Background

Around 20% of the Dutch population is living with from chronic musculoskeletal pain (CMP) [1, 2]. CMP is defined as pain lasting longer than 3 months. Patients with CMP report a lower quality of life and CMP is associated with problems like difficulties with activities of daily living (ADLs), depression and other mental health problems [2]. CMP is a complex problem due to the interplay of biological, psychological and social factors on the development and persistence of CMP [3, 4].

The complexity of CMP and the frequent presence of comorbidity with psychological complaints complicates the development of one single valid classification system to categorize patients with CMP, which leads to insufficient quality of referring [5]. This results in a diminished quality of care, due to healthcare providers sending back patients to their general practitioner (GP) when treatment is not effective and leads to higher healthcare costs [6]. A previous study found that more than 30% of the GPs’ referrals were potentially avoidable [6]. Common healthcare providers that treat chronic pain include physiotherapists, occupational therapists, medical specialists and mental healthcare professionals [5].

In the Netherlands, the GP is usually central in the patients’ treatment as the gatekeeper within the Dutch healthcare system [7]. So, to improve the quality of referring, it is crucial to better understand the factors GPs use for referring patients with CMP. Itz, Huygen and van Kleef [8] point out the importance of GPs evaluating the risk factors for chronicity and explaining the treatment plan to the patient. This might help in selecting the appropriate treatment for patients with CMP earlier. Additionally, Pitt, O’Conner and Green [9] pointed out that the GPs’ familiarity with different treatment options for osteoarthritis is an important factor for referring. For example, their knowledge about self-management programmes was insufficient, which influenced their referral. Most studies focused on a specific target group such as low back pain [8] or osteoarthritis [9], but little research has been done with a focus on referring patients with CMP in general.

To improve the referral of patients with CMP it is crucial to first get more insight in factors GPs focus on when referring. To accomplish this, the aim of this study was to identify those factors used by GPs when referring patients with CMP for further treatment.

Method

Research design and participants

This research is part of a larger project called PReferral, that is focused on the design of a decision support tool to support the GPs in the referral of patients with CMP.

This explorative qualitative study, analysed using conventional content analysis, took place in the east of the Netherlands (Twente) among practicing GPs. A qualitative design was chosen, because referral of patients (with CMP) to treatment is a complex process [10] of which theoretical background is lacking. In the first phase, 10 semi-structured interviews with GPs were conducted about factors related to the referral of their patients with primary or secondary chronic pain. In the second phase, the results of these interviews were verified and supplemented where necessary by a focus group with 4 GPs. For this second phase, a focus group was chosen because this enabled social interaction, which could yield referral factors that were not identified in the interviews [11]. Using convenience sampling 139 GPs were approached of which 14 GPs participated in this research, a response rate of 10%. The demographics of the interviewed and focus group GPs are respectively presented in Tables 1 and 2. The study was approved by the ethics committee of the University of Twente (approval number: 201287).

Table 1 Demographics of interviewed GPs
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Table 2 Demographics of focus group GPs
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Measures/materials

The Dutch version of the semi-structured interview scheme (Additional file 1) consisted of 33 open- and closed-ended questions which were based on the literature and consensus of the researchers (S.S., A.M., J.B., G.P.). Using the open questions, the participants were encouraged to give examples during the interview. The focus group used the results from the interviews to verify and supplement (Additional file 3).

Procedure

The GPs were contacted for the interviews using a newsletter of two GP organizations, named THOON and FEA, with a link to additional information about the study. Furthermore, a list of GPs was made by these organisations and GPs were approached personally by phone by a student from the University of Twente (A.M.). Moreover, a rehabilitation doctor of a local hospital (ZGT) (J.B.) contacted GPs that often referred to the ZGT. The GPs for the focus group were contacted by the research coordinator of THOON (P.L.), using convenience sampling. After agreeing to be interviewed or participate in the focus group, the participants answered demographic questions (i.e. sex, location of practice, type of practice, age, and years of experience as GP), a question about their professional interest in patients with CMP on a scale from 0 to 10 and their satisfaction with their referral of patients with CMP on a scale from 0 to 10. The interviews were conducted by one researcher (A.M.) and the focus group was conducted by one researcher (S.S.) and moderated by another researcher (J.B.). Because of COVID-19, the conducted interviews and focus group were online via Microsoft Teams and the interviews lasted between 25 and 84 minutes, with a median of 54 minutes and the focus group lasted 79 minutes. All participants were informed about the project goals beforehand and gave verbal informed consent to participate in the study and be recorded. The interviews and focus group were recorded in Microsoft Teams, transcribed using Amberscript software and manually corrected by the researchers. The recordings and transcripts of the interviews and focus group are stored in a secured online environment of the University of Twente.

