1. Improved Adherence to Clinical Practice Guidelines in Patients with Low Back Pain: A Two Step Multifaceted Implementation Strategy
Claude E. Maroun, PT, MPH1, Philip J. Van der Wees, PhD 2, Marie T. Aouad MD3, Rob AB. Oostendorp, PhD, 4 Maria W.G. Nijhuis-Van der Sanden, PhD 5
American University of Beirut Medical Center. Beirut, Lebanon.1,3 Radboud University Nijmegen Medical Centre, Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands. 2,4,5
Introduction
Two implementation cycles of the clinical practice guideline for low back pain (CPG-LBP) were performed at the American University of Beirut Medical Center.
Methods (Continued)
Patient files were audited to evaluate physiotherapists’ adherence to guideline recommendations based on thirteen quality indicators.
Outcome of care in the second cycle was measured by assessing patients’ health status with the Quebec Back Pain Disability Scale (QBPDS) and Numeric Rating Scale for Pain (NRS-P). Adherence was calculated using descriptive statistics. Results of the second cycle and differences between the two cycles were analyzed with Chi-square statistics and Fisher’s exact test (p value = 0.05).
Results (Continued)
respectively). Overall percentage of adherence in the treatment process improved significantly in the second cycle (42% and 64% for first and second cycle respectively). Health status of patients after treatment during the second cycle was improved significantly for the QBPDS and NRS-P. In the second cycle patients reported d 85% agreement with the therapists’ education, 72% satisfaction with the outcome of care, and 70% in overall satisfaction with their recovery.
Figure I. Comparison of the first and second implementation cycles results. Percentage of adherence of physiotherapists to the 9 Quality Indicators (QI) in the assessment process of care in patients (n=23 in 1st implementation and n=44 in 2nd implementation) with low back pain (LBP).
Abbreviations: LBP: Low back pain; QBPDS: Quebec Back Pain Disability Scale; NRS- P: Numerical rating scale for pain. QI: quality indicator (number of QIs).
Figure II. Comparison of the first and second implementation cycles results. Percentage of adherence of physiotherapists to the 3 Quality Indicators (QI) in the therapeutic process of care in patients (n= 23 in the 1st implementation and n= 44 in the 2nd implementation) with low back pain (LBP).
Discussion & Conclusions
A multi-faceted implementation strategy based on identifying barriers to change and continuous evaluation was effective in improving therapists’ adherence to CPG-LBP and patient satisfaction with care.
Recommendations
Checking the feasibility of such an implementation strategy nationally is needed.
Purpose
The objectives of this paper are to assess the effectiveness of the second implementation cycle on patient satisfaction, physiotherapists’ knowledge of and adherence to the CPG-LBP, as well as to compare the results of the two cycles.
Participants
All physiotherapists (n=9) in the Medical Cente participated.
Methods
The Focus-PDCA (Plan-Do-Check-Act) cycle was selected as a tool for multi-faceted and continuous quality improvement. Physiotherapists were educated focusing on guideline recommendations and patient education, and received monthly reminders. A competency test was conducted to test the therapists’ knowledge and ability in clinical decision-making.
Results
The competency test in the second cycle resulted in an average score of 73% in correct definitions and 60% in clinical decision–making. Adherence to guideline recommendations was derived from 44 patient files. For the diagnostic process, the overall percentages of adherence were high (90% and 93% in first and second cycle respectively). Overall percentage of adherence in the treatment process improved significantly in the second cycle (42% and 64% for first and second cycle respectively). Overall percentage of adherence in the treatment process improved significantly in the second cycle (42% and 64% for first and second cycle
References
Grol R, Wensing M, Eccles M. Improving patient care. The implementation of change in clinical practice Edinburgh, Elsevier Limited.
van der Wees P, Jamtvedt G, Rebbeck T, de Bie RA, Dekker J, Hendriks EJM. Multifaceted strategies may increase implementation of physiotherapy clinical guidelines: a systematic review. Aust J Physiother 2008;54(4): .
Contact details
Claude Maroun: