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Kühn L, Lindert L, Kuper P, Prill R, Choi KE(A. Research designs and instruments to detect physiotherapy overuse of low-value care services in low back pain management: a scoping review. BMC Health Serv Res 2023; 23:193. [PMID: 36823581 PMCID: PMC9949696 DOI: 10.1186/s12913-023-09166-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 02/09/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND The provision of low-value physiotherapy services in low back pain management is a known but complex phenomenon. Thus, this scoping review aims to systematically map existing research designs and instruments of the field in order to discuss the current state of research methodologies and contextualize results to domains and perspectives of a referred low-value care typology. Ultimately, results will be illustrated and transferred to conditions of the German health care setting as care delivery conditions of physiotherapy in Germany face unique particularities. METHODS The development of this review is guided by the analysis framework of Arksey and O'Malley. A two-stage, audited search strategy was performed in Medline (PubMed), Web of Science, and google scholar. All types of observational studies were included. Identified articles needed to address a pre-determined population, concept, and context framework and had to be published in English or German language. The publication date of included articles was not subject to any limitation. The applied framework to assess the phenomenon of low-value physiotherapy services incorporated three domains (care effectiveness; care efficiency; patient alignment of care) and perspectives (provider; patient; society) of care. RESULTS Thirty-three articles met the inclusion criteria. Seventy-nine percent of articles focused on the appropriateness of physiotherapeutic treatments, followed by education and information (30%), the diagnostic process (15%), and goal-setting practice (12%). Study designs were predominantly cross-sectional (58%). Data sources were mainly survey instruments (67%) of which 50% were self-developed. Most studies addressed the effectiveness domain of care (73%) and the provider perspective (88%). The perspective of patient alignment was assessed by 6% of included articles. None of included articles assessed the society perspective. Four methodical approaches of included articles were rated to be transferrable to Germany. CONCLUSION Identified research on low-value physiotherapy care in low back pain management was widely unidimensional. Most articles focused on the effectiveness domain of care and investigated the provider perspective. Most measures were indirectly and did not monitor low-value care trends over a set period of time. Research on low-value physiotherapy care in secondary care conditions, such as Germany, was scarce. REGISTRATION This review has been registered on open science framework ( https://osf.io/vzq7k https://doi.org/10.17605/OSF.IO/PMF2G ).
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Affiliation(s)
- Lukas Kühn
- Center for Health Services Research, Seebad 82/83, 15562 Rüdersdorf Bei Berlin, Brandenburg Medical School, Neuruppin, Germany. .,Faculty of Health Sciences Brandenburg, Brandenburg Medical School, Fehrbelliner Straße 38, 16816, Neuruppin, Germany.
| | - Lara Lindert
- grid.473452.3Center for Health Services Research, Seebad 82/83, 15562 Rüdersdorf Bei Berlin, Brandenburg Medical School, Neuruppin, Germany
| | - Paulina Kuper
- grid.473452.3Center for Health Services Research, Seebad 82/83, 15562 Rüdersdorf Bei Berlin, Brandenburg Medical School, Neuruppin, Germany
| | - Robert Prill
- grid.473452.3Faculty of Health Sciences Brandenburg, Brandenburg Medical School, Fehrbelliner Straße 38, 16816 Neuruppin, Germany ,grid.473452.3Center of Orthopaedics and Traumatology, Universtiy Hospital Brandenburg/Havel, Brandenburg Medical School, Neuruppin, Germany
| | - Kyung-Eun (Anna) Choi
- grid.473452.3Center for Health Services Research, Seebad 82/83, 15562 Rüdersdorf Bei Berlin, Brandenburg Medical School, Neuruppin, Germany ,grid.473452.3Faculty of Health Sciences Brandenburg, Brandenburg Medical School, Fehrbelliner Straße 38, 16816 Neuruppin, Germany ,grid.465811.f0000 0004 4904 7440Health Services Research, Faculty of Medicine/Dentistry, Danube Private University, Steiner Landstraße 124, 3500 Krems-Stein, Austria
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Schröder K, Öberg B, Enthoven P, Hedevik H, Abbott A. Improved adherence to clinical guidelines for low back pain after implementation of the BetterBack model of care: A stepped cluster randomized controlled trial within a hybrid type 2 trial. Physiother Theory Pract 2022:1-15. [PMID: 35230212 DOI: 10.1080/09593985.2022.2040669] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The BetterBack model of care (MoC) for low back pain (LBP) was recently developed in Swedish physiotherapy (PT) primary care. OBJECTIVE To evaluate if PTs' adherence to LBP clinical practice guidelines (CPGs) improves after implementation of the BetterBack MoC (intervention). METHODS This was a stepped, single-blinded cluster randomized controlled trial. Patients nested in the three clusters were allocated to routine care (n = 222) or intervention (n = 278). The primary outcome was referral to specialist consultation. This was among five best practice recommendations divided into an assessment quality index (no referral to specialist consultation and no medical imaging) and a treatment quality index (use of educational interventions; use of exercise interventions; no use of non-evidence-based physiotherapy). For overall adherence, patients had to be treated with all five recommendations fulfilled. Logistic regression was used for between-group comparisons. RESULTS The proportion of patients receiving referral to specialist consultation during the PT treatment period was low in both groups with no between-group differences. However, patients in the intervention group showed significantly higher assessment quality index, treatment quality index and overall adherence compared to routine care. Adherence to the separate recommendations showed improved stratified number of visits, use of exercise was maintained high, patient educational intervention increased and use of non-evidence-based physiotherapy decreased. A reduction of medical imaging during the physiotherapy treatment period was also observed. CONCLUSIONS The adoption of CPGs could be substantially improved by introducing a MoC through PT training and supportive materials.
