Table 3
Studies that tested ongoing, intermittently re-enforced implementation interventions
| Study | Intervention and control | Outcome measures | Results | Overall intervention success | ||
|---|---|---|---|---|---|---|
| Becker et al., 2008 [44] | GPE: 3 MFE sessions with feedback for GPs MC: 3 MFE sessions with feedback for GPs and motivational counselling training for practice nurses CG: Postal dissemination of guidelines only | Primary outcome measure: | Primary outcome measure at 6 months: | Primary outcome measure at 12 months: | Partially successful. There was a statistically significant difference between the MC and CG at 6 months on the HFAQ but not at 12 months Days in pain at 6 months in the MC and GPE were also statistically less than the CG, with the GPE maintaining that difference at 12 months Quality of life score was statistically significantly higher in the MC than the CG at 12 months | |
| Mean score on the HFAQ | 72.94 GPE v 73.94 MC v 70.29 CG GPE v CG: CI: −0.704 to 6.007; ρ = 0.12 MC v CG: CI: 0.32 to 6.979; ρ = 0.032* | 72.96 GPE v 74.64 MC v 71.56 CG GPE v CG: CI: −2.224 to 5.017; ρ = 0.446 MC v CG: CI: −0.47 to 6.697; ρ = 0.088 | ||||
| Secondary outcome measures: | Secondary outcome measures at 6 months: | Secondary outcome measures at 12 months: | ||||
| 1. Mean score on the FQPA | 1. 36.47 GPE v 36.29 v 33.51 CG GPE v CG: CI: −1.628 to 7.545; ρ = 0.203 MC v CG: CI: −1.784 to 7.347; ρ = 0.23 | 1. 46.43 GPE v 45.40 MC v 42.88 CG GPE v CG: CI: −1.452 to 8.543; ρ = 0.202 MC v CG: CI: −2.476 to 7.495; ρ = 0.396 | ||||
| 2. Mean days in pain over the last 6 months. | 2. 63.34 GPE v 62.91 MC v 80.78 CG GPE v CG: CI: −26.833 to −6.034; ρ = 0.002* MC v CG: CI: −28.183 to −7.553; ρ = 0.001* | 2. 58.48 GPE v 61.57 MC v 71.32 CG GPE v CG: CI: −23.382 to −2.296; ρ = 0.018* MC v CG: CI: −20.198 to −0.689; ρ = 0.067 | ||||
| 3. Mean days of sick leave in the previous 6 months | 3.12.99 GPE v 13.05 MC v 14.34 CG GPE v CG: CI: −5.972 to 3.287; ρ = 0.569 MC v CG: CI: −5.905 to 3.331; ρ = 0.584 | 3. 6.16 GPE v 6.46 MC v 9.27 CG GPE v CG: CI: −8.582 to 2.358; ρ = 0.256 MC v CG: CI: −8.463 to 2.837; ρ = 0.32 | ||||
| 4. Quality of life score (Euro Qol) | 4. 66.59 GPE v 67.53 MC v 66.85 CG GPE v CG: CI: −2.864 to 2.355; ρ = 0.847 MC v CG: CI: −1.924 to 3.302; ρ = 0.602 | 4. 68.46 GPE v 70.37 MC v 67.65 CG GPE v CG: CI: −1.736 to 3.344; ρ = 0.535 MC v CG: CI: 0.185 to 5.26; ρ = 0.036* | ||||
| 5. FABQ | 5. Not expressed as a result | 5. Not expressed as a result | ||||
| Bishop & Wing, 2006 [28] | IG1: Copy of the guidelines appropriate to management at that time frame sent at assessment; 0–4 weeks; 5–12 weeks and 12 weeks+ IG2: As the IG1 but with patient educational materials at the same stages. CG: No guidelines sent | Primary outcome measure not specified Outcome measures: | Results in percentage of patients: | Largely unsuccessful. The only statistically significant differences between groups were: recommending aerobic exercise in the IG2 v CG and bed rest=/<4 days recommended in the IG1 v CG. | ||
| At assessment: | At assessment: | |||||
| History of initiating event | History of initiating event recorded: 87 % IG1 v 85 % IG2 v 89 % CG ρ values not stated | |||||
| Prior history of a similar symptoms | Prior history of similar symptoms recorded: 30 % IG1 v 27 % IG2 v 24 % CG ρ values not stated | |||||
| Neurological examination | Neurological examination recorded: 63 % IG1 v 71 % IG2 v 63 % CG ρ values not stated | |||||
| Regional back examination | Regional back examination performed recorded: 93 % IG1 v 93 % IG2 v 91 % CG ρ values not stated | |||||
| Reference to presence or absence of red flags | Reference to presence or absence of red flags recorded: 4 % IG1 v 4 % IG2 v 5 % GC ρ values not stated | |||||
| 0-4 weeks: | 0-4 weeks: | |||||
| Exercise and reassurance given | Education and reassurance recorded as given: 10 % IG1 v 6 % IG2 v 7 % CG ρ values not stated | |||||
