Evaluation of the theory-based Quality Improvement in Physical Therapy (QUIP) programme: a one-group, pre-test post-test pilot study.
ABSTRACT: BACKGROUND: Guideline adherence in physical therapy is far from optimal, which has consequences for the effectiveness and efficiency of physical therapy care. Programmes to enhance guideline adherence have, so far, been relatively ineffective. We systematically developed a theory-based Quality Improvement in Physical Therapy (QUIP) programme aimed at the individual performance level (practicing physiotherapists; PTs) and the practice organization level (practice quality manager; PQM). The aim of the study was to pilot test the multilevel QUIP programme's effectiveness and the fidelity, acceptability and feasibility of its implementation. METHODS: A one-group, pre-test, post-test pilot study (N?=?8 practices; N?=?32 PTs, 8 of whom were also PQMs) done between September and December 2009. Guideline adherence was measured using clinical vignettes that addressed 12 quality indicators reflecting the guidelines' main recommendations. Determinants of adherence were measured using quantitative methods (questionnaires). Delivery of the programme and management changes were assessed using qualitative methods (observations, group interviews, and document analyses). Changes in adherence and determinants were tested in the paired samples T-tests and expressed in effect sizes (Cohen's d). RESULTS: Overall adherence did not change (3.1%; p?=?.138). Adherence to three quality indicators improved (8%, 24%, 43%; .000 ? p ? .023). Adherence to one quality indicator decreased (-15.7%; p?=?.004). Scores on various determinants of individual performance improved and favourable changes at practice organizational level were observed. Improvements were associated with the programme's multilevel approach, collective goal setting, and the application of self-regulation; unfavourable findings with programme deficits. The one-group pre-test post-test design limits the internal validity of the study, the self-selected sample its external validity. CONCLUSIONS: The QUIP programme has the potential to change physical therapy practice but needs considerable revision to induce the ongoing quality improvement process that is required to optimize overall guideline adherence. To assess its value, the programme needs to be tested in a randomized controlled trial.
Project description:BACKGROUND:The Active Script Programme (ASP) aimed to increase the number of general practitioners (GPs) in Victoria, Australia who deliver appropriate, consistent, and effective advice on physical activity to patients. To maximise GP participation, a capacity building strategy within Divisions of General Practice (DGPs) was used. The objectives of the programme were to (a) train and support GPs in advising sedentary patients, and (b) develop tools and resources to assist GPs. OBJECTIVE:To evaluate the effectiveness of the ASP. METHODS:A systems approach was used to promote capacity in Victorian general practice. Economic analyses were incorporated into the programme's evaluation. Participants were selected DGPs and their GP members. The programme worked with DGPs to train GPs and provide relevant resources. The main outcome measures were (a) changes in GP knowledge and behaviour and (b) cost effectiveness, based on modelled estimates of numbers of patients advised and adopting physical activity and gaining the associated health benefits. RESULTS:GP awareness and provision of physical activity advice increased. Although the programme's reach was modest, based on actual GP involvement, the cost effectiveness figures (138 Australian dollars per patient to become sufficiently active to gain health benefits, and 3647 Australian dollars per disability adjusted life year saved) are persuasive. CONCLUSIONS:The ASP increased DGPs' capacity to support GPs to promote physical activity. There is a strong economic argument for governments to invest in such programmes. However, caution is warranted about the maintenance of patients' activity levels. Programme refinement to encourage GPs to use community supports more effectively will guide future development. Further research on long term patient adherence through a multisectorial approach is warranted.
