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Noble AJ, Morris B, Bonnett LJ, Reuber M, Mason S, Wright J, Pilbery R, Bell F, Shillito T, Marson AG, Dickson JM. 'Knowledge exchange' workshops to optimise development of a risk prediction tool to assist conveyance decisions for suspected seizures - Part of the Risk of ADverse Outcomes after a Suspected Seizure (RADOSS) project. Epilepsy Behav 2024; 151:109611. [PMID: 38199055 DOI: 10.1016/j.yebeh.2023.109611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024]
Abstract
PURPOSE Suspected seizures present challenges for ambulance services, with paramedics reporting uncertainty over whether or not to convey individuals to emergency departments. The Risk of ADverse Outcomes after a Suspected Seizure (RADOSS) project aims to address this by developing a risk assessment tool utilizing structured patient care record and dispatch data. It proposes a tool that would provide estimates of an individual's likelihood of death and/or recontact with emergency care within 3 days if conveyed compared to not conveyed, and the likelihood of an 'avoidable attendance' occurring if conveyed. Knowledge Exchange workshops engaged stakeholders to resolve key design uncertainties before model derivation. METHOD Six workshops involved 26 service users and their significant others (epilepsy or nonepileptic attack disorder), and 25 urgent and emergency care clinicians from different English ambulance regions. Utilizing Nominal Group Techniques, participants shared views of the proposed tool, benefits and concerns, suggested predictors, critiqued outcome measures, and expressed functionality preferences. Data were analysed using Hamilton's Rapid Analysis. RESULTS Stakeholders supported tool development, proposing 10 structured variables for predictive testing. Emphasis was placed on the tool supporting, not dictating, care decisions. Participants highlighted some reasons why RADOSS might struggle to derive a predictive model based on structured data alone and suggested some non-structured variables for future testing. Feedback on prediction timeframes for service recontact was received, along with advice on amending the 'avoidable attendance' definition to prevent the tool's predictions being undermined by potential overuse of certain investigations in hospital. CONCLUSION Collaborative stakeholder engagement provided crucial insights that can guide RADOSS to develop a user-aligned, optimized tool.
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Affiliation(s)
- Adam J Noble
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK.
| | - Beth Morris
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Laura J Bonnett
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Markus Reuber
- Department of Neuroscience, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Suzanne Mason
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | | | | | - Fiona Bell
- Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | | | - Anthony G Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Jon M Dickson
- Population Health, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
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Rebbeck T, Bandong AN, Leaver A, Ritchie C, Armfield N, Arora M, Cameron ID, Connelly LB, Daniell R, Gillett M, Ingram R, Jagnoor J, Kenardy J, Mitchell G, Refshauge K, Scotti Requena S, Robins S, Sterling M. Implementation of a risk-stratified, guideline-based clinical pathway of care to improve health outcomes following whiplash injury (Whiplash ImPaCT): a multicentre, randomized, controlled trial. Pain 2023; 164:2216-2227. [PMID: 37318019 DOI: 10.1097/j.pain.0000000000002940] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 02/24/2023] [Indexed: 06/16/2023]
Abstract
ABSTRACT Current pathways of care for whiplash follow a "stepped care model," result in modest treatment outcomes and fail to offer efficient management solutions. This study aimed to evaluate the effectiveness of a risk-stratified clinical pathway of care (CPC) compared with usual care (UC) in people with acute whiplash. We conducted a multicentre, 2-arm, parallel, randomised, controlled trial in primary care in Australia. Participants with acute whiplash (n = 216) were stratified for risk of a poor outcome (low vs medium/high risk) and randomised using concealed allocation to either the CPC or UC. In the CPC group, low-risk participants received guideline-based advice and exercise supported by an online resource, and medium-risk/high-risk participants were referred to a whiplash specialist who assessed modifiable risk factors and then determined further care. The UC group received care from their primary healthcare provider who had no knowledge of risk status. Primary outcomes were neck disability index (NDI) and Global Rating of Change (GRC) at 3 months. Analysis blinded to group used intention-to-treat and linear mixed models. There was no difference between the groups for the NDI (mean difference [MD] [95% confidence interval (CI)] -2.34 [-7.44 to 2.76]) or GRC (MD 95% CI 0.08 [-0.55 to 0.70]) at 3 months. Baseline risk category did not modify the effect of treatment. No adverse events were reported. Risk-stratified care for acute whiplash did not improve patient outcomes, and implementation of this CPC in its current form is not recommended.
