Evaluating two implementation strategies for whiplash guidelines in physiotherapy: a cluster randomised trial. Effect on the process of care of an active strategy to implement clinical guidelines on physiotherapy for low back pain: a cluster randomised controlled trial Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial. European Respiratory Society guidelines for the management of adult bronchiectasis A multi-faceted strategy to improve the use of national fertility guidelines; a cluster-randomized controlled trial. Testing the effectiveness of an innovative information package on practitioner reported behaviour and beliefs: The UK Chiropractors, Osteopaths and Musculoskeletal Physiotherapists Low back pain ManagemENT (COMPLeMENT) trial [ISRCTN77245761] Implementation of a clinical dementia guideline Management of headache disorders: design of a randomised clinical trial screening for prognostic patient characteristics Adherence to physiotherapy clinical guideline acute ankle injury and determinants of adherence: a cohort study
QUESTION Are implementation strategies involving education any more effective than mere dissemination of clinical practice guidelines in changing physiotherapy practice and reducing patient disability after acute whiplash ? DESIGN Cluster-r and omised trial . PARTICIPANTS Twenty-seven physiotherapists from different private physiotherapy clinics and the 103 patients ( 4 dropouts ) who presented to them with acute whiplash . INTERVENTION The implementation group of physiotherapists underwent education by opinion leaders about whiplash guidelines and the dissemination group had the guidelines mailed to them . OUTCOME MEASURES The primary outcome was patient disability , measured using the Functional Rating Index , collected on admission to the trial and at 1.5 , 3 , 6 and 12 months . Physiotherapist knowledge about the guidelines was measured using a custom-made question naire . Physiotherapist practice and cost of care were measured by audit of patient notes . RESULTS There were no significant differences between groups for any of the patient outcomes at any time . The implementation patients had 0.6 points ( 95 % CI -7.8 to 6.6 ) less disability than the dissemination patients at 12 months ; 44 % more physiotherapists in the implementation group reported that they prescribed two out of the five guideline -recommended treatments ; and 32 % more physiotherapists actually prescribed them . The cost of care for patients in the implementation group was $ 255 ( 95 % CI -1505 to 996 ) less than for patients in the dissemination group . CONCLUSION Although the active implementation program increased guideline -consistent practice , patient outcomes and cost of care were not affected Objectives : To evaluate the effect on the process of care of an active strategy to implement clinical guidelines on physiotherapy for low back pain . Design : A cluster r and omised controlled trial comparing an active strategy with st and ard dissemination . Setting : Primary care physiotherapy practice s. Participants : 113 physiotherapists were r and omly allocated to receive the guidelines by mail ( control group ) or to receive an additional active strategy ( intervention group ) which consisted of a multifaceted programme including education , discussion , role playing , feedback , and reminders . Main outcome measures : Adherence to the guidelines was measured by means of individual patients ’ forms recording the treatment completed by the physiotherapist . The forms were assessed using an algorithm based on the number of treatment sessions , treatment goals , interventions , and patient education . Results : Physiotherapists in the intervention group more often correctly limited the number of treatment sessions for patients with a normal course of back pain ( OR 2.39 ; 95 % CI 1.12 to 5.12 ) , more often set functional treatment goals ( OR 1.99 ; 95 % CI 1.06 to 3.72 ) , more often used mainly active interventions ( OR 2.79 ; 95 % CI 1.19 to 6.55 ) , and more often gave adequate patient education ( OR 3.59 ; 95 % CI 1.35 to 9.55 ) . They also adhered more to all four criteria ( OR 2.05 ; 95 % CI 1.15 to 3.65 ) . Conclusions : The active strategy moderately improved adherence to the guidelines . Active strategies are recommended to implement the clinical guidelines on physiotherapy for low back pain BACKGROUND The Royal College of General Practitioners ( RCGP ) has produced guidelines for the management of acute low back pain in primary care . AIM To investigate the impact on patient management of an educational strategy to promote these guidelines among general practitioners ( GPs ) . DESIGN OF STUDY Group r and omised controlled trial , using the health centre as the unit of r and omisation . SETTING Primary care teams in north-west Engl and . METHOD Twenty-four health centres were r and