

Low-value care in musculoskeletal conditions: back pain, neck pain, and osteoarthritis

Literature search

Repeated searches of PubMed and Scopus to identify guideline recommendations, systematic reviews, and primary studies on adherence to MSK care guidelines

Focus areas

Prevalence of low-value care, drivers of low-value care, and implementation frameworks and examples for promoting high-value care

What they found

• Fewer than 2% of back pain patients seeing GPs received evidence-based information and advice; around 2% received imaging referral; and up to 6% in emergency departments were prescribed opioids
• A systematic review by Zadro et al. found that approximately 50% of physiotherapists did not provide guideline-consistent care for back pain
• Chiropractors provided inappropriate care to back pain patients 38% of the time (Amorin-Woods)
• 72% of chiropractors and 6% of physiotherapists in Australia had advertising guideline breaches
• Less than half of primary care osteoarthritis patients received pain and/or function assessment; fewer than 4% received exercise recommendations or education and self-management support
• Among more than 80,000 people with newly diagnosed knee or hip osteoarthritis in Sweden, more than half of incident opioid prescriptions were inappropriate according to national guidelines
• Only 4% of Australians and less than 3% of UK patients with osteoarthritis receive evidence-based care
• Olsson et al. reviewed 34 studies from 8 countries and found patient involvement in service design can increase collaboration and motivation for change but is time consuming
• A Cochrane review of 20 studies (Tzortzio Brown et al.) found feedback on performance combined with guideline dissemination may lead to small improvements in guideline-consistent GP behaviour for low back pain
• A systematic review identified 28 studies evaluating clinical pathways for MSK care; service efficiency improved through decreased wait times, but whether patient outcomes improved was uncertain
• In the ALIGN cluster randomised trial (French et al.), clinicians in the intervention group were more likely to advise staying active, but there were no important differences in X-ray referral and no difference in patient outcomes
• Only 2.2% of implementation interventions reviewed by Davis et al. were based on a theory; in just 6% was the theory explicit
• Choosing Wisely has been established in more than 20 countries with more than 100 participating professional associations, but large-scale impact has not yet been documented

Limitations

• This is a narrative review, not a systematic review, so evidence selection may reflect author perspectives and is not exhaustive
• The paper is based on a conference keynote and is broad in scope, limiting depth of analysis for any single condition or intervention
• Specific numeric statistics are often partially obscured due to OCR/text extraction issues in the source document, making precise replication difficult
• Convincing evidence that behaviour-change implementation interventions improve patient outcomes is lacking, meaning the clinical benefit of reducing low-value care remains incompletely demonstrated

Why it matters

For patients

Patients with back pain, neck pain, or osteoarthritis are frequently receiving tests, imaging, and treatments such as opioids or surgery that guidelines recommend against, while missing out on exercise and self-management support that evidence supports.

For clinicians

Clinicians across all professions contribute to low-value care through knowledge gaps, financial incentives, and system pressures, and interventions targeting individual clinicians alone are unlikely to achieve lasting change without broader system-level reforms.

For readers

This paper provides a comprehensive overview of the scale and drivers of low-value musculoskeletal care globally, and outlines promising but not yet definitive implementation science frameworks for reform.