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Affiliation(s)
- Trudy Rebbeck
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Aila Nica Bandong
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Physical Therapy, The University of the Philippines, Manila, Philippines
| | - Andrew Leaver
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Carrie Ritchie
- RECOVER Injury Research Centre and National Health and Medical Research Council (NHMRC) Centre of Research Excellence: Better Health Outcomes for Compensable Injury, The University of Queensland, Brisbane, Queensland, Australia
| | - Nigel Armfield
- RECOVER Injury Research Centre and National Health and Medical Research Council (NHMRC) Centre of Research Excellence: Better Health Outcomes for Compensable Injury, The University of Queensland, Brisbane, Queensland, Australia
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Mohit Arora
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Luke B Connelly
- Centre for the Business and Economics of Health, University of Queensland, Brisbane, Queensland, Australia
- Departimento di Sociologia e Diritto Dell'Economia Bologna, Emilia-Romagna, Italy
| | - Roy Daniell
- Belconnen Physiotherapy Clinic, Canberra, Australia
| | - Mark Gillett
- Emergency Department, Royal North Shore Hospital, Sydney, Australia
| | - Rodney Ingram
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jagnoor Jagnoor
- The George Institute for Global Health, School of Population Health, University of New South Wales, New South Wales, Australia
| | - Justin Kenardy
- School of Psychology, The University of Queensland, Queensland, Brisbane, Australia
| | - Geoffrey Mitchell
- Primary Care Clinical Unit, School of Medicine, University of Queensland Brisbane, Australia
| | - Kathryn Refshauge
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Simone Scotti Requena
- RECOVER Injury Research Centre and National Health and Medical Research Council (NHMRC) Centre of Research Excellence: Better Health Outcomes for Compensable Injury, The University of Queensland, Brisbane, Queensland, Australia
- Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Victoria, Australia
| | - Sarah Robins
- RECOVER Injury Research Centre and National Health and Medical Research Council (NHMRC) Centre of Research Excellence: Better Health Outcomes for Compensable Injury, The University of Queensland, Brisbane, Queensland, Australia
| | - Michele Sterling
- RECOVER Injury Research Centre and National Health and Medical Research Council (NHMRC) Centre of Research Excellence: Better Health Outcomes for Compensable Injury, The University of Queensland, Brisbane, Queensland, Australia
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3
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Bandong AN, Rebbeck T, Mackey M, Sterling M, Kelly J, Ritchie C, Leaver A. Selective acceptance of acute whiplash guidelines: a qualitative analysis of perceptions of health professionals in Australia. Disabil Rehabil 2022:1-8. [PMID: 35654750 DOI: 10.1080/09638288.2022.2080286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE To explore health professionals' acceptance of the guidelines for acute whiplash associated disorders (WAD), and to identify barriers and facilitators to adherence. MATERIALS AND METHODS Qualitative descriptive study involving focus group discussions among health professionals who treat people with WAD in primary and secondary care settings in New South Wales and Queensland, Australia. Twenty-eight health professionals (physiotherapists = 19; chiropractors = 6; osteopaths = 3) participated in six semi-structured focus group discussions that were held in independent offices in Sydney and Brisbane, Australia between September and December 2015. Discussions were audio recorded and verbatim, de-identified transcripts produced. Thematic analysis was conducted using an inductive approach to identify commonly held beliefs. RESULTS Acceptance of guideline recommendations appeared to be influenced by factors related to the guideline itself, practitioner and practice characteristics, and patient-related factors. Specifically, acceptance was hindered by conflicting belief systems, ambiguity in guideline recommendations, and patient characteristics and expectations. CONCLUSIONS Practitioners demonstrated a positive attitude towards the use of the guidelines in general; however, in some cases, acceptance of key recommendations appeared selective. Future guideline revision and implementation might focus on explaining the underlying principles of the guidelines, providing more detailed recommendations, and involving strategies that challenge inconsistent beliefs and promote informed decision-making. IMPLICATIONS FOR REHABILITATIONSelective acceptance of guideline recommendations in favour of those not requiring practice change may present a challenge for the implementation of evidence-based practice in the management of whiplash.Participants demonstrated variable, sometimes polar attitudes to guideline key messages and recommendations.Guideline developers need to focus more strongly on changing practitioner beliefs and attitudes, as well as better explaining the underlying principles of the guidelines, and providing more detailed recommendations.
