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Implementation of clinical practice guidelines for low back pain: A case control cohort study of knowledge translation in a multi-site healthcare organization.

RATIONALE
The benefits of clinical practice guideline (CPG) adoption for the management of patients with back pain are well documented. However, the gap between knowledge creation and implementation remains wide with few studies documenting the iterative process of comprehensive implementation in clinical settings. The objective of this study was to improve adherent physical therapy care according to CPG's for low back pain and describe the knowledge to action (K2A) process used in a rural healthcare organization.


METHODS
A prospective case control cohort design was used to evaluate physical therapy provider practice changes during an 18 month intervention. Four clinical sites were selected, two of which received multifaceted educational and process interventions tailored to feedback from ongoing K2A cycle outcomes. Overall program assessment included monthly charge code reports for adherence and a pre-post survey of confidence for guideline use. Pragmatic Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) criteria were used to complete the process evaluation.


RESULTS
A significant difference (p < 0.001, mean difference 13.5, CI [8.5,18.5]) for charge code adherence favoured education site-1 over control site-2 after implementation. Adherence scores remained above target at both education sites 18 months after implementation. Survey differences were significant for confidence scores at education sites in use of the cognitive behavioural category, overall treatment category use and guideline communication. Process evaluation supported multifaceted interventions tailored to education sites with average cost measured by staff education time of 15.5 h per therapist trained.


CONCLUSION
This study extends the literature of guideline implementation by describing the unique cycles required for promoting provider behaviour change within a rural healthcare system. Adherence and confidence results suggest increased provider CPG use which was supported by the process evaluation. This study demonstrates the importance of multiple site comparisons, long-term reporting and standardized frameworks for assessment of real-world CPG implementation.