Stakeholder perceptions of the VIrtual Physiotherapist-led Evaluation of low back pain Referrals to spine surgeons (VIPER) model of care: a qualitative study

Introduction: Despite guidelines advising that non-serious low back pain (LBP) should be managed with self-management advice and exercise, referrals to spine surgeons are common. High referral rates to public hospital spine surgery clinics means many surgeons can't assess new cases within 1-2 years. In many cases, patients referred to these clinics have not tried recommended non-surgical care, and while they wait for surgical review, they develop symptoms which are complex and costly to manage. We developed the VIrtual Physiotherapist-led Evaluation of low back pain Referrals to spine surgeons (VIPER) model of care to help clinics identify new referrals who can be managed sooner by a physiotherapist and reduce wait times for those needing surgical review. Aim: To qualitatively explore stakeholder perceptions of the VIPER model of care, as part of a broader program of work to co-design VIPER and then evaluate it in a large, multi-site randomised controlled trial. Methods: We conducted semi-structured interviews with people with LBP (including those with lived experience of being referred to spine surgery clinics), clinicians who manage patients with LBP (e.g., physiotherapists, spine surgeons), and other key stakeholders (e.g., physiotherapy and spine surgery departments managers). Participants were recruited via social media advertisements, the authors networks, and snowball sampling. Participants completed pre-interview questionnaires capturing data to support purposive sampling based on demographics, symptoms and professional characteristics. Interview transcripts were analysed using an inductive descriptive qualitative analysis. Results: Interviews with 39 participants (6 people with LBP, 26 clinicians, and 7 other key stakeholders) highlighted four key themes: 1) current gaps in LBP care pathways and implementation considerations (covering need for appropriate patient and clinician education, referral inefficiencies, coordination challenges, and access barriers); 2) perceptions of the role of physiotherapy in LBP care and patient selection for VIPER; 3) support for VIPER as a means to improve patient outcomes and health system efficiency; and 4) views on virtual assessment and escalation, recognising the value of hybrid models and its limitations. Conclusion: The proposed VIPER model of care appears feasible, acceptable, and well-suited to improve LBP care by promoting guideline-based non-surgical management and reducing wait times for surgical review among those who need it most. The virtual component of the model offers flexible, patient-centred delivery with potential system-wide benefits, supporting further piloting and evaluation, and possibly wider applications in musculoskeletal care.