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Affiliation(s)
- Aila Nica Bandong
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,College of Allied Medical Professions, The University of the Philippines, Manila, Philippines
| | - Trudy Rebbeck
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,John Walsh Centre for Rehabilitation Research, Kolling Institute, The University of Sydney, Sydney, Australia
| | - Martin Mackey
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Michele Sterling
- Recover Injury Research Centre, The University of Queensland, Herston, Australia.,Centre of Research Excellence in Road Traffic Injury Recovery, The University of Queensland, Herston, Australia
| | - Joan Kelly
- Griffith University, Menzies Health Institute Queensland, Gold Coast, Australia
| | - Carrie Ritchie
- Recover Injury Research Centre, The University of Queensland, Herston, Australia
| | - Andrew Leaver
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Griffin AR, Sterling M, Ritchie C, Kifley A, Jagnoor J, Cameron ID, Rebbeck T. Do expectations of recovery improve risk assessment for people with whiplash-associated disorders? Secondary analysis of a prospective cohort study. BMC Musculoskelet Disord 2022; 23:395. [PMID: 35477438 PMCID: PMC9044895 DOI: 10.1186/s12891-022-05242-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/09/2022] [Indexed: 12/02/2022] Open
Abstract
Background WhipPredict, which includes prognostic factors of pain-related disability, age and hyperarousal symptoms, was developed and validated for prediction of outcome in people with whiplash associated disorders (WAD). Patient expectations of recovery was not an included factor, though is known to mediate outcomes. The aim of this study was to determine whether the addition of expectations of recovery could improve the accuracy of WhipPredict. Methods Two hundred twenty-eight participants with acute WAD completed questionnaires (WhipPredict and expectations of recovery) at baseline. Health outcomes (neck disability index (NDI) and Global Perceived Recovery (GPR)) were assessed at 6- and 12-months post injury. Cut-off points for expectations of recovery predictive of both full recovery (NDI ≤10 % , GPR ≥ 4) and poor outcome (NDI ≥30 % , GPR ≤ − 3) were determined, and multivariate logistic regression analyses were used to compare models with and without this variable. Results Expectations of recovery improved or maintained the accuracy of predictions of poor outcome (6-months: sensitivity 78 to 83%, specificity maintained at 79.5%; 12-months: sensitivity maintained at 80%, specificity 69 to 73%). The sensitivity of predictions of full recovery improved (6-months: 68 to 76%; 12-months: 57 to 81%), though specificity did not change appreciably at 6 months (80 to 81%) and declined at 12 (83 to 76%). ROC curves indicated a larger and more consistent improvement in model performance when expectations of recovery were added to the pathway predictive of full recovery. Conclusions The addition of expectations of recovery may improve the accuracy of WhipPredict, though further validation is required. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05242-8.
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Affiliation(s)
- Alexandra R Griffin
- Faculty of Medicine and Health, The University of Sydney, D18 Susan Wakil Health Building, Western Ave, Camperdown, NSW, 2050, Australia. .,John Walsh Centre for Rehabilitation Research, Faculty and Medicine and Health, The University of Sydney, St Leonards, NSW, Australia.
