Guideline Implementation in Physiotherapy
Guideline Implementation in Physiotherapy
The purpose of this study is 1) to develop an intervention strategy to increase
 physiotherapists' adherence to evidence-based practice guidelines, 2) to try out this
 intervention on a small scale to determine what efficacy may be expected from it, and 3) to
 determine the value of a planned, systematic and theory-based approach that was followed in
 developing and implementing the intervention.
Summary

 The main objective is the planned, systematic, and theory-based development and pilot testing
 of an intervention strategy to increase physiotherapists' adherence to evidence-based
 practice guidelines for low back pain. Although it has been demonstrated that the
 recommendations of these guidelines are effective, its implementation in physiotherapy
 practice remains limited. This incomplete implementation results in a considerable
 inefficiency in physiotherapy practice (e.g. the regular use of less effective treatment
 strategies) and consequently contributes to the extensive socio-economic problems associated
 with low back pain (1.7% of the BNP). Until now, however, implementation strategies to
 increase guideline adherence have not been very effective. The lack of a coherent theoretical
 framework has been pointed out as a possibly important explanatory factor. Recent reports
 therefore emphasize an expansion of the theoretical basis with regards implementation
 problems.

 The present project (January 2007) will build on the promising results of a cross-sectional
 study among Dutch physiotherapists, which applied the Precede-Proceed planning model to
 assess determinants of guideline adherence. To that end, a theoretical framework was
 constructed that combined the Diffusion of Innovations Theory, the Precaution Adoption
 Process Model, and elements of Organization Development. The questionnaire based on this
 framework turned out to be a very useful tool for systematically studying barriers and
 facilitators associated with guideline adherence. However, a similar, but longitudinal study
 is needed to assess determinants that actually predict guideline adherence. For this
 longitudinal study, the framework needs to be slightly revised (5 months). The adapted
 theoretical framework in turn, will guide the subsequent revision of the determinant
 questionnaire (3 months).

 The longitudinal determinant study (10 months) among primary care physiotherapists (N =
 1,600) will be performed via mail. Determinants of guideline adherence will be assessed with
 the revised questionnaire. Actual guideline adherence will be determined with recently
 developed longitudinal paper&pencil vignettes that cover the eleven most important indicators
 of adherence. Statistical analyses of these combined data will disclose which individual,
 social and / or organizational determinants in fact predict guideline adherence.

 The results of the longitudinal study will be used to systematically develop an
 implementation enhancing strategy (8 months), specifically aimed at modifying the
 determinants predicting adherence. The development will be based on the Intervention Mapping
 approach. This approach will, for instance, assists in choosing objectives and strategies of
 change, and in combining these into a coherent program plan. To assess the efficacy of this
 combination of implementation strategies, a pilot test (4 months) will be performed among
 primary care physiotherapists (N = 30) within a network of physiotherapy practices (N = 10).
 The short-term effects on determinants predicting guideline adherence and on actual guideline
 implementation will be assessed in a similar way as during the preceding longitudinal study.
 Additional process information will be collected to refine the implementation enhancing
 strategy and to explore opportunities for further implementation of this strategy in primary
 care. A secondary objective of the present study is to further examine the value of the
 planned, systematic, and theory-based approach for the implementation of practice guidelines
 in general. Depending on the findings of the present study, we expect to be able to formulate
 implications for the use of a coherent theoretical framework in the current practice of
 guideline implementation and in the development of strategies to increase guideline adherence
 among a wider variety of health care professions, as well as the use of planning models and
 systematic intervention development models in future implementation efforts and guideline
 adherence studies.

 This study will be the first in the field of guideline implementation that applies (1) a
 comprehensive theoretical framework for guideline adherence, (2) the Precede-Proceed planning
 model for the assessment of determinants predicting guideline adherence, and (3) the
 systematic approach of Intervention Mapping for the development of an implementation
 strategy. The results will be reported in peer-reviewed articles and included in a
 dissertation (December 2009).
Inclusion Criteria:

 Arm 1 Quality improvement program

 -  Physiotherapy practices that have started or finalized a quality registration
 procedure (HNK)

 Arm 2 Electronic patient device

 -  Physiotherapists that are acquainted with the use of EPDs in their practice

 Exclusion Criteria:

 -  Physiotherapists enrolled in other quality improvement programs