Data Analysis

The data of the interviews was analysed in Atlas.ti, using inductive conventional content analysis [12]. This method was deemed most appropriate, because existing literature about GPs’ referral factors for patients with CMP is limited [13]. The first step in the iterative process was for the two researchers (S.S. and A.M.) to separately read all transcripts freely. In the second step, these two researchers independently generated initial codes using meaningful words and sentences of three interview transcripts, using the following question: “which factors do GPs use for the referral of patients with CMP?”. Subsequently, these codes were discussed and fine-tuned with three researchers (S.S., A.M., D.J.) until consensus was reached. This was repeated iteratively with the remainder of the interviews, until all data was analysed. Next, the identified codes were categorized and developed in themes by three researchers (S.S., A.M., D.J.). A priori it was decided to use a benchmark of 50%, meaning that at least half of the GPs had to mention a code in order to describe it in the results. This was done because a large amount of codes was expected to be mentioned, of which we wanted to extract the most important ones. To analyse the interrater reliability, Cohen’s Kappa was calculated based on the coding of one random interview by two researchers (S.S., A.M.). The level of agreement was categorized according to the Kappa values as none (0–.20), minimal (.21–.39), weak (.40–.59), moderate (.60–.79), strong (.80–.90) and almost perfect (>.90) [14]. For this interview, Cohen’s Kappa was 0.67, which means that the agreement between the two researchers was moderate. Finally, the results were discussed with all authors and consensus was reached on both the themes and factors GPs used for referral of patients with CMP. The input of the focus group was checked for both known and new codes. This was done independently by two researchers (S.S. and J.B.), using Microsoft Word and discussed with all authors until consensus was reached.

Results

In total, 83 factors for referring patients with CMP were stated by the interviewed GPs (Additional file 2). These 28 factors (34% of total factors) were divided in six themes and are explained per theme. The factors that were mentioned by 50% or more of the interviewed GPs, are presented in Fig. 1.

Fig. 1
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Final coding scheme with themes and codes

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Physical factors

The physical factors, as shown in Table 3, were related to the somatic aspects of CMP, for example this could have been about the location or duration of the pain.

Table 3 Explanation of the factors within the theme “physical factor”
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Psychological factors

The psychological factors, explained in Table 4, contained the cognitive or emotional aspects of CMP, these factors were about the mental state of the patient.

Table 4 Explanation of the factors within the theme “psychological factors”
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Complaint factors

The complaint factors, as shown in Table 5, were about the pain and possible other problems occurring within the patient which were contributing to the complaint of the patient with CMP.

Table 5 Explanation of the factors within the theme “complaint factors”
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Patient factors

The patient factors, discussed in Table 6, contained the factors associated specifically to the person suffering from the CMP and the daily life of the patient.

Table 6 Explanation of the factors within the theme “patient factors”
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GP factors

The GP factors were associated with the different aspects related to the GP, as the referrer of the patient with CMP. These factors are discussed in more detail in Table 7.

Table 7 Explanation of the factors within the theme “GP factors”
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Treatment factors

The treatment factors, shown in Table 8, included the factors related to the medical treatment options, according to the GPs.

Table 8 Explanation of the factors within the theme “treatments factors”
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Focus group

The focus group received aforementioned results and verified found themes and factors by explicitly confirming these results and mentioning referral factors from each of the six identified categories. Moreover, some additional factors for referring patients with CMP were mentioned in the focus group. These additional factors were also mentioned by interviewed GPs, but not by more than 50% of the GPs, as shown in Table 9.

Table 9 Results focus group
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Discussion

The present study aimed to investigate the factors related to GP referral of patients with CMP for further treatment. In total, 83 factors were found that influenced the referral of patients with CMP, of which 28 factors were mentioned by 50% or more of the interviewed GPs and verified by the focus group. All interviewed GPs within this study mentioned the somatic explainability, location of the pain complaints, psychological complaints, the treatment history, physical functioning of the patient and referral request of the patient as specific factors influencing the referral of patients with CMP. The found factors in this study were categorized in the following six themes: GP, treatment and patient (physical, psychological, complaint, general) factors. A seventh theme was identified, called “external factors”, with factors like social environment and financial situation. However, none of the factors in this theme were mentioned by 50% or more of the GPs and therefore this theme was not discussed in the results. The six identified categories, correspond to previous studies that found that the GPs’ referral is based on (1) GP factors, (2) treatment factors and (3) patient factors [10, 11].