Project description:BACKGROUND:Programmes have had limited success in improving guideline adherence for chronic disease. Use of theory is recommended but is often absent in programmes conducted in 'real-world' rather than research settings. MATERIALS AND METHODS:This mixed-methods study tested a retrospective theory-based approach to evaluate a 'real-world' programme in primary care to improve adherence to national guidelines for chronic obstructive pulmonary disease (COPD). Qualitative data, comprising analysis of documents generated throughout the programme (n>300), in-depth interviews with planners (clinicians, managers and improvement experts involved in devising, planning, and implementing the programme, n = 14) and providers (practice clinicians, n = 14) were used to construct programme theories, experiences of implementation and contextual factors influencing care. Quantitative analyses comprised controlled before-and-after analyses to test 'early' and evolved' programme theories with comparators grounded in each theory. 'Early' theory predicted the programme would reduce emergency hospital admissions (EHA). It was tested using national analysis of standardized borough-level EHA rates between programme and comparator boroughs. 'Evolved' theory predicted practices with higher programme participation would increase guideline adherence and reduce EHA and costs. It was tested using a difference-in-differences analysis with linked primary and secondary care data to compare changes in diagnosis, management, EHA and costs, over time and by programme participation. RESULTS:Contrary to programme planners' predictions in 'early' and 'evolved' programme theories, admissions did not change following the programme. However, consistent with 'evolved' theory, higher guideline adoption occurred in practices with greater programme participation. CONCLUSIONS:Retrospectively constructing theories based on the ideas of programme planners can enable evaluators to address some limitations encountered when evaluating programmes without a theoretical base. Prospectively articulating theory aided by existing models and mid-range implementation theories may strengthen guideline adoption efforts by prompting planners to scrutinise implementation methods. Benefits of deriving programme theory, with or without the aid of mid-range implementation theories, however, may be limited when the evidence underpinning guidelines is flawed.
Project description:BACKGROUND:Low back pain (LBP) is common and associated healthcare costs are significant. While clinical practice guidelines have been established in an attempt to reduce costs and healthcare utilization, it is unclear if adherence to physical therapy guidelines for those with LBP is efficacious. Therefore, the purpose of this study was to assess current evidence and evaluate the impact of physical therapy guideline adherence on subsequent healthcare costs and utilization for patients with LBP. METHODS:An electronic search was conducted in PubMed, CINAHL (EBSCO Host), AMED (Ovid), and PEDro. Studies included in this review were published in peer reviewed journals and the primary mode of treatment was administered by a physical therapist. Also, the definition of adherence was clearly defined based on claims data and at least one measure of cost or utilization reported. Quality assessment was evaluated via a modified Downs and Black checklist. Due to the conceptual heterogeneity in variable measurements, data were qualitatively synthesized and stratified by reported utilization and cost measures. RESULTS:A total of 256 results were identified and after omitting duplicates, 4 articles were retained, which were all retrospective in nature. Quality scores ranged between 19 and 21 points out of a possible 26 on the modified Downs and Black checklist. All identified studies used the same definition of guideline adherence, which focused on billing active codes and minimizing use of passive codes. The results demonstrated trends that, with a few exceptions, suggested those patients with LBP that were treated with an adherent guideline program demonstrated decreased healthcare utilization and an overall healthcare savings. CONCLUSION:Preliminary evidence suggests that adherence to established clinical practice guidelines may assist with decreasing healthcare utilization and costs. Additional research based on prospective randomized controlled trials are needed to provide high quality evidence regarding the impact of guideline adherence among patients with LBP.
Project description:The Dutch Healthcare Inspectorate supervises care providers in order to improve quality of care. Recently the inspectorate assessed and promoted the use of a guideline on smoking-cessation counselling in midwifery practices. The supervision programme consisted of an announcement of the enforcement deadline for the guideline and site visits. The purpose of our qualitative study was to identify factors related to guideline adherence after the supervision programme, and investigate whether the programme had helped improve adherence.We conducted semi-structured interviews with inspected and non-inspected midwives. Additionally, we studied documents and observed the inspection process. The sampled midwives all work in primary care midwifery practices providing care to pregnant smokers. The questions included the current provision of smoking-cessation counselling, support to the midwife in counselling, recent changes in provision of counselling, reasons for recent changes, knowledge about the supervision programme, and experiences with supervision by the inspectorate.Our results show that guideline adherence depends on several factors. Awareness and familiarity with the guideline are important, as is outcome expectancy. Additionally, motivation, guideline factors and environment factors were mentioned. Besides these previously documented factors, we found that professional collaboration also determined guideline adherence. Increased collaboration in counselling is associated with greater adherence to the guideline, such as provision of counselling and taking required training. The supervision programme helped improve stop-smoking counselling, by making midwives aware of the counselling and giving them an extrinsic motivation to provide counselling.Motivation and environmental aspects were the most important factors related to guideline adherence, and professional environment was added as significant factor. The improved guideline adherence is partly attributable to the supervision programme.
Project description:To assess the cost-effectiveness of a multifaceted quality improvement programme