| | - Michele Sterling
- Recover Injury Research Centre, The University of Queensland, Herston, QLD, Australia
| | - Carrie Ritchie
- Recover Injury Research Centre, The University of Queensland, Herston, QLD, Australia
| | - Annette Kifley
- John Walsh Centre for Rehabilitation Research, Faculty and Medicine and Health, The University of Sydney, St Leonards, NSW, Australia
| | - Jagnoor Jagnoor
- John Walsh Centre for Rehabilitation Research, Faculty and Medicine and Health, The University of Sydney, St Leonards, NSW, Australia.,The George Institute for Global Health, The University of New South Wales, Kensington, NSW, Australia
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Faculty and Medicine and Health, The University of Sydney, St Leonards, NSW, Australia
| | - Trudy Rebbeck
- Faculty of Medicine and Health, The University of Sydney, D18 Susan Wakil Health Building, Western Ave, Camperdown, NSW, 2050, Australia.,John Walsh Centre for Rehabilitation Research, Faculty and Medicine and Health, The University of Sydney, St Leonards, NSW, Australia
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Existing validated clinical prediction rules for predicting response to physiotherapy interventions for musculoskeletal conditions have limited clinical value: A systematic review. J Clin Epidemiol 2021; 135:90-102. [PMID: 33577988 DOI: 10.1016/j.jclinepi.2021.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 01/18/2021] [Accepted: 02/03/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To systematically review clinical prediction rules (CPRs) that have undergone validation testing for predicting response to physiotherapy-related interventions for musculoskeletal conditions. STUDY DESIGN AND SETTING PubMed, EMBASE, CINAHL and Cochrane Library were systematically searched to September 2020. Search terms included musculoskeletal (MSK) conditions, physiotherapy interventions and clinical prediction rules. Controlled studies that validated a prescriptive CPR for physiotherapy treatment response in musculoskeletal conditions were included. Two independent reviewers assessed eligibility. Original derivation studies of each CPR were identified. Risk of bias was assessed with the PROBAST tool (derivation studies) and the Cochrane Effective Practice and Organisation of Care group criteria (validation studies). RESULTS Nine studies aimed to validate seven prescriptive CPRs for treatment response for MSK conditions including back pain, neck pain, shoulder pain and carpal tunnel syndrome. Treatments included manipulation, traction and exercise. Seven studies failed to demonstrate an association between CPR prediction and outcome. Methodological quality of derivation studies was poor and for validation studies was good overall. CONCLUSION Results do not support the use of any CPRs identified to aid physiotherapy treatment selection for common musculoskeletal conditions, due to methodological shortcomings in the derivation studies and lack of association between CPR and outcome in validation studies.
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Vaniyapong T, Phinyo P, Patumanond J, Ratanalert S, Limpastan K. Development of clinical decision rules for traumatic intracranial injuries in patients with mild traumatic brain injury in a developing country. PLoS One 2020; 15:e0239082. [PMID: 32946468 PMCID: PMC7500687 DOI: 10.1371/journal.pone.0239082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/28/2020] [Indexed: 11/20/2022] Open
Abstract
Background The majority of clinical decision rules for prediction of intracranial injury in patients with mild traumatic brain injury (TBI) were developed from high-income countries. The application of these rules in low or middle-income countries, where the primary mechanism of injury was traffic accidents, is questionable. Methods We developed two practical decision rules from a secondary analysis of a multicenter, prospective cohort of 1,164 patients with mild TBI who visited the emergency departments from 2013 to 2016. The clinical endpoints were the presence of any intracranial injury on CT scans and the requirement of neurosurgical interventions within seven days of onset. Results Thirteen predictors were included in both models, which were age ≥60 years, dangerous mechanism of injury, diffuse headache, vomiting >2 episodes, loss of consciousness, posttraumatic amnesia, posttraumatic seizure, history of anticoagulant use, presence of neurological deficits, significant wound at the scalp, signs of skull base fracture, palpable stepping at the skull, and GCS <15 at 2 hours. For the model-based score, the area under the receiver operating characteristic curve (AuROC) was 0.85 (95%CI 0.82, 0.87) for positive CT results and 0.87 (95%CI 0.83, 0.91) for requirement of neurosurgical intervention. For the clinical-based score, the AuROC for positive CT results and requirement of neurosurgical intervention was 0.82 (95%CI 0.79, 0.85) and 0.84 (95%CI 0.80, 0.88), respectively. Conclusions The models delivered good calibration and excellent discrimination both in the development and internal validation cohort. These rules can be used as assisting tools in risk stratification of patients with mild TBI to be sent for CT scans or admitted for clinical observation.
