CLUSTER RANDOMIZED CONTROLLED TRIAL TO EVALUATE THE EFFECTIVENESS OF A MULTIFACETED ACTIVE STRATEGY TO IMPLEMENT LOW BACK PAIN PRACTICE GUIDELINES; EFFECT ON COMPETENCE, PROCESS OF CARE AND PATIENT OUTCOMES IN PHYSICAL THERAPY

The study was a cluster randomized controlled trial designed to evaluate the effectiveness of an active strategy to implement practice guidelines for low back pain in physical therapy. Physical therapy clinics (clinics=28, therapists=41) were randomized to receive a multifaceted active intervention (education, audit, feedback) (clinics=16, therapists=24) to increase awareness regarding key recommendations in guidelines or mailed guidelines (clinics=12, therapists=18). Primary outcome measures were change in pre to post intervention competence score (18 clinical vignettes), adherence to guidelines and change in patient Oswestry scores from first to last visit. The competence test was administered at baseline and on completion of the education course. Data on LBP patients treated by participating therapists in a 12-week pre (therapists=41, patients=50) and post (therapists=41, patients=107) intervention period (education, audit and feedback) was extracted from the UPMC electronic database. Patient care was classified as being adherent or non-adherent using 6 quality indicators developed to reflect recommendations in the guidelines. Overall percentage of adherence and adherence to individual criterion on the guidelines were also calculated. The results of the study indicated that education did not have an effect improving knowledge measured by change in total competence score. However, there were significant differences between groups on the ability to appropriately identify directional preference with movement testing, where the intervention group did better than the control. Adherence to guidelines and patient outcomes did not improve as a result of the active intervention strategy. The groups were not significantly different when comparing overall adherence to guidelines or to individual criterion on guidelines. There was an underutilization of mobilization thrust (82.3%), traction (78.5%) and graded exercises (47.6%) for fear avoidant patients, while stabilization was over-utilized in 51% of patients. Although therapists demonstrated moderate to high scores on the competence test, they failed to apply this knowledge in clinical practice. Future research should focus on a qualitative inquiry into organizational and environmental barriers to adoption of clinical practice guidelines. These include evaluating if payment policies and reimbursement from providers are aligned with guidelines and also assessing the extent to which patient demands and compliance influences adherence to guidelines