omly allocated to an intervention or control arm . Practice s in the intervention arm were offered outreach visits to promote national guidelines on acute low back pain , as well as access to fast-track physiotherapy and to a triage service for patients with persistent symptoms . RESULTS Twenty-four centres were r and omised . Two thous and , one hundred and eighty-seven eligible patients presented with acute low back pain during the study period : 1049 in the intervention group and 1138 in the control group . There were no significant differences between study groups in the proportion of patients who were referred for X-ray , issued with a sickness certificate , prescribed opioids or muscle relaxants , or who were referred to secondary care , but significantly more patients in the intervention group were referred to physiotherapy or the back pain unit ( difference in proportion = 12.2 % , 95 % confidence interval [ CI ] = 2.8 % to 21.6 % ) . CONCLUSION The management of patients presenting with low back pain to primary care was mostly unchanged by an outreach educational strategy to promote greater adherence to RCGP guidelines among GPs . An increase in referral to physiotherapy or educational programmes followed the provision of a triage service Bronchiectasis in adults is a chronic disorder associated with poor quality of life and frequent exacerbations in many patients . There have been no previous international guidelines . The European Respiratory Society guidelines for the management of adult bronchiectasis describe the appropriate investigation and treatment strategies determined by a systematic review of the literature . A multidisciplinary group representing respiratory medicine , microbiology , physiotherapy , thoracic surgery , primary care , methodology and patients considered the most relevant clinical questions ( for both clinicians and patients ) related to management of bronchiectasis . Nine key clinical questions were generated and a systematic review was conducted to identify published systematic review s , r and omised clinical trials and observational studies that answered these questions . We used the GRADE approach to define the quality of the evidence and the level of recommendations . The result ing guideline addresses the investigation of underlying causes of bronchiectasis , treatment of exacerbations , pathogen eradication , long term antibiotic treatment , anti-inflammatories , mucoactive drugs , bronchodilators , surgical treatment and respiratory physiotherapy . These recommendations can be used to benchmark quality of care for people with bronchiectasis across Europe and to improve outcomes . The publication of the first ERS guidelines for bronchiectasis BACKGROUND Proper use of clinical practice guidelines can decrease variation in care between setting s. However , actual use of fertility guidelines is suboptimal and in need of improvement . Hence , a cluster-r and omized controlled trial was design ed to study the effects of two strategies to implement national Dutch guidelines on comprehensive fertility care . METHODS Sixteen fertility clinics participated in the trial . A minimal , professional-oriented implementation strategy of audit and feedback was tested versus a maximal multi-faceted strategy that was both professional and patient oriented . The extent of adherence to guideline recommendations , reflected in quality indicator scores , was the primary outcome measure . To gain an insight into unwanted side effects , patient anxiety and depression scores were gathered as secondary outcomes . Data collection encompassed medical record search , patient and professional question naires . RESULTS A total of 1499 couples were included at baseline and 1396 at the after-measurement . No overall significant improvement in indicator scores was found for either strategy [ odds ratios ranging from 0.23 ( 95 % confidence interval ( CI ) : 0.06 - 0.95 ) to 6.66 ( 95 % CI : 0.33 - 132.8 ] . Secondary outcomes did not differ significantly for both groups , although selected anxiety scores appeared lower in the maximal intervention group . Process evaluation of the trial revealed positive patient experiences with the intervention material [ e.g. an increased underst and ing of their doctor 's treatment policy ( 61 % ) , an increased ability to ask questions about the treatment ( 61 % ) ] . Professionals ' appreciation of intervention elements varied , and execution of the multi-faceted strategy appeared incomplete . DISCUSSION Absence of an intervention effect may be due to the nature of the strategies , incomplete execution or flaws in study design . Process evaluation data raise the question of whether professionals should be the only stakeholder responsible for guideline implementation . This study therefore contributes to an increased underst and ing of fertility guideline