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Affiliation(s)
- Tanat Vaniyapong
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Phichayut Phinyo
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- * E-mail:
| | - Jayanton Patumanond
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Kriengsak Limpastan
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Knox GM, Snodgrass SJ, Southgate E, Rivett DA. A Delphi study to establish consensus on an educational package of musculoskeletal clinical prediction rules for physiotherapy clinical educators. Musculoskelet Sci Pract 2019; 44:102053. [PMID: 31561180 DOI: 10.1016/j.msksp.2019.102053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 08/05/2019] [Accepted: 08/26/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Clinical prediction rules (CPRs) are evidence-based tools to aid clinical decision-making, and there are many that are relevant for physiotherapists, especially in the musculoskeletal field. However, a lack of awareness and understanding by physiotherapy clinical educators could limit students' exposure to these potentially valuable tools. An educational package tailored for clinical educators could help them recognise the value of CPRs and implement them in clinical practice with students. OBJECTIVES To determine consensus on the essential content and optimal delivery of an educational package on musculoskeletal CPRs for physiotherapy clinical educators. DESIGN An online survey of physiotherapy experts who have published on CPRs, using a Delphi approach. METHOD Sixteen experts were recruited for a two-round reactive Delphi study in which they rated previously identified elements, as well as suggesting new items for an educational package. FINDINGS A pre-defined consensus of ≥70% identified that the content of an educational package should cover fundamental aspects of CPRs including why, when and how to use them clinically, and their limitations. Information on the evidence-base of different types of CPRs, with specific examples, was also identified as important. Online delivery was recommended via self-directed learning and webinars, along with electronic versions of actual CPRs. A self-assessment component was also supported. CONCLUSIONS An educational package on musculoskeletal CPRs for clinical educators was supported with key elements outlined by an international panel of experts. IMPLICATIONS Improving clinical educators' knowledge of CPRs may lead to physiotherapy students having a greater understanding and ability to use CPRs.
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Affiliation(s)
- Grahame M Knox
- The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia; Physiotherapy Department, Orange Health Service, PO Box 319, Orange, NSW, 2800, Australia.
| | - Suzanne J Snodgrass
- School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
| | - Erica Southgate
- School of Education, Faculty of Education and Arts, The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
| | - Darren A Rivett
- School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
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Bandong AN, Mackey M, Leaver A, Ingram R, Sterling M, Ritchie C, Kelly J, Rebbeck T. An Interactive Website for Whiplash Management (My Whiplash Navigator): Process Evaluation of Design and Implementation. JMIR Form Res 2019; 3:e12216. [PMID: 31452515 PMCID: PMC6732967 DOI: 10.2196/12216] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 05/02/2019] [Accepted: 05/20/2019] [Indexed: 12/24/2022] Open
Abstract
Background Whiplash is a health and economic burden worldwide. Contributing to this burden is poor guideline adherence and variable management by health care professionals (HCPs). Web-based tools that facilitate clinical pathways of care are an innovative solution to improve management. Objective The study aimed to develop, implement, and evaluate a Web-based tool to support whiplash management following a robust process. Methods This study followed the first 3 processes of a research translation framework (idea generation, feasibility, and efficacy) to inform the development, implementation, and evaluation of a website that supports HCPs in whiplash management. Development followed the idea generation and feasibility processes to inform the content, design, features, and functionality of the website. This involved stakeholder (eg, industry partners, website developers, and HCPs) consultations through face-to-face meetings, surveys, and focus group discussions. Implementation followed the feasibility process to determine the practicality of the website for clinical use and the most effective strategy to promote wider uptake. Implementation strategies included classroom education, educational meetings, educational outreach, reminders, and direct phone contact. The analysis of website use and practicality of implementation involved collection of website metrics. Evaluation followed the feasibility and efficacy processes to investigate the acceptability and extent to which the website assisted HCPs in gaining knowledge about whiplash management. Surveys were conducted among student, primary, and specialist HCPs to explore ease of access, use, and satisfaction with the website, as well as self-rated improvements in knowledge of risk assessment, management, and communication between HCPs. Website logs of specialist management decisions (eg, shared care, specialist care, and referred care) were also obtained to determine actual practice. Results The development process delivered an interactive, user-friendly, and acceptable website, My Whiplash Navigator, tailored to the needs of HCPs. A total of 260 registrations were recorded from June 2016 to March 2018, including 175 student, 65 primary, and 20 specialist HCPs. The most effective implementation strategies were classroom education for students (81% uptake, 175/215) and educational meetings for primary HCPs (43% uptake, 47/110). Popular pages visited included advice and exercises and risk assessment. Most HCPs agreed that their knowledge about risk management (79/97, 81%) and exercises (85/97, 88%) improved. The specialists’ most common management decision was shared care, an improvement from a previous cohort. Areas to improve were navigation and access to outcome measures. Conclusions A robust process resulted in an innovative, interactive, user-friendly, and acceptable website, the My Whiplash Navigator. Implementation with HCPs was best achieved through classroom education and educational meetings. Evaluation of the website showed improved knowledge and practice to be more consistent with a risk-based clinical care pathway for whiplash. The positive results provide sufficient evidence to scale implementation nationally and involve other target markets such as people with whiplash, insurers, and insurance regulators.