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Affiliation(s)
- Karin Schröder
- Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Birgitta Öberg
- Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Paul Enthoven
- Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Henrik Hedevik
- Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Allan Abbott
- Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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3
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Shah S, Prakash V. Limited evidence exists on determinants of physiotherapists' adherence to high value interventions in nonspecific low back pain management: A scoping review. Musculoskeletal Care 2021; 20:442-453. [PMID: 34875125 DOI: 10.1002/msc.1609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Examining the emerging body of evidence investigating what drives physiotherapist's clinical decisions in the management of low back pain can guide future research into identifying barriers and facilitators of their adherence to evidence recommended interventions. OBJECTIVE To establish the body of evidence regarding factors that improve or hinder physiotherapists' adherence to high-value interventions on the management of non-specific low back pain. DESIGN Scoping review. METHODS We conducted a Scoping review by searching MEDLINE, CINAHL, and SPORTDiscus databases on 13 February 2021. Two reviewers independently screened the retrieved literature and selected articles for inclusion. We included quantitative research that investigated an association between physiotherapists' personal characteristics or setting related characteristics with their clinical management of patients with non-specific low back pain. RESULTS Twelve studies reported in 13 publications were included. The majority of the studies were conducted in high-income countries including, the United States, Canada and UK. Twenty-six factors were investigated as potentially influencing physiotherapists' adherence to high value interventions in low back pain management. The most commonly examined physiotherapists' attributes were educational qualification that is postgraduate or certification course (58%, N = 7 studies), years of experience (41%, N = 5 studies), and beliefs and attitude about low back pain (41%, N = 5 studies). Work setting (N = 4) and workload (N = 3) were frequently investigated setting related factors. CONCLUSION Currently, there is limited evidence available to understand determinants controlling practice behaviours of physiotherapists' management of nonspecific low back pain. Future researches conceptualized within contemporary theories of clinician behaviour change and models of knowledge translation are needed.
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Affiliation(s)
- Sweni Shah
- Ashok and Rita Patel Institute of Physiotherapy, Charotar University of Science and Technology (CHARUSAT), Changa, Anand, Gujarat, India
| | - V Prakash
- Ashok and Rita Patel Institute of Physiotherapy, Charotar University of Science and Technology (CHARUSAT), Changa, Anand, Gujarat, India
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4
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Sorondo D, Delpierre C, Côté P, Salmi LR, Cedraschi C, Taylor-Vaisey A, Lemeunier N. Determinants of clinical practice guidelines' utilization for the management of musculoskeletal disorders: a scoping review. BMC Musculoskelet Disord 2021; 22:507. [PMID: 34074285 PMCID: PMC8170973 DOI: 10.1186/s12891-021-04204-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/25/2021] [Indexed: 11/23/2022] Open
Abstract
Context Many clinical practice guidelines have been developed for the management of musculoskeletal disorders (MSDs). However, there is a gap between evidence-based knowledge and clinical practice, and reasons are poorly understood. Understanding why healthcare providers use clinical practice guidelines is essential to improve their implementation, dissemination, and adherence. Aim To identify determinants of clinical practice guidelines’ utilization by health care providers involved in the assessment and management of MSDs. Method A scoping review of the literature was conducted. Three databases were searched from inception to March 2021. Article identification, study design, methodological quality, type of healthcare providers, MSDs, barriers and facilitators associated with guidelines’ utilization were extracted from selected articles. RESULTS: 8671 citations were retrieved, and 43 articles were selected. 51% of studies were from Europe, and most were quantitative studies (64%) following a cross-sectional design (88%). Almost 80% of articles dealt with low back pain guidelines, and the most studied healthcare providers were general practitioners or physiotherapists. Five main barriers to guideline utilization were expressed by providers: 1) disagreement between recommendations and patient expectations; 2) guidelines not specific to individual patients; 3) unfamiliarity with “non-specific” term, or with the bio psychosocial model of MSDs; 4) time consuming; and 5) heterogeneity in guideline methods. Four main facilitators to guideline utilization were cited: 1) clinician’s interest in evidence-based practice; 2) perception from clinicians that the guideline will improve triage, diagnosis and management; 3) time efficiency; and 4) standardized language. Conclusion Identifying modifiable determinants is the first step in developing implementation strategies to improve guideline utilization in clinical practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04204-w.
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Affiliation(s)
- Delphine Sorondo
- UMR1295, Toulouse III University, Inserm, Equipe EQUITY, Equipe constitutive du CERPOP, Toulouse, France. .,Institut Franco-Européen de Chiropraxie, 72 chemin de la Flambère-31,300, Toulouse, France.
| | - Cyrille Delpierre
- UMR1295, Toulouse III University, Inserm, Equipe EQUITY, Equipe constitutive du CERPOP, Toulouse, France
| | - Pierre Côté
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada.,Centre for Disability Prevention and Rehabilitation at Ontario Tech University and the Canadian Memorial Chiropractic College, Oshawa and Toronto, Ontario, Canada
| | - Louis-Rachid Salmi
- Univ. Bordeaux, ISPED, Centre INSERM U1219-Bordeaux Population Health, F-33000, Bordeaux, France.,CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, F-33000, Bordeaux, France
| | - Christine Cedraschi
- Division of General Medical Rehabilitation, University of Geneva, Geneva, Switzerland.,Division of Clinical Pharmacology and Toxicology, Multidisciplinary Pain Centre, Geneva University Hospitals, Geneva, Switzerland
| | - Anne Taylor-Vaisey
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada.,Centre for Disability Prevention and Rehabilitation at Ontario Tech University and the Canadian Memorial Chiropractic College, Oshawa and Toronto, Ontario, Canada
| | - Nadège Lemeunier
- UMR1295, Toulouse III University, Inserm, Equipe EQUITY, Equipe constitutive du CERPOP, Toulouse, France.,Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
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Meerhoff GA, van Dulmen SA, Cruijsberg JK, Nijhuis-van der Sanden MWG, Van der Wees PJ. Which Factors Influence the Use of Patient-Reported Outcome Measures in Dutch Physiotherapy Practice? A Cross-Sectional Study. Physiother Can 2020; 72:63-70. [PMID: 34385750 DOI: 10.3138/ptc-2018-0028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Purpose: Patient-reported outcome measures (PROMs) have the potential to enhance the quality of health care but, as a result of suboptimal implementation, it is unclear whether they fulfil this role in physiotherapy practice. This cross-sectional study aimed to identify the factors influencing PROM use in Dutch private physiotherapy practices. Method: A total of 444 physiotherapists completed a self-assessment questionnaire and uploaded the data from their electronic health record (EHR) systems to the national registry of outcome data. Univariate and multivariate ordinal logistic and linear regression analysis were used to identify the factors associated with self-reported PROM use and PROM use registered in the EHR systems, which were derived from the self-assessment questionnaire and from the data in the national registry, respectively. Five categories with nine independent variables were selected as potential factors for regression analysis. The similarity between self-reported and registered PROM use was verified. Results: On the basis of self-report and EHR report, we found that 21.6% and 29.8% of participants, respectively, used PROMs with more than 80% of their patients, and we identified the factors associated with PROM use. Conclusions: The factors associated with PROM use are EHR systems that support PROM use and more knowledge about PROM use. These findings can guide future strategies to enhance the use of PROMs in physiotherapy practice.
