IDENTIFYING FACTORS ASSOCIATED WITH PHYSICAL THERAPISTS’ ADHERENCE TO LOW BACK PAIN GUIDELINES ACROSS THE DOMAINS OF THE CONSOLIDATED FRAMEWORK FOR IMPLEMENTATION RESEARCH: A MIXED METHODS STUDY

In 2007 a regional physical therapy (PT) organization implemented low back pain (LBP) guidelines throughout its 50 outpatient clinical sites. Despite multiple improvement efforts since that time guideline adherence is suboptimal (38%). In this study the Consolidated Framework for Implementation Research (CFIR) guided an evaluation to identify determinants of adherence. A sequential, mixed methods design was used to identify determinants of adherence to LBP guidelines. We surveyed PTs using instruments pertinent to LBP management and implementation success to explore factors associated with guideline adherence across three CFIR domains: Individual, Innovation, and Inner Setting. Instruments included the Pain Attitudes and Beliefs Scale, Intolerance of Uncertainty Scale, Ottawa Acceptability of Decision Rules Instrument, and Alberta Context Tool. Survey responses, provider demographics and professional characteristics were merged with risk-adjusted measures of guideline adherence using data from the organization’s database. Generalized linear models (GLM) were first used to assess univariate associations, then main effects and 2x2 interactions were evaluated using GLM with forced, backward stepwise elimination. The sample was stratified by quartile using the risk-adjusted adherence measure. Purposive maximum variation sampling identified 15 high and 15 low performing providers for semi-structured telephonic interviews. One hundred and twelve survey completers (74%) had a risk-adjusted guideline adherence measure and were included in the study. There was no association between PT’s acceptability of individual guideline recommendations and adherence. There were significant interactions between Professional Certification (PC) and Uncertainty Paralysis (β=-0.06, p>0.05), PC and Time to Deliver Quality Care (β=0.26, p=0.03), and PC and Connections with Colleagues (β=0.36, p=0.01). Qualitative interviews identified barriers to adherence resulting from the complexity of the guidelines and limited skills required to carry out some of the recommendations. The interviews also revealed that perceived support for the initiative was stronger from senior management compared to front line supervisors. This study addresses three gaps in the dissemination and implementation literature: 1) it describes one method to identify determinants for tailoring interventions; 2) it quantifies interaction effects within and between CFIR domains; and 3) it assesses determinants of sustainability in a mature implementation initiative