Table 3 Taxonomy of barriers and facilitators to diagnosis and treatment initiation

Patients experience pain that is severe and different to any pain they have experienced before.

Patients’ back pain doesn’t get better with time.

Other people noticed the symptoms and encouraged them to visit healthcare professionals.

Patients talk to other people about the pain. Other people include friends or family who encourage them to visit a healthcare professional.

Patients associate their pain with an injury such as a fall.

Patients do not know what a vertebral fracture is and what the symptoms are.

Patients living with osteoporosis are not aware that they are at risk of vertebral fractures.

Patients do not think the pain is serious.

Patients mistake the pain for another issue such as a kidney infection, arthritis, broken rib or muscular pain.

Patients have a vertebral fracture that doesn’t have any symptoms.

Patients do not associate their pain with an injury such as a fall.

Patients choose to self-manage symptoms.

Patients don’t think getting help for their back pain is important and prioritises other conditions or feels that they are too busy.

Patients feel that they do not want to ‘bother’ healthcare professionals or ‘make a fuss’.

Patients feel that their healthcare professional does not take their pain seriously and do not want to re-visit them for help if their pain doesn’t improve.

“It did cross my mind that I was just being a big baby and the pain was not as bad as what I thought it was, if you know what I mean.” [Olivia, patient with vertebral fractures]

“I wouldn’t have known what to recognise actually to be quite honest, no I wouldn’t. If I had something wrong with my back I’d just [think I] pulled something or done something. [Anthony, patient with vertebral fractures]

“I was taking so many tablets I think I was overdosing. I was putting Deep Heat, Ibuprofen and heat patches on because as I say, I didn’t know what it was. And I was taking eight tramadol a day, four amitriptyline, eight paracetamol and I was just going round the bend I reckon.” [Beth, patient with vertebral fractures]]

“I’ve had quite a lot of pain with prolapsed discs and all sorts of things but [the vertebral fracture] was different pain” [Anthony,, patient with vertebral fractures]

“I have a friend…he said ‘You look like a hunchback!’ and I thought ‘Well, that’s a bit cruel!’” [Alice, patient with vertebral fractures]

“They [healthcare professionals] didn’t seem to be particularly bothered [about my back pain] and I was made to feel like I was just being a nuisance basically.” [Claire]

Healthcare professional appraisal, investigations, referrals and appointments

Facilitators

Barriers

Illustrative quotations

Healthcare professionals in general practice are aware of risk factors for vertebral fractures such as age, sex, and low BMI.

Healthcare professionals in general practice have knowledge of the symptoms of vertebral fracture such as height loss and severe back pain.

Knowledge of referral pathways to request imaging to confirm diagnosis and to specialists in hospital for assessment.

Suspicion of vertebral fracture is clearly described on radiology request.

Diagnosis of vertebral fracture clearly and unambiguously indicated on the imaging report.

Healthcare professionals in general practice refer patients to A&E to speed up access to imaging.

Healthcare professionals in general practice and Accident and Emergency (A&E) mistake the symptoms of vertebral fractures for other conditions or causes such as a pulled muscle or broken rib.

Healthcare professionals in general practice tell patients to ‘wait and see’ if their vertebral fracture symptoms get better on their own before initiating further investigations.

Healthcare professionals find vertebral fractures harder to identify in men and young people because they are less likely to be at risk.

Healthcare professionals find it more difficult to identify vertebral fractures in patients who do not present with severe symptoms.

Healthcare professionals are discouraged from routinely imaging patients who present with low back pain due to NICE guidelines.

Lack of incentive to identify osteoporosis in primary care through reimbursement schemes.