| Aerobic exercise promoted | Aerobic exercise recommended recorded: 38 % IG1 v 53 % IG2 v 43 % CG IG2 v CG; ρ = 0.05* | |||||
| Non-narcotic medication prescription | Appropriate medication prescribed: 85 % IG1 v 81 % IG2 v 77 % CG IG1 v CG ρ = 0.14; IG2 v CG ρ = 0.08* | |||||
| Physical therapy modalities usage | Not reported ρ values not stated | |||||
| Spinal mobilisation usage | Spinal manipulation usage: 2.5 % IG1 v 5 % IG2 v 6 % CG ρ values not stated | |||||
| Bed rest of 4 days or less recommended | Best rest greater than 4 days recommended: 10 % IG1 v 18 % IG2 v17 % GC IG1 v CG ρ = 0.05*; IG2 v CG ρ value not stated | |||||
| 5-12 weeks: | 5-12 weeks: | |||||
| Work conditioning programmes utilised | Not reported ρ values not stated | |||||
| 5-12 weeks discordant: | 5-12 weeks discordant: | |||||
| Physical therapy modalities usage. | Continued use of PT: 41 % IG1 v 42 % IG2 v 43 % CG ρ values not stated Continued use of spinal manipulation: 3 % IG1 v 3 % IG2 v 3 % CG ρ values not stated | |||||
| 12 weeks + concordant: | 12 weeks + concordant: | |||||
| Return to full or modified work. | Not reported ρ values not stated | |||||
| 12 weeks + discordant: | 12 weeks + discordant: | |||||
| Continued passive therapy or spinal manipulation; recycling through treatments; use of programmes that had previously failed. | Not reported ρ values not stated | |||||
| Goldberg et al., 2001 [31] | IG: Surgeon study group meetings; use of local opinion leaders; GP education sessions; printed educational materials; audit; patient educational materials; financial data analysis meetings. CG: Usual care. | Primary outcome measure: Lumbar spine surgery rate per 100,000 adults. | Net reduction in the IG of 20.9 surgeries per 100,000 adults or 8.9 % v CG; ρ = 0.01* | Successful. The difference between the IG and the CG was statistically significant | ||
| Kerry et al., 2000 [22] | IG: Guidelines and a covering letter posted at baseline; revised guidelines at 9 months with feedback on referral rates over previous 6 months CG: No guidelines sent | Primary outcome measure: Radiograph request rates. | 15 % reduction in the IG compared to 5 % increase in the CG. CI: 3 to 37; ρ ≤ 0.05* but actual value not stated | Successful. The difference between the IG and the CG was statistically significant | ||
| Schectman et al., 2003 [23] | E&F: 90-min education session, a copy of the guideline, audit report of patient care during prior year. Follow up at 6 months with a further audit report E&F&PE: As above but with addition of patient educational materials (printed and audio-visual) PE: Patient educational materials only CG: No intervention | Primary outcome measure not specified. Outcome measures: | Unsuccessful. There were no statistically significant differences between groups. | |||
| 1. Lumbar spine radiograph request rates | 1. 19 % E&F v 18 % CG ρ values not stated | |||||
| 2. CT/MRI request rates | 2. 5.6 E&F v 7.1 CG ρ values not stated | |||||
| 3. Sub-speciality referral rates | 3. 8.6 E&F to 7.1 CG ρ values not stated | |||||
| 4. PT referral rates | 4.10 E&F to 13 in CG No data reported for PE or E&F&PE ρ values not stated | |||||
| Winkens et al., 1995 [47] | IG: Regular feedback (x 5 over 2 yrs 7 months) on audit of quantity and quality of diagnostic test referrals CG: No feedback. | Primary outcome measures: | Partially successful. No statistically significant differences between groups in lumbar spine request rate. There was a statistically significant difference between non-rational requests for lumbar spine radiographs pre and post intervention. ρ = 0.004* | |||
| 1. Radiograph request rate | 1. Not specified but IG before intervention 1128, 1212 at 1 year and 1127 at 2 years. ρ values not stated | |||||
| 2. Rate of non-rational requests. | 2. % total per Dr: Pre-intervention: 1.92 and 1.38 IG v 1.38 and 1.54 CG 1st data collection point: 0.96 IG v 1.39 CG 2nd DCP: 1.44 IG v 1.22 CG 3rd DCP: IG 0.91 v 1.65 CG 4th DCP: 1.04 IG v 1.24 CG 5th DCP: 1.21 IG v 1.67 CG | |||||