implementation in general , and the role of patients in particular Background Low back pain ( LBP ) is a common and costly problem . Initiatives design ed to assist practitioner and patient decisions about appropriate healthcare for LBP include printed evidence -based clinical guidelines . The three professional groups of chiropractic , osteopathy and musculoskeletal physiotherapy in the UK share common ground with their approaches to managing LBP and are amongst those targeted by LBP guidelines . Even so , many seem unaware that such guidelines exist . Furthermore , the behaviour of at least some of these practitioners differs from that recommended in these guidelines .Few r and omised controlled trials evaluating printed information as an intervention to change practitioner behaviour have utilised a no-intervention control . All these trials have used a cluster design and most have method ological flaws . None specifically focus upon practitioner behaviour towards LBP patients . Studies that have investigated other strategies to change practitioner behaviour with LBP patients have produced conflicting results . Although numerous LBP guidelines have been developed worldwide , there is a paucity of data on whether their dissemination actually changes practitioner behaviour . Primarily because of its low unit cost , sending printed information to large numbers of practitioners is an attractive dissemination and implementation strategy . The effect size of such a strategy , at an individual practitioner level , is likely to be small . However , if large numbers of practitioners are targeted , this strategy might achieve meaningful changes at a population level . Methods The primary aim of this prospect i ve , pragmatic r and omised controlled trial is to test the short-term effectiveness ( six-months following intervention ) of a directly-posted information package on the reported clinical behaviour ( primary outcome ) , attitudes and beliefs of UK chiropractors , osteopaths and musculoskeletal physiotherapists . We sought to r and omly allocate a combined sample of 1,800 consenting practitioners to receive either the information package ( intervention arm ) or no information above that gained during normal practice ( control arm ) . We collected question naire data at baseline and six-months post-intervention . The analysis of the primary outcome will assess between-arm differences of proportions of responses to questions on recommendations about activity , work and bed-rest , that fall within categories previously defined by an expert consensus exercise as either ' guideline -consistent ' and ' guideline -inconsistent ' Implementation of clinical practice guidelines has been proposed to improve quality in health care . Multifaceted implementation did not increase guideline acceptance . GPs ' self-reports may overestimate performance . Objective - To assess the impact of a multifaceted implementation strategy aim ing to improve GP adherence to a clinical guideline on dementia . Design - Controlled before and after study using data records from regional laboratories . The guideline was mailed to all GPs . The multifaceted implementation strategy was planned with local GPs , and consisted of seminars , outreach visits , reminders and continuing medical education ( CME ) small group training . Setting - Primary health care . Subjects - 535 GP practice s with 727 physicians in Denmark . Main outcome measures - The diffusion and use of the guideline was measured by a mailed survey . Adherence to guideline recommendations was monitored by data on laboratory tests from general practice in patient 's S 65 years : thyroid stimulating hormone requested with vitamin B 12 or methylmalonate . The use of these tests as part of a diagnostic evaluation of dementia was subsequently verified by a question naire to the practice s. Results - Of the GPs who read the guideline , 88 % found it applicable in primary care . No increase in the adherence to guideline recommendations was observed regarding the use of laboratory tests or cognitive tests in the diagnostic evaluation of dementia in general practice . Conclusion - Although GPs regarded the guideline applicable in primary care , no change in practice adherence to guideline recommendations was detected after a multifaceted implementation Background Treatment of headache disorders is not always optimal . Patients are treated in multiple ways , and the lack of scientific arguments for referral and the insufficient implementation of guidelines result in unclear treatment strategies . The coexistence of headache and neck pain can lead to the referral to a musculoskeletal physiotherapist . This treatment can only be successful if an underlying cervical segmental dysfunction is present . In such cases a physical treatment can be a valuable option that should be considered . The aim of this study is to identify prognostic therapeutic patient characteristics and to increase the number of correct physiotherapy referrals . Methods / design This trial is design ed to identify patient characteristics which can influence the prognosis of the patient . Patients with recurrent headache and co-existent neck pain are recruited via a multicenter setup . After screening for eligibility , subjects are tested at baseline and r and omly allocated to one of two treatment groups . Testing includes the administering of question naires ( a  Headache Diagnosis Question naire ,  Headache Inventory List  and the Headache Impact Test ( HIT-6 ) ) and physical tests ( Thermal Stimuli , Manual Cervical Spine Examination and Pressure Algometry ) . Treatment groups are a usual care group ( UC ) administered by the General Practitioner ( GP ) and a usual care plus musculoskeletal physiotherapy treatment group ( UCMT ) . UC is based on the Dutch GP Guideline for Headache . UCMT consists of the UC plus a combination of exercises and spinal cervical mobilisations . Follow-up measurements consist of the completion of the Headache Inventory List , the HIT-6 and scoring of the global perceived effect ( GPE ) . The latter allowing the distinction between responders ( positive effect ) and non-responders ( no effect or worse ) . Logistic regression analysis will be used to identify the specific patient characteristics of the responders and the non-responders . The additional value of the musculoskeletal physiotherapy will be examined . Follow-up measurements up to 52 weeks are scheduled . Discussion This trial aims to identify prognostic patient characteristics , in order to supply a useful diagnostic tool for all health care workers , dealing with headache sufferers Background Clinical guidelines are considered important instruments to improve quality in health care . In physiotherapy , insight in adherence to guidelines is limited . Knowledge of adherence is important to identify barriers and to enhance implementation . Purpose of this study is to investigate the ability to adherence to recommendations of the guideline Acute ankle injury , and to identify patient characteristics that determine adherence to the guideline . Methods Twenty-two physiotherapists collected data of 174 patients in a prospect i ve cohort study , in which the course of treatment was systematic ally registered . Indicators were used to investigate adherence to recommendations . Patient characteristics were used to identify prognostic factors that may determine adherence to the guideline . Correlation between patient characteristics and adherence to outcome -indicators ( treatment sessions , functioning of patient , accomplished goals ) was calculated using univariate logistic regression . To calculate explained variance of combined patient characteristics , multivariate analysis was performed . Results Adherence to individual recommendations varied from 71 % to 100 % . In 99 patients ( 57 % ) the physiotherapists showed adherence to all indicators . Adherence to preset maximum of six treatment sessions for patients with severe ankle injury was 81 % ( 132 patients ) .The odds to receive more than six sessions were statistically significant for three patient characteristics : females ( OR:3.89 ; 95%CI : 1.41–10.72 ) , recurrent sprain ( OR : 6.90 ; 95%CI : 2.34 – 20.37 ) , co-morbidity ( OR : 25.92 ; 95 % CI : 6.79 – 98.93 ) . All factors together explained 40 % of the variance . Inclusion of physiotherapist characteristics in the regression model showed that work-experience reduced the odds to receive more than six sessions ( OR : 0.2 ; 95%CI : 0.06 – 0.77 ) , and increased explained variance to 45 % . Conclusion Adherence to the clinical guideline Acute ankle sprain showed that the guideline is applicable in daily practice . Adherence to the guideline , even in a group of physiotherapists familiar with the guideline , showed possibilities for improvement . The necessity to exceed the expected number of treatment sessions may be explained by co-morbidity and recurrent sprains . It is not clear why female patients were treated with more sessions . Experience of the physiotherapist reduced the number of treatment sessions . Quality indicators may be used for audit and feedback as part of the implementation strategy
There was no evidence that patient health was improved or that the cost of care was reduced .
This review shows that multifaceted interventions based on educational meetings to increase implementation of clinical guidelines may improve some outcomes of professional practice but do not improve patient health or reduce cost of care .
These findings are comparable with results among other health professions
QUESTION What is the effectiveness of strategies to increase the implementation of physiotherapy clinical guidelines ?