A Policy-into-Practice Intervention to Increase the Uptake of Evidence-Based Management of Low Back Pain in Primary Care: A Prospective Cohort Study

Abstract

BackgroundPersistent non-specific low back pain (nsLBP) is poorly understood by the general community, by educators, researchers and health professionals, making effective care problematic. This study evaluated the effectiveness of a policy-into-practice intervention developed for primary care physicians (PCPs).MethodsTo encourage PCPs to adopt practical evidence-based approaches and facilitate time-efficient, integrated management of patients with nsLBP, we developed an interdisciplinary evidence-based, practical pain education program (gPEP) based on a contemporary biopsychosocial framework. One hundred and twenty six PCPs from primary care settings in Western Australia were recruited. PCPs participated in a 6.5-hour gPEP. Self-report measures recorded at baseline and at 2 months post-intervention included PCPs' attitudes, beliefs (modified Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS), evidence-based clinical practices (knowledge and skills regarding nsLBP management: 5-point Likert scale with 1 = nil and 5 = excellent) and practice behaviours (recommendations based on a patient vignette; 5-point Likert scale).ResultsNinety one PCPs participated (attendance rate of 72%; post-intervention response rate 88%). PCP-responders adopted more positive, guideline-consistent beliefs, evidenced by clinically significant HC-PAIRS score differences (mean change = −5.6±8.2, p<0.0001; 95% confidence interval: −7.6 to −3.6) and significant positive shifts on all measures of clinical knowledge and skills (p<0.0001 for all questions). Self management strategies were recommended more frequently post-intervention. The majority of responders who were guideline-inconsistent for work and bed rest recommendations (82% and 62% respectively) at pre-intervention, gave guideline-consistent responses at post-intervention.ConclusionAn interprofessional pain education program set within a framework that aligns health policy and practice, encourages PCPs to adopt more self-reported evidence-based attitudes, beliefs and clinical behaviours in their management of patients with nsLBP. However, further research is required to determine cost effectiveness of this approach when compared with other modes of educational delivery and to examine PCP behaviours in actual clinical practice.

Are They Complying? Physicians’ Knowledge, Attitudes, and Readiness to Change Regarding Low Back Pain Treatment Guideline Adherence

“…Other studies have found an association between the GPs and PCPs orientation or beliefs with his/her recommendations and consistency with guidelines, similar to our GK measurement. 10,14,17,29,[30][31] Additional studies also found a connection between RTI and CA&B, 2, 5, 32 an association that was not evident in our results.It is possible that RTI and CA&B are associated in Europe and the U.S. due to the differences in family medicine education among Israel, Europe and the U.S. 33 In order to complete a residency in Family Medicine (FM) in Israel, the student must first complete the sixyear MDprogram, pass a national exam, fulfill a one year rotating internship and finishthe FM residency program. This includes 15 months in primary care teaching clinics, 10 months in the internal medicine department, 5 months in pediatrics, two in Emergency Medicine and four months spent in two month rotations chosen from other specialties including oncology, gastroenterology, etc...…”

“…This has been done successfully in specific populations with training sessions, courses, printed educational material, and media campaigns. 4,9,[15][16][17][18] Another practitioner related factor which may pose a challenge to LBP guideline implementation may be the PCPs' readiness-to-change their practice behavior. If PCPs are familiar with the recommended LBP guidelines, but lack a willingness to change their management of LBP patients, then dissemination of guidelines will be ineffective.…”

Models of care for musculoskeletal health in Australia: now more than ever to drive evidence into health policy and practice

“…Further, although the wait to access pain medicine services in Australia has been protracted for consumers, 17 timely access has been dramatically improved in WA owing to the introduction of a system-oriented MoC for pain services, 18 introduced in parallel with initiatives to build workforce and consumer capacity to better manage musculoskeletal pain syndromes. [19][20][21][22][23] A recent audit in WA identified positive uptake of all disease-group MoCs across the WA Health Services, particularly with respect to awareness and service planning, yet responders identified that sustainable implementation efforts were stymied by lack of resources to sustainably support implementation efforts. 24 In this regard, long-term sustainability and impact of MoCs will be dependent on their uptake and support by middle and senior health managers and policy makers and research providing evidence of their benefit for improving health outcomes and system efficiencies.…”

Management of LBP at primary care level in South Africa: up to standards?

“…Scott et al (2010) conducted a systematic review on 14 studies published in Europe, Canada and the USA with the aim to identify the so called 'know-do' gap in primary care setting [23]. The know-do gap refers to the discrepancy between management advised by the guideline and management executed in clinical practice [23,24]. Evidence of the existence of this know-do gap among physicians and physiotherapists could be seen in the choice of treatments strategies.…”

“…A more thorough screening for yellow flags should be done at first consultation, after which the LBP patient, according to the phase of recovery he is in, can be appropriately referred. CHC staff should receive training to improve their knowledge of LBP and risk factors for chronicity [24]. Within the current shift taking place in South African CHCs towards a patient-centered perspective, attention should be given to improving patients' health literacy.…”