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Affiliation(s)
- Guus A Meerhoff
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen.,Royal Dutch Society for Physiotherapy, Amersfoort, the Netherlands
| | - Simone A van Dulmen
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen
| | - Juliette K Cruijsberg
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen
| | | | - Philip J Van der Wees
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen
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6
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Akindele M, Rabiu M, Useh E. Assessment of the awareness, adherence, and barriers to low back pain clinical practice guidelines by practicing physiotherapists in a low‐resourced country. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2019; 25:e1811. [DOI: 10.1002/pri.1811] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/27/2019] [Accepted: 08/25/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Mukadas Akindele
- Department of Physiotherapy, Faculty of Allied Health SciencesBayero University Kano Nigeria
| | - Mubasshir Rabiu
- Department of Physiotherapy, Faculty of Allied Health SciencesBayero University Kano Nigeria
| | - Efe Useh
- Lifestyle Diseases Research Entity, Faculty of Health SciencesNorth West University Mahikeng South Africa
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Abstract
PURPOSE This study describes survey responses about implementation of the congenital muscular torticollis clinical practice guideline (CMT-CPG) by pediatric physical therapists (PT) and successes and challenges with knowledge-brokering activities. METHODS An online survey was distributed to pediatric PTs who self-identified with practice experience with congenital muscular torticollis. Data were analyzed for implementation frequency of guideline recommendations and differences pre and postpublication of the CMT-CPG. RESULTS After publication, guideline recommendation implementation improved such that no recommendation was being implemented by less than 50% of respondents, and most were implemented by greater than 90%. The majority of respondents participated in knowledge brokering; however, many indicated minimal effectiveness of those activities. CONCLUSIONS The CMT-CPG has successfully aided in changing practice. Participants identified areas of challenge and success in translating recommendations into practice and in knowledge brokering that may be helpful for the development of future CPGs.
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8
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Durks D, Fernandez-Llimos F, Hossain LN, Franco-Trigo L, Benrimoj SI, Sabater-Hernández D. Use of Intervention Mapping to Enhance Health Care Professional Practice: A Systematic Review. HEALTH EDUCATION & BEHAVIOR 2017; 44:524-535. [DOI: 10.1177/1090198117709885] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Intervention Mapping is a planning protocol for developing behavior change interventions, the first three steps of which are intended to establish the foundations and rationales of such interventions. Aim. This systematic review aimed to identify programs that used Intervention Mapping to plan changes in health care professional practice. Specifically, it provides an analysis of the information provided by the programs in the first three steps of the protocol to determine their foundations and rationales of change. Method. A literature search was undertaken in PubMed, Scopus, SciELO, and DOAJ using “Intervention Mapping” as keyword. Key information was gathered, including theories used, determinants of practice, research methodologies, theory-based methods, and practical applications. Results. Seventeen programs aimed at changing a range of health care practices were included. The social cognitive theory and the theory of planned behavior were the most frequently used frameworks in driving change within health care practices. Programs used a large variety of research methodologies to identify determinants of practice. Specific theory-based methods (e.g., modelling and active learning) and practical applications (e.g., health care professional training and facilitation) were reported to inform the development of practice change interventions and programs. Discussion. In practice, Intervention Mapping delineates a three-step systematic, theory- and evidence-driven process for establishing the theoretical foundations and rationales underpinning change in health care professional practice. Conclusion. The use of Intervention Mapping can provide health care planners with useful guidelines for the theoretical development of practice change interventions and programs.
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Affiliation(s)
- Desire Durks
- University of Technology Sydney, Sydney, New South Wales, Australia
| | | | | | | | | | - Daniel Sabater-Hernández
- University of Technology Sydney, Sydney, New South Wales, Australia
- University of Granada, Granada, Spain
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9
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Barriers to Primary Care Clinician Adherence to Clinical Guidelines for the Management of Low Back Pain. Clin J Pain 2016; 32:800-16. [DOI: 10.1097/ajp.0000000000000324] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Maas MJM, van Dulmen SA, Sagasser MH, Heerkens YF, van der Vleuten CPM, Nijhuis-van der Sanden MWG, van der Wees PJ. Critical features of peer assessment of clinical performance to enhance adherence to a low back pain guideline for physical therapists: a mixed methods design. BMC MEDICAL EDUCATION 2015; 15:203. [PMID: 26563246 PMCID: PMC4643538 DOI: 10.1186/s12909-015-0484-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 11/03/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Clinical practice guidelines are intended to improve the process and outcomes of patient care. However, their implementation remains a challenge. We designed an implementation strategy, based on peer assessment (PA) focusing on barriers to change in physical therapy care. A previously published randomized controlled trial showed that PA was more effective than the usual strategy "case discussion" in improving adherence to a low back pain guideline. Peer assessment aims to enhance knowledge, communication, and hands-on clinical skills consistent with guideline recommendations. Participants observed and evaluated clinical performance on the spot in a role-play simulating clinical practice. Participants performed three roles: physical therapist, assessor, and patient. This study explored the critical features of the PA program that contributed to improved guideline adherence in the perception of participants. METHODS Dutch physical therapists working in primary care (n = 49) organized in communities of practice (n = 6) participated in the PA program. By unpacking the program we identified three main tasks and eleven subtasks. After the program was finished, a questionnaire was administered in which participants were asked to rank the program tasks from high to low learning value and to describe their impact on performance improvement. Overall ranking results were calculated. Additional semi-structured interviews were conducted to elaborate on the questionnaires results and were transcribed verbatim. Questionnaires comments and interview transcripts were analyzed using template analysis. RESULTS Program tasks related to performance in the therapist role were perceived to have the highest impact on learning, although task perceptions varied from challenging to threatening. Perceptions were affected by the role-play format and the time schedule. Learning outcomes were awareness of performance, improved attitudes towards the guideline, and increased self-efficacy beliefs in managing patients with low back pain. Learning was facilitated by psychological safety and the quality of feedback. CONCLUSION The effectiveness of PA can be attributed to the structured and performance-based design of the program. Participants showed a strong cognitive and emotional commitment to performing the physical therapist role. That might have contributed to an increased awareness of strength and weakness in clinical performance and a motivation to change routine practice.
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Affiliation(s)
- Marjo J M Maas
- HAN University of Applied Sciences, Institute for Health Studies, Kapittelweg 33, 5425 EN, Nijmegen, The Netherlands.