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Affiliation(s)
- Aila Nica Bandong
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia.,Department of Physical Therapy, College of Allied Medical Professions, The University of the Philippines, Manila, Philippines
| | - Martin Mackey
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | - Andrew Leaver
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | - Rodney Ingram
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | - Michele Sterling
- Recover Injury Research Centre, The University of Queensland, Brisbane, Australia.,Centre of Research Excellence in Road Traffic Injury Recovery, The University of Queensland, Brisbane, Australia
| | - Carrie Ritchie
- Recover Injury Research Centre, The University of Queensland, Brisbane, Australia.,Centre of Research Excellence in Road Traffic Injury Recovery, The University of Queensland, Brisbane, Australia
| | - Joan Kelly
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Trudy Rebbeck
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia.,Kolling Institute, John Walsh Centre for Rehabilitation Research, The University of Sydney, Sydney, Australia
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Cowley LE, Farewell DM, Maguire S, Kemp AM. Methodological standards for the development and evaluation of clinical prediction rules: a review of the literature. Diagn Progn Res 2019; 3:16. [PMID: 31463368 PMCID: PMC6704664 DOI: 10.1186/s41512-019-0060-y] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 05/12/2019] [Indexed: 12/20/2022] Open
Abstract
Clinical prediction rules (CPRs) that predict the absolute risk of a clinical condition or future outcome for individual patients are abundant in the medical literature; however, systematic reviews have demonstrated shortcomings in the methodological quality and reporting of prediction studies. To maximise the potential and clinical usefulness of CPRs, they must be rigorously developed and validated, and their impact on clinical practice and patient outcomes must be evaluated. This review aims to present a comprehensive overview of the stages involved in the development, validation and evaluation of CPRs, and to describe in detail the methodological standards required at each stage, illustrated with examples where appropriate. Important features of the study design, statistical analysis, modelling strategy, data collection, performance assessment, CPR presentation and reporting are discussed, in addition to other, often overlooked aspects such as the acceptability, cost-effectiveness and longer-term implementation of CPRs, and their comparison with clinical judgement. Although the development and evaluation of a robust, clinically useful CPR is anything but straightforward, adherence to the plethora of methodological standards, recommendations and frameworks at each stage will assist in the development of a rigorous CPR that has the potential to contribute usefully to clinical practice and decision-making and have a positive impact on patient care.
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Affiliation(s)
- Laura E. Cowley
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff University, Wales, CF14 4YS UK
| | - Daniel M. Farewell
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff University, Wales, CF14 4YS UK
| | - Sabine Maguire
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff University, Wales, CF14 4YS UK
| | - Alison M. Kemp
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff University, Wales, CF14 4YS UK
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10
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Best Evidence Rehabilitation for Chronic Pain Part 4: Neck Pain. J Clin Med 2019; 8:jcm8081219. [PMID: 31443149 PMCID: PMC6723111 DOI: 10.3390/jcm8081219] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 08/05/2019] [Accepted: 08/08/2019] [Indexed: 12/28/2022] Open
Abstract
Neck pain, whether from a traumatic event such as a motor vehicle crash or of a non-traumatic nature, is a leading cause of worldwide disability. This narrative review evaluated the evidence from systematic reviews, recent randomised controlled trials, clinical practice guidelines, and other relevant studies for the effects of rehabilitation approaches for chronic neck pain. Rehabilitation was defined as the aim to restore a person to health or normal life through training and therapy and as such, passive interventions applied in isolation were not considered. The results of this review found that the strongest treatment effects to date are those associated with exercise. Strengthening exercises of the neck and upper quadrant have a moderate effect on neck pain in the short-term. The evidence was of moderate quality at best, indicating that future research will likely change these conclusions. Lower quality evidence and smaller effects were found for other exercise approaches. Other treatments, including education/advice and psychological treatment, showed only very small to small effects, based on low to moderate quality evidence. The review also provided suggestions for promising future directions for clinical practice and research.