“I don’t think [diagnosing vertebral fractures is] as straightforward… males do get osteoporosis. So it’s always on your differential diagnosis… I’d say [diagnosis is] moderately difficult.” [Ava, FCP]

“Sometimes it’s acute and clear cut that yes someone’s had a sort of sudden collapse, sometimes it’s a more of a gradual crumble I imagine.” [Sophie, GP]

“What I tend to find…Is just that severity of pain and their inability to straighten up… They really struggle standing and straightening up” [Emma, FCP]

“We’re encouraged not to image people’s backs so you know we never, hardly ever send people for [spine] x-rays … we’re told not to do that.” [Isabelle, GP]

Communication of diagnosis

Facilitators

Barriers

Illustrative quotations

A diagnosis of vertebral fracture is clearly communicated to patients either verbally by their GP or specialist in hospital.

Patients are given information about vertebral fractures and osteoporosis when they are diagnosed to help them understand what they are and how to manage them.

Patients provided with clarity on how their vertebral fracture was diagnosed and how many they have sustained.

Patients informed in writing are provided with a patient friendly letter.

Healthcare professionals explain what a vertebral fracture is to help reduce the feelings of shock and surprise when they are diagnosed.

Clarity on which healthcare professional should be informing patients about their vertebral fracture, preferably by referring clinician.

Patients find out about their diagnosis by being copied into medical letters and find some of the ‘big words’ confusing and difficult to understand as they are not explained.

Healthcare professionals use confusing words to inform patients that they have had a vertebral fracture such as ‘compression fracture’ or ‘wedge deformity’. Patients are therefore unsure if they have had a vertebral fracture.

Patients find the term “vertebral fractures” alarming as it makes it sound like they have had a catastrophic injury.

Patients are not clearly told how many vertebral fractures they have had.

Healthcare professionals are unclear if a patient has been told about their vertebral fracture as they are being managed by healthcare professionals in hospital and at their GP surgery. Some patients are therefore not informed.

“It’s just the terminology that’s maybe used in telling the patient what the, it can be very, very scary if a patient is told they’ve got a fracture in their spine. And it’s just sometimes the way it’s relayed. So that’s why I always try and follow up my own x-ray requests.” [Amelia, FCP]

“[The Fracture Liaison Service reviewed images and] picked up some fractures and then we’re at the stage where we don’t know if they’ve been told, they’ve forgotten, or I’m meant to tell them and we don’t know which one it is.” [Akal, GP]

“The letter says, ‘We were able to visualise L4-T5. Appearance of VFA were suspicious of vertebral fracture.’ I don’t know where that is [laughter]. I know it’s in your back somewhere but I thought, ‘Is it low, medium or high up in the back.’ It would have been nice to have known where it actually was.” [Georgia, patient with vertebral fractures]

“Oh God, it was awful [laughter]. I’m sorry, I just find it hysterical. It’s like, ‘Oh my God I’ve broken my back.’ You know, you’ve been given this information of a spinal fracture, that sounded pretty serious to me. And obviously I haven’t broken my back at all, it’s not quite like that.” [Susan, patient with vertebral fractures]

Planning and scheduling of treatment

Facilitators

Barriers

Illustrative quotations

Patients are proactive in arranging appointments with their GP and asking for treatment for their vertebral fractures.

Healthcare professionals forget to prescribe bone protection therapies as they are focused on the immediate injury.

Healthcare professionals in primary care are unsure whether treatment has been initiated by healthcare professionals at the hospital.

Lack of clarity over referral criteria to specialist services in hospital for management.

“So [prescription of bone protection therapies] could quite easily get overlooked there and you know you might look at it and think, ‘oh well I’ll check if their pain’s okay’, and if their pain’s okay you might not be at the top of your mind thinking ‘oh gosh they do need bone protection’. So I think it could potentially get missed there. [Sophie, GP]

“In interface clinics I think they aren’t prescribed bone protection medication, and they have had previous low impact fractures” [Ava, FCP]

“There are cases where a patient’s been admitted to hospital. Been in for a long time or been in for something else. Picked up some fractures and then we’re at the stage where we don’t know if they’ve been told… We’re supposed to deal with it and make the referrals and manage things moving forward and we don’t know what’s being told. Sometime later you find out that they didn’t know and that hasn’t been managed or it’s been forgotten about.” [Akal, GP]