- Radboud University Medical Center, Institute for Health Sciences, IQ healthcare, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands.
| | - Simone A van Dulmen
- Radboud University Medical Center, Institute for Health Sciences, IQ healthcare, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands.
| | - Margaretha H Sagasser
- Radboud University Medical Center Department of Primary and Community Care, Nijmegen, The Netherlands.
| | - Yvonne F Heerkens
- HAN University of Applied Sciences, Institute for Health Studies, Kapittelweg 33, 5425 EN, Nijmegen, The Netherlands.
- Dutch Institute of Allied Health Care, Amersfoort, The Netherlands.
| | - Cees P M van der Vleuten
- Maastricht University, Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands.
| | - Maria W G Nijhuis-van der Sanden
- Radboud University Medical Center, Institute for Health Sciences, IQ healthcare, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands.
| | - Philip J van der Wees
- Radboud University Medical Center, Institute for Health Sciences, IQ healthcare, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands.
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Slade SC, Kent P, Bucknall T, Molloy E, Patel S, Buchbinder R. Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: protocol of a systematic review and meta-synthesis of qualitative studies. BMJ Open 2015; 5:e007265. [PMID: 25900462 PMCID: PMC4410131 DOI: 10.1136/bmjopen-2014-007265] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 02/27/2015] [Accepted: 03/02/2015] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Low back pain is the highest ranked condition contributing to years lived with disability, and is a significant economic and societal burden. Evidence-based clinical practice guidelines are designed to improve quality of care and reduce practice variation by providing graded recommendations based on the best available evidence. Studies of low back pain guideline implementation have shown no or modest effects at changing clinical practice. OBJECTIVES To identify enablers and barriers to adherence to clinical practice guidelines for the management of low back pain. METHODS AND ANALYSIS A systematic review and meta-synthesis of qualitative studies that will be conducted and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement guidelines. Eight databases will be searched using a priori inclusion/exclusion criteria. Two independent reviewers will conduct a structured review and meta-synthesis, and a third reviewer will arbitrate where there is disagreement. This protocol has been registered on PROSPERO 2014. ETHICS AND DISSEMINATION Ethical approval is not required. The systematic review will be published in a peer-reviewed journal. The review will also be disseminated electronically, in print and at conferences. Updates of the review will be conducted to inform and guide healthcare translation into practice. TRIAL REGISTRATION NUMBER PROSPERO 2014:CRD42014012961. Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014012961.
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Affiliation(s)
- Susan C Slade
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
- Monash Department of Clinical Epidemiology, Cabrini Hospital, Melbourne, Australia
| | - Peter Kent
- Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Tracey Bucknall
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
- School of Nursing & Midwifery, Deakin University, Melbourne, Australia
- Alfred Health, Melbourne, Australia
| | - Elizabeth Molloy
- Health Professions Education and Educational Research (HealthPEER), Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Shilpa Patel
- Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
- Monash Department of Clinical Epidemiology, Cabrini Hospital, Melbourne, Australia
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12
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The contribution of conceptual frameworks to knowledge translation interventions in physical therapy. Phys Ther 2015; 95:630-9. [PMID: 25060959 PMCID: PMC4384052 DOI: 10.2522/ptj.20130483] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 07/13/2014] [Indexed: 11/17/2022]
Abstract
There is growing recognition of the importance of knowledge translation activities in physical therapy to ensure that research findings are integrated into clinical practice, and increasing numbers of knowledge translation interventions are being conducted. Although various frameworks have been developed to guide and facilitate the process of translating knowledge into practice, these tools have been infrequently used in physical therapy knowledge translation studies to date. Knowledge translation in physical therapy implicates multiple stakeholders and environments and involves numerous steps. In light of this complexity, the use of explicit conceptual frameworks by clinicians and researchers conducting knowledge translation interventions is associated with a range of potential benefits. This perspective article argues that such frameworks are important resources to promote the uptake of new evidence in physical therapist practice settings. Four key benefits associated with the use of conceptual frameworks in designing and implementing knowledge translation interventions are identified, and limits related to their use are considered. A sample of 5 conceptual frameworks is evaluated, and how they address common barriers to knowledge translation in physical therapy is assessed. The goal of this analysis is to provide guidance to physical therapists seeking to identify a framework to support the design and implementation of a knowledge translation intervention. Finally, the use of a conceptual framework is illustrated through a case example. Increased use of conceptual frameworks can have a positive impact on the field of knowledge translation in physical therapy and support the development and implementation of robust and effective knowledge translation interventions that help span the research-practice gap.
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13
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An innovative peer assessment approach to enhance guideline adherence in physical therapy: single-masked, cluster-randomized controlled trial. Phys Ther 2015; 95:600-12. [PMID: 25234274 DOI: 10.2522/ptj.20130469] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 08/28/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Clinical practice guidelines (CPGs) are not readily implemented in clinical practice. One of the impeding factors is that physical therapists do not hold realistic perceptions of their adherence to CPGs. Peer assessment (PA) is an implementation strategy that aims at improving guideline adherence by enhancing reflective practice, awareness of professional performance, and attainment of personal goals. OBJECTIVE The purpose of this study was to compare the effectiveness of PA with the usual case discussion (CD) strategy on adherence to CPGs for physical therapist management of upper extremity complaints. DESIGN A single-masked, cluster-randomized controlled trial with pretest-posttest design was conducted. INTERVENTION Twenty communities of practice (n=149 physical therapists) were randomly assigned to groups receiving PA or CD, with both interventions consisting of 4 sessions over 6 months. Both PA and CD groups worked on identical clinical cases relevant to the guidelines. Peer assessment focused on individual performance observed and evaluated by peers; CD focused on discussion. OUTCOMES Guideline adherence was measured with clinical vignettes, reflective practice was measured with the Self-Reflection and Insight Scale (SRIS), awareness of performance was measured via the correlation between perceived and assessed improvement, and attainment of personal goals was measured with written commitments to change. RESULTS The PA groups improved more on guideline adherence compared with the CD groups (effect=22.52; 95% confidence interval [95% CI]=2.38, 42.66; P=.03). The SRIS scores did not differ between PA and CD groups. Awareness of performance was greater for the PA groups (r=.36) than for the CD groups (r=.08) (effect=14.73; 95% CI=2.78, 26.68; P=.01). The PA strategy was more effective than the CD strategy in attaining personal goals (effect=0.50; 95% CI=0.04, 0.96; P=.03). LIMITATIONS Limited validity of clinical vignettes as a proxy measure of clinical practice was a limitation of the study. CONCLUSIONS Peer assessment was more effective than CD in improving adherence to CPGs. Personal feedback may have contributed to its effectiveness. Future research should address the role of the group coach.
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Döpp CME, Graff MJL, Teerenstra S, Olde Rikkert MGM, Nijhuis-van der Sanden MWG, Vernooij-Dassen MJFJ. Effectiveness of a training package for implementing a community-based occupational therapy program in dementia: a cluster randomized controlled trial. Clin Rehabil 2014; 29:974-86. [PMID: 25547113 DOI: 10.1177/0269215514564699] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 11/22/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Evaluate the effectiveness of a training package to implement a community occupational therapy program for people with dementia and their caregiver (COTiD). DESIGN Cluster randomized controlled trial. SUBJECTS A total of 45 service units including 94 occupational therapists, 48 managers, 80 physicians, treating 71 client-caregiver couples. INTERVENTIONS Control intervention: A postgraduate course for occupational therapists only. EXPERIMENTAL INTERVENTION A training package including the usual postgraduate course, additional training days, outreach visits, regional meetings, and access to a reporting system for occupational therapists. Physicians and managers received newsletters, had access to a website, and were approached by telephone. MAIN MEASURES PRIMARY OUTCOME The intended adherence of therapists to the COTiD program. This was assessed using vignettes. SECONDARY OUTCOMES clients' daily functioning, caregivers' sense of competence, quality of life, and self-perceived performance of daily activities of both clients and caregivers. Between-group differences were assessed using multilevel analyses with therapist and intervention factors as covariates. RESULTS No significant between-group differences between baseline and 12 months were found for adherence (1.58, 95% CI -0.10 to 3.25), nor for any client or caregiver outcome. A higher number of coaching sessions and higher self-perceived knowledge of dementia at baseline positively correlated with adherence scores. In contrast, experiencing more support from occupational therapy colleagues or having conducted more COTiD treatments at baseline negatively affected adherence scores. CONCLUSION The training package was not effective in increasing therapist adherence and client-caregiver outcomes. This study suggests that coaching sessions and increasing therapist knowledge on dementia positively affect adherence. CLINICAL TRIAL NUMBER NCT01117285.
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Affiliation(s)
- Carola M E Döpp
- Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), Nijmegen, The Netherlands The Nijmegen Alzheimer Centre, Nijmegen, The Netherlands
| | - Maud J L Graff
- Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), Nijmegen, The Netherlands The Nijmegen Alzheimer Centre, Nijmegen, The Netherlands Department of Rehabilitation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Steven Teerenstra
- Department for Health Evidence (Biostatistics section), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel G M Olde Rikkert
- The Nijmegen Alzheimer Centre, Nijmegen, The Netherlands Department of Geriatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maria W G Nijhuis-van der Sanden
- Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), Nijmegen, The Netherlands Department of Rehabilitation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Myrra J F J Vernooij-Dassen
- Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), Nijmegen, The Netherlands The Nijmegen Alzheimer Centre, Nijmegen, The Netherlands Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands Kalorama Foundation, Beek-Ubbergen, The Netherlands
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Effectiveness of peer assessment for implementing a Dutch physical therapy low back pain guideline: cluster randomized controlled trial. Phys Ther 2014; 94:1396-409. [PMID: 24830716 DOI: 10.2522/ptj.20130286] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Clinical practice guidelines are considered important instruments to improve quality of care. However, success is dependent on adherence, which may be improved using peer assessment, a strategy in which professionals assess performance of their peers in a simulated setting. OBJECTIVE The aim of this study was to determine whether peer assessment is more effective than case-based discussions to improve knowledge and guideline-consistent clinical reasoning in the Dutch physical therapy guideline for low back pain (LBP). DESIGN A cluster randomized controlled trial was conducted. SETTING AND PARTICIPANTS Ten communities of practice (CoPs) of physical therapists were cluster randomized (N=90): 6 CoPs in the peer-assessment group (n=49) and 4 CoPs in the case-based discussion group (control group) (n=41). INTERVENTION Both groups participated in 4 educational sessions and used clinical patient cases. The peer-assessment group reflected on performed LBP management in different roles. The control group used structured discussions. MEASUREMENTS Outcomes were assessed at baseline and at 6 months. The primary outcome measure was knowledge and guideline-consistent reasoning, measured with 12 performance indicators using 4 vignettes with specific guideline-related patient profiles. For each participant, the total score was calculated by adding up the percentage scores (0-100) per vignette, divided by 4. The secondary outcome measure was reflective practice, as measured by the Self-Reflection and Insight Scale (20-100). RESULTS Vignettes were completed by 78 participants (87%). Multilevel analysis showed an increase in guideline-consistent clinical reasoning of 8.4% in the peer-assessment group, whereas the control group showed a decline of 0.1% (estimated group difference=8.7%, 95% confidence interval=3.9 to 13.4). No group differences were found on self-reflection. LIMITATIONS The small sample size, a short-term follow-up, and the use of vignettes as a proxy for behavior were limitations of the study. CONCLUSIONS Peer assessment leads to an increase in knowledge and guideline-consistent clinical reasoning.
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Maas MJM, Sluijsmans DMA, van der Wees PJ, Heerkens YF, Nijhuis-van der Sanden MWG, van der Vleuten CPM. Why peer assessment helps to improve clinical performance in undergraduate physical therapy education: a mixed methods design. BMC MEDICAL EDUCATION 2014; 14:117. [PMID: 24928420 PMCID: PMC4064265 DOI: 10.1186/1472-6920-14-117] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 06/02/2014] [Indexed: 06/03/2023]
Abstract
BACKGROUND Peer Assessment (PA) in health professions education encourages students to develop a critical attitude towards their own and their peers' performance. We designed a PA task to assess students' clinical skills (including reasoning, communication, physical examination and treatment skills) in a role-play that simulated physical therapy (PT) practice. Students alternately performed in the role of PT, assessor, and patient. Oral face-to-face feedback was provided as well as written feedback and scores.This study aims to explore the impact of PA on the improvement of clinical performance of undergraduate PT students. METHODS The PA task was analyzed and decomposed into task elements. A qualitative approach was used to explore students' perceptions of the task and the task elements. Semi-structured interviews with second year students were conducted to explore the perceived impact of these task elements on performance improvement. Students were asked to select the elements perceived valuable, to rank them from highest to lowest learning value, and to motivate their choices. Interviews were transcribed verbatim and analyzed, using a phenomenographical approach and following template analysis guidelines. A quantitative approach was used to describe the ranking results. RESULTS Quantitative analyses showed that the perceived impact on learning varied widely. Performing the clinical task in the PT role, was assigned to the first place (1), followed by receiving expert feedback (2), and observing peer performance (3). Receiving peer feedback was not perceived the most powerful task element.Qualitative analyses resulted in three emerging themes: pre-performance, true-performance, and post-performance triggers for improvement. Each theme contained three categories: learning activities, outcomes, and conditions for learning.Intended learning activities were reported, such as transferring prior learning to a new application context and unintended learning activities, such as modelling a peer's performance. Outcomes related to increased self-confidence, insight in performance standards and awareness of improvement areas. Conditions for learning referred to the quality of peer feedback. CONCLUSIONS PA may be a powerful tool to improve clinical performance, although peer feedback is not perceived the most powerful element. Peer assessors in undergraduate PT education use idiosyncratic strategies to assess their peers' performance.
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Affiliation(s)
- Marjo JM Maas
- HAN University of Applied Sciences, Department Allied Health Studies, Kapittelweg 33, 5425 EN Nijmegen, The Netherlands
- Radboud University Medical Center, Scientific Institute for Quality of Healthcare, Geert Grooteplein 21, 6525 EZ Nijmegen, The Netherlands
| | | | - Philip J van der Wees
- Radboud University Medical Center, Scientific Institute for Quality of Healthcare, Geert Grooteplein 21, 6525 EZ Nijmegen, The Netherlands
| | - Yvonne F Heerkens
- Radboud University Medical Center, Scientific Institute for Quality of Healthcare, Geert Grooteplein 21, 6525 EZ Nijmegen, The Netherlands
- Dutch Institute of Allied Health Care, Amersfoort, The Netherlands
| | - Maria WG Nijhuis-van der Sanden
- Radboud University Medical Center, Scientific Institute for Quality of Healthcare, Geert Grooteplein 21, 6525 EZ Nijmegen, The Netherlands
| | - Cees PM van der Vleuten
- Maastricht University, Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands
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Bernhardsson S, Larsson MEH, Eggertsen R, Olsén MF, Johansson K, Nilsen P, Nordeman L, van Tulder M, Öberg B. Evaluation of a tailored, multi-component intervention for implementation of evidence-based clinical practice guidelines in primary care physical therapy: a non-randomized controlled trial. BMC Health Serv Res 2014; 14:105. [PMID: 24589291 PMCID: PMC3975873 DOI: 10.1186/1472-6963-14-105] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 02/21/2014] [Indexed: 12/21/2022] Open
Abstract
Background Clinical practice guidelines are important for transmitting research findings into practice and facilitating the application of evidence-based practice (EBP). There is a paucity of knowledge about the impact of guideline implementation strategies in primary care physical therapy. The aim of this study was to evaluate the effect of a guideline implementation intervention in primary care physical therapy in western Sweden. Methods An implementation strategy based on theory and current evidence was developed. A tailored, multi-component implementation intervention, addressing earlier identified determinants, was carried out in three areas comprising 28 physical therapy practices including 277 physical therapists (PTs) (intervention group). In two adjacent areas, 171 PTs at 32 practices received no intervention (control group). The core component of the intervention was an implementation seminar with group discussions. Among other components were a website and email reminders. Data were collected at baseline and follow-up with a web-based questionnaire. Primary outcomes were the self-reported awareness of, knowledge of, access to, and use of guidelines. Secondary outcomes were self-reported attitudes toward EBP and guidelines. Analyses were performed using Pearson’s χ2 test and approximative z-test. Results 168 PTs (60.6%) in the intervention group and 88 PTs (51.5%) in the control group responded to the follow-up questionnaire. 186/277 PTs (67.1%) participated in the implementation seminars, of which 97 (52.2%) responded. The proportions of PTs reporting awareness of (absolute difference in change 20.6%, p = 0.023), knowledge where to find (20.4%, p = 0.007), access to (21.7%, p < 0.001), and frequent use of (9.5%, NS) guidelines increased more in the intervention group than in the control group. The proportion of PTs reporting frequent guideline use after participation in the implementation seminar was 15.2% (p = 0.043) higher than the proportion in the control group. A higher proportion considered EBP helpful in decision making (p = 0.018). There were no other significant differences in secondary outcomes. Conclusions A tailored, theory- and evidence-informed, multi-component intervention for the implementation of clinical practice guidelines had a modest, positive effect on awareness of, knowledge of, access to, and use of guidelines, among PTs in primary care in western Sweden. In general, attitudes to EBP and guidelines were not affected.
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Determinants of guideline use in primary care physical therapy: a cross-sectional survey of attitudes, knowledge, and behavior. Phys Ther 2014; 94:343-54. [PMID: 24179140 DOI: 10.2522/ptj.20130147] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Understanding of attitudes, knowledge, and behavior related to evidence-based practice (EBP) and use of evidence-based clinical practice guidelines in primary care physical therapy is limited. OBJECTIVES The objectives of this study were: (1) to investigate self-reported attitudes, knowledge, behavior, prerequisites, and barriers related to EBP and guideline use among physical therapists in primary care and (2) to explore associations of self-reported use of guidelines with these social cognitive factors along with demographic and workplace characteristics. DESIGN This was a cross-sectional survey. METHODS A web-based survey of 419 physical therapists in primary care in western Sweden was performed. Multiple logistic regression analysis was performed to examine factors associated with guideline use. RESULTS The response rate was 64.7%. Most respondents had positive attitudes toward EBP and guidelines: 90% considered EBP necessary, and 96% considered guidelines important. Approximately two thirds reported confidence in finding and using evidence. One third reported being aware of guidelines. Thirteen percent knew where to find guidelines, and only 9% reported having easy access to guidelines. Fewer than half reported using guidelines frequently. The most important barriers to using guidelines were lack of time, poor availability, and limited access to guidelines. Young age and brief work experience were associated with positive attitudes toward EBP. A postgraduate degree was associated with higher application of EBP. Positive attitudes, awareness of guidelines, considering guidelines to facilitate practice, and knowing how to integrate patient preferences with guideline use were associated with frequent use of guidelines. LIMITATIONS Data were self-reported, which may have increased the risk of social desirability bias. CONCLUSIONS Use of guidelines was not as frequent as could be expected in view of the positive attitudes toward EBP and guidelines among physical therapists. Awareness of and perceived access to guidelines were limited. The identified determinants can be addressed when developing guideline implementation strategies.