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Kelly J, Ritchie C, Sterling M. Agreement is very low between a clinical prediction rule and physiotherapist assessment for classifying the risk of poor recovery of individuals with acute whiplash injury. Musculoskelet Sci Pract 2019; 39:73-79. [PMID: 30522090 DOI: 10.1016/j.msksp.2018.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 09/06/2018] [Accepted: 11/09/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND A prognostic clinical prediction rule (whiplash CPR) has been validated for use in individuals with acute whiplash associated disorders (WAD). The clinical utility of this tool is unknown. OBJECTIVES To investigate: 1) the level of agreement between physiotherapist- and whiplash CPR-determined prognostic risk classification of people with acute WAD; 2) which clinical findings are used by physiotherapists to classify prognostic risk; and 3) whether physiotherapists plan to differ the number of treatment sessions provided based on prognostic risk classification. DESIGN Pragmatic, observational. METHOD 38 adults with acute WAD were classified as low, medium, or high risk of poor recovery by their treating physiotherapist (n = 24) at the conclusion of the initial consultation. A weighted Cohen's kappa examined the agreement between physiotherapist estimated risk classification and the whiplash CPR. Physiotherapists' reasons for classification were provided and summarised descriptively. Kruskal-Wallis and post-hoc Dunn's tests compared projected number of treatment sessions between risk subgroups. RESULTS Physiotherapist agreement with the whiplash CPR occurred in 29% of cases (n = 11/38), which was less than what is expected by chance (K = -0.03; 95%CI -0.17 to 0.12). Physiotherapists most frequently considered range of movement (n = 23/38, 61%), a premorbid pain condition (n = 14/38, 37%), response to initial physiotherapy treatment (n = 12/38, 32%), and pain intensity (n = 12/38, 32%) when classifying prognostic risk. The projected number of treatment sessions was not different between risk groups using classifications provided by the physiotherapists (χ2(2) = 2.69, p = 0.26). CONCLUSIONS Physiotherapists should consider incorporating the whiplash CPR into current assessment processes to enhance accuracy in prognostic decision-making.
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Affiliation(s)
- Joan Kelly
- Menzies Health Institute Queensland, Griffith University, G05, 3.20E Parklands Drive, Southport, 4222, Australia.
| | - Carrie Ritchie
- Recover Injury Research Centre, NHMRC Centre of Research Excellence in Recovery Following Road Traffic Injuries, The University of Queensland, Level 7 Oral Health Centre, 288 Herston Road, Herston, Queensland, 4006, Australia.
| | - Michele Sterling
- Menzies Health Institute Queensland, Griffith University, G05, 3.20E Parklands Drive, Southport, 4222, Australia; Recover Injury Research Centre, NHMRC Centre of Research Excellence in Recovery Following Road Traffic Injuries, The University of Queensland, Level 7 Oral Health Centre, 288 Herston Road, Herston, Queensland, 4006, Australia.
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Knox GM, Snodgrass SJ, Southgate E, Rivett DA. The preferences of physiotherapy clinical educators on a learning package for teaching musculoskeletal clinical prediction rules - A qualitative study. Musculoskelet Sci Pract 2019; 39:16-23. [PMID: 30463046 DOI: 10.1016/j.msksp.2018.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/25/2018] [Accepted: 10/22/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is a growing number of clinical prediction rules (CPRs) relevant to physiotherapy, particularly in the musculoskeletal area, but many students are not learning about them due to lack of awareness or understanding by clinical educators. An educational package specifically designed for physiotherapy clinical educators would aid their understanding of CPRs and ability to utilise them clinically, and also to be able to teach them to students. OBJECTIVES To determine the desired content and preferred methods of delivery of an educational package for clinical educators on musculoskeletal CPRs. DESIGN A qualitative descriptive approach using semi-structured group and individual interviews with clinical educators. METHOD Educators working in the clinical area of musculoskeletal physiotherapy who had an awareness of or interest in CPRs were recruited and interviewed on their views regarding the content and delivery of an educational package on musculoskeletal CPRs. Audio files were transcribed and analysed using framework analysis to explore and develop themes and subthemes. FINDINGS Content of an educational package should include general information on CPRs to improve familiarity and understanding, including a brief description, purpose, stages of development, application, limitations, and Information to dispel common myths and misunderstandings, as well as some specific examples of commonly-used CPRs. The package should be available in multiple formats to allow for different learning styles, both online via video, webinars, and podcasts, and face-to-face in practical sessions. CONCLUSIONS Clinical educators would find an educational package useful in assisting them to learn about musculoskeletal CPRs and to teach them to students.
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Affiliation(s)
| | - Suzanne J Snodgrass
- School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Australia.
| | - Erica Southgate
- School of Education, Faculty of Education and Arts, The University of Newcastle, Australia.
| | - Darren A Rivett
- School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Australia.
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