According to the guidelines of the Dutch GP organization, a combination of physical, psychological and social factors is contributing to and causing CMP [13, 15]. Additionally, many of the referral factors found in this study are mentioned in this guideline, like risk factors for chronicity (e.g. pain duration, comorbidity and psychological complaints) and diagnostic factors (e.g. location of pain, somatic explainability and functioning). The guidelines mention social factors as one of the main contributing and causal explanations of chronic pain, however in this study not a single social factor was mentioned as a referral factor by at least 50% of the GPs. This is noteworthy, since the biopsychosocial approach is crucial for the understanding and treatment of CMP [16]. Social factors that are related to CMP include social support [17, 18], social isolation, [19, 20] and job satisfaction [21, 22]. Our findings are in line with prior studies on referral factors, that found that biomedical elements and GP factors are most important in the referral process [23, 24]. The GPs’ identification of the social environment of their patients is limited and they are having difficulties estimating the loneliness and social participation of their patients, despite them being aware of the consequences for their health and health perception [25, 26]. Hansen, Rosendal, Fink and Risor [27] focused on patients with medically unexplained symptoms and found that GPs seldom act on psychosocial cues. One possible explanation for this could be that due to time constraints, GPs mainly focus on identifiable and treatable pathology [28] and disregard social factors, as described in our results. The biopsychosocial model is supported with empirical evidence, but in practice the psychosocial factors are often viewed as secondary and as a reaction to the pain [29]. Moreover, Knoop et al. [30] found that guidelines for chronic low back pain vary widely regarding recommendations for prognostic psychosocial factors. These studies might explain why GPs do not focus on the social factors when referring patients with CMP. When the GP is not familiar with the social environment of the patients, it will not be used as a factor for referring which might lead to a suboptimal referral. Furthermore, these studies confirm that the referral of patients with CMP is very complex [28]. This can also be concluded based on the finding that a total of 83 referral factors were found in this study, but only 34% of these factors were mentioned by 50% or more of the GPs and the complexity of referring was confirmed and again explicitly mentioned by GPs in the focus group.

Within this study, 90% of the interviewed GPs mentioned their unfamiliarity with treatment options as an influencing factor for their referrals of patients with CMP. This unfamiliarity was either about unfamiliarity with the content of a certain treatment or the presence of this treatment in the region. In relation to the physiotherapy related treatments, it was mentioned GPs often did not seem to make a distinction between the different forms of physiotherapy, because of unfamiliarity with these therapies. For example, it is hard for GPs to make a distinction between manual physiotherapy and regular physiotherapy, resulting in referring towards the more familiar option, regular physiotherapy [31]. Previous studies found that the unfamiliarity with treatment options could be a barrier for referring towards non-pharmacological treatment [32, 33], like self-management programmes [12]. The unfamiliarity with treatment options is in contrast with the referral factor “availability of treatment options”, which was mentioned by 40% of the interviewed GPs and in the focus group. This suggests that there might be a blind spot for certain treatment options for patients with CMP, possibly accounting for incorrect referrals.

Strengths and limitations

This study was the first study to identify factors GPs use to refer patients with CMP. Another strength of this study was the sample, with a wide range in age, years of experience as a GP and satisfaction with referring, which increased the representativeness of the factors found within this study. Furthermore, the study design had two phases, where the results of the interviews were verified by the focus group, which increased thoroughness. Also, the interpretation and coding of the interviews by multiple researchers was a strength. Constantly discussing and checking the codes with multiple researchers ensured an open-minded approach for creating codes.

The willingness of GPs to cooperate to this research was an important limiting factor in this study. The GPs indicated that their time and focus was on the COVID-19 pandemic, because a lot of changes had to be made within primary care [34]. A large number of GPs were approached via an online article but only a few participated. This might have caused a selection bias and the sample might not be representative for (the east of) the Netherlands. Additionally, the sample size might have been too small, given that additional referral factors were found in the focus group. However, it should be noted that these referral factors were mentioned by some of the GPs, but did not meet the 50% benchmark. Furthermore, the focus group was not analysed following all steps of qualitative research, which possibly could have let to missed referral factors. Also, due to the subjective nature of qualitative research, some factors and themes overlap and might not be as distinctive as reported in this study.

Suggestions for further research

This study specifically focused on the referral of patients with CMP by the GPs in the east of the Netherlands. Further research should expand the region and number of the participants to increase the representability. By interviewing more GPs, either using interviews or focus groups, it will be possible to allocate more detailed weight to referral factors and to gain more insight in referrals to different kind of treatments. Specifically, the reason why social factors currently seem to be overlooked in the referral of patients with CMP should be further investigated. Also, this study provides factors GPs use for the referral of patients with CMP, but does not give an explanation as to why these factors are used for referral. Additionally, this study covered patients with both primary and secondary chronic pain, while it might be possible that there are different referral factors for these groups of patients. Further research could specify a patient group to get better insight in referral factors for specific chronic pain conditions.

Practical implications

Based on the results of this research, it is evident that GPs should take social factors into account when referring patients with CMP. This could be supported by promoting the use of guideline suggested tools, like the SCEGS (somatic, cognitive, emotional, behaviour and social) method [35].

Further, unfamiliarity of the GP with the different treatment options seems to be an important factor for their referral. An implication for improving the familiarity of the GPs, would be to support them in their awareness of treatment options for patients with CMP. For example, by developing an easily accessible and usable (digital) tool or eHealth application, in which all treatment options and characteristics in this region are mentioned, including both mono- and multidisciplinary treatment options. On the other hand, there is a public social map in the Netherlands where patients are able to see possible treatments near to them. Therefore, the responsibility of finding the most fitting treatment could also be shared between the GP and the patient.

Conclusion

Concluding, this study identified different factors important for the referral of patients with CMP by the GP. The referral factors were most often related to physical, psychological or GP factors. Important results were the apparent absence of social factors used for referral and the unfamiliarity of the GP with the treatment options. The factors mentioned by the participants should be taken into account when setting up a decision support tool for improving the referral process of patients with CMP.