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Rutten GM, Harting J, Bartholomew LK, Braspenning JC, van Dolder R, Heijmans MF, Hendriks EJ, Kremers SP, van Peppen RP, Rutten ST, Schlief A, de Vries NK, Oostendorp RA. Development of a theory- and evidence-based intervention to enhance implementation of physical therapy guidelines for the management of low back pain. ACTA ACUST UNITED AC 2014; 72:1. [PMID: 24428945 PMCID: PMC3897896 DOI: 10.1186/2049-3258-72-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 12/16/2013] [Indexed: 12/04/2022]
Abstract
Background Systematic planning could improve the generally moderate effectiveness of interventions to enhance adherence to clinical practice guidelines. The aim of our study was to demonstrate how the process of Intervention Mapping was used to develop an intervention to address the lack of adherence to the national CPG for low back pain by Dutch physical therapists. Methods We systematically developed a program to improve adherence to the Dutch physical therapy guidelines for low back pain. Based on multi-method formative research, we formulated program and change objectives. Selected theory-based methods of change and practical applications were combined into an intervention program. Implementation and evaluation plans were developed. Results Formative research revealed influential determinants for physical therapists and practice quality managers. Self-regulation was appropriate because both the physical therapists and the practice managers needed to monitor current practice and make and implement plans for change. The program stimulated interaction between practice levels by emphasizing collective goal setting. It combined practical applications, such as knowledge transfer and discussion-and-feedback, based on theory-based methods, such as consciousness raising and active learning. The implementation plan incorporated the wider environment. The evaluation plan included an effect and process evaluation. Conclusions Intervention Mapping is a useful framework for formative data in program planning in the field of clinical guideline implementation. However, a decision aid to select determinants of guideline adherence identified in the formative research to analyse the problem may increase the efficiency of the application of the Intervention Mapping process.
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Affiliation(s)
- Geert M Rutten
- NUTRIM, Department of Health Promotion, Maastricht University; Faculty of Health, Medicine and Life Sciences, P,O, Box 616, Maastricht 6200, MD, The Netherlands.
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Collinge WR, Gross DP, Bostick GP, Cutforth GS, Rutten GM, Maroun C, Oostendorp RAB. Evaluating physical therapy students' knowledge of and adherence to the ambassador low back pain guideline. Physiother Can 2014; 65:384-95. [PMID: 24396169 DOI: 10.3138/ptc.2012-33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To examine a process for evaluating physiotherapy (PT) students' knowledge of and adherence to the Ambassador Low Back Pain (LBP) guideline using vignettes. METHODS The study used a cross-sectional survey design. Participants were PT students who had received information related to the guideline as part of their curriculum. Primary measures were responses to questions about the management of four clinical vignettes. Adherence to guideline recommendations was measured by comparing participant scores to a "guideline-based" set of responses from a physiotherapist involved in developing the Ambassador guideline, which was considered a criterion standard. RESULTS A total of 74 respondents provided complete data, for a response rate of 89%; 65 (88%) reported no knowledge of the guideline. Overall consistency with the criterion standard was high (>70%). Respondents demonstrated high adherence when identifying red flags and deciding whether to refer to another provider. CONCLUSION Despite known exposure, knowledge of the guideline was low in this sample of Canadian PT students. Nevertheless, in several key areas, unconscious adherence was high relative to the guideline-based criterion standard. With minor modifications, the vignettes are suitable for evaluating the Ambassador LBP guidelines in a larger study.
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Affiliation(s)
| | | | | | | | - Geert M Rutten
- NUTRIM, Department of Health Promotion, Maastricht University, The Netherlands
| | - Claude Maroun
- American University of Beirut Medical Center, Physical Therapy Department, Lebanon
| | - Rob A B Oostendorp
- Radboud University Nijmegen Medical Centre, Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands
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Rebbeck T, Macedo LG, Maher CG. Compliance with clinical guidelines for whiplash improved with a targeted implementation strategy: a prospective cohort study. BMC Health Serv Res 2013; 13:213. [PMID: 23758939 PMCID: PMC3734039 DOI: 10.1186/1472-6963-13-213] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 05/30/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementation strategies for clinical guidelines have shown modest effects in changing health professional's knowledge and practice, however, targeted implementations are suggested to achieve greater improvements. This study aimed to examine the effect of a targeted implementation strategy of the Australian whiplash guidelines on health professionals' knowledge, beliefs and practice and to identify predictors of improved knowledge. METHODS 94 health professionals (Physiotherapists, Chiropractors and Osteopaths) who manage whiplash participated in this study. Prior to their inclusion in the study, health professionals were classified as compliant with clinical guidelines for whiplash (n = 52) or non-compliant (n = 42), according to a record of clinical practice. All participants completed a 2- day interactive workshop with outcomes measured at baseline and 3 months following the workshop. The workshop was delivered by opinion leaders, with the educational content focused on the pre-identified knowledge and practice gaps in relation to clinical guidelines for whiplash. Knowledge and health professional beliefs were assessed by a questionnaire and professional practice by record of clinical practice. RESULTS Participants significantly increased knowledge (p < 0.0001) and were more likely to be compliant with the guidelines at follow-up (compliant at baseline 58%, follow-up 79%, p = 0.002). Health professional belief systems significantly changed to be more behavioural (p = 0.02) and less biomedical (p = 0.000). Predictors of improved knowledge were baseline knowledge (parameter estimate = -0.6, p = 0.000) and profession (parameter estimate = -3.8, p = 0.003) (adj R2 = 35%). CONCLUSIONS A targeted implementation strategy improved health professional's knowledge and clinical practice so that they became more compliant with clinical guidelines for whiplash. In addition health professionals' belief systems significantly changed to be more behavioural in orientation. Baseline knowledge and profession predicted 35% of the variance in improved knowledge.
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Affiliation(s)
- Trudy Rebbeck
- Discipline of Physiotherapy, Faculty of Health Science, The University of Sydney, PO Box 170, Sydney, Lidcombe NSW 1825, Australia
| | - Luciana G Macedo
- Common Spinal Disorders Research Group, Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, 2-50 Corbett Hall, Edmonton, AB T6G 2G4, Canada
| | - Christopher G Maher
- The George Institute for Global Health, Sydney Medical School, The University of Sydney, Level 13, 321 Kent St, Sydney NSW 2000, Australia
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Rutten GM, Harting J, Bartholomew LK, Schlief A, Oostendorp RAB, de Vries NK. Evaluation of the theory-based Quality Improvement in Physical Therapy (QUIP) programme: a one-group, pre-test post-test pilot study. BMC Health Serv Res 2013; 13:194. [PMID: 23705912 PMCID: PMC3688482 DOI: 10.1186/1472-6963-13-194] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 05/22/2013] [Indexed: 11/16/2022] Open
Abstract
Background Guideline adherence in physical therapy is far from optimal, which has consequences for the effectiveness and efficiency of physical therapy care. Programmes to enhance guideline adherence have, so far, been relatively ineffective. We systematically developed a theory-based Quality Improvement in Physical Therapy (QUIP) programme aimed at the individual performance level (practicing physiotherapists; PTs) and the practice organization level (practice quality manager; PQM). The aim of the study was to pilot test the multilevel QUIP programme’s effectiveness and the fidelity, acceptability and feasibility of its implementation. Methods A one-group, pre-test, post-test pilot study (N = 8 practices; N = 32 PTs, 8 of whom were also PQMs) done between September and December 2009. Guideline adherence was measured using clinical vignettes that addressed 12 quality indicators reflecting the guidelines’ main recommendations. Determinants of adherence were measured using quantitative methods (questionnaires). Delivery of the programme and management changes were assessed using qualitative methods (observations, group interviews, and document analyses). Changes in adherence and determinants were tested in the paired samples T-tests and expressed in effect sizes (Cohen’s d). Results Overall adherence did not change (3.1%; p = .138). Adherence to three quality indicators improved (8%, 24%, 43%; .000 ≤ p ≤ .023). Adherence to one quality indicator decreased (−15.7%; p = .004). Scores on various determinants of individual performance improved and favourable changes at practice organizational level were observed. Improvements were associated with the programme’s multilevel approach, collective goal setting, and the application of self-regulation; unfavourable findings with programme deficits. The one-group pre-test post-test design limits the internal validity of the study, the self-selected sample its external validity. Conclusions The QUIP programme has the potential to change physical therapy practice but needs considerable revision to induce the ongoing quality improvement process that is required to optimize overall guideline adherence. To assess its value, the programme needs to be tested in a randomized controlled trial.
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Affiliation(s)
- Geert M Rutten
- Department of Health Promotion, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.
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Josephson I, Bülow P, Hedberg B. Physiotherapists' clinical reasoning about patients with non-specific low back pain, as described by the International Classification of Functioning, Disability and Health. Disabil Rehabil 2011; 33:2217-28. [DOI: 10.3109/09638288.2011.563819] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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McKenzie JE, O'Connor DA, Page MJ, Mortimer DS, French SD, Walker BF, Keating JL, Grimshaw JM, Michie S, Francis JJ, Green SE. Improving the care for people with acute low-back pain by allied health professionals (the ALIGN trial): A cluster randomised trial protocol. Implement Sci 2010; 5:86. [PMID: 21067614 PMCID: PMC2994785 DOI: 10.1186/1748-5908-5-86] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 11/10/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Variability between clinical practice guideline recommendations and actual clinical practice exists in many areas of health care. A 2004 systematic review examining the effectiveness of guideline implementation interventions concluded there was a lack of evidence to support decisions about effective interventions to promote the uptake of guidelines. Further, the review recommended the use of theory in the development of implementation interventions. A clinical practice guideline for the management of acute low-back pain has been developed in Australia (2003). Acute low-back pain is a common condition, has a high burden, and there is some indication of an evidence-practice gap in the allied health setting. This provides an opportunity to develop and test a theory-based implementation intervention which, if effective, may provide benefits for patients with this condition. AIMS This study aims to estimate the effectiveness of a theory-based intervention to increase allied health practitioners' (physiotherapists and chiropractors in Victoria, Australia) compliance with a clinical practice guideline for acute non-specific low back pain (LBP), compared with providing practitioners with a printed copy of the guideline. Specifically, our primary objectives are to establish if the intervention is effective in reducing the percentage of acute non-specific LBP patients who are either referred for or receive an x-ray, and improving mean level of disability for patients three months post-onset of acute LBP. METHODS The design of the study is a cluster randomised trial. Restricted randomisation was used to randomise 210 practices (clusters) to an intervention or control group. Practitioners in the control group received a printed copy of the guideline. Practitioners in the intervention group received a theory-based intervention developed to address prospectively identified barriers to practitioner compliance with the guideline. The intervention primarily consisted of an educational symposium. Patients aged 18 years or older who visit a participating practitioner for acute non-specific LBP of less than three months duration over a two-week data collection period, three months post the intervention symposia, are eligible for inclusion. Sample size calculations are based on recruiting between 15 to 40 patients per practice. Outcome assessors will be blinded to group allocation. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12609001022257 (date registered 25th November 2009).
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Affiliation(s)
- Joanne E McKenzie
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
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A qualitative application of the diffusion of innovations theory to examine determinants of guideline adherence among physical therapists. Phys Ther 2009; 89:221-32. [PMID: 19168713 DOI: 10.2522/ptj.20080185] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Evidence-based practice has become a major issue in physical therapy. Many evidence-based guidelines, however, are not used extensively after dissemination, and interventions aimed at increasing guideline adherence often have limited effects. OBJECTIVE As a prerequisite for changing this situation, the aims of this study were to gain an in-depth understanding of the determinants of guideline adherence among physical therapists in the Netherlands and to evaluate the opportunities of a theoretical framework in this respect. DESIGN AND METHODS This observational study consisted of 3 focus group interviews (n=12, 10, and 8) between November 2002 and January 2003. Physical therapists were asked to discuss their opinions about and experiences with the Dutch guidelines for low back pain. Data were analyzed qualitatively using a directed approach to content analysis. Both the interview route and the analysis of the interviews were informed by Rogers' Diffusion of Innovations Theory. RESULTS Our study yielded in-depth insights into the various determinants of guideline adherence. Overall, the participants had rather unfavorable opinions about issues related to the dissemination of the guidelines (first phase of the diffusion process) and provided relatively little information on the subsequent adoption process (second phase of the diffusion process). The theoretical framework appeared to be a useful tool to properly structure the focus group interviews, to systematically analyze the data collected, and to determine that supplementary interviews would be necessary to cover the entire diffusion process. CONCLUSIONS Our findings indicated that the diffusion process of guidelines among physical therapists was not yet completed. The use of theory can provide added value to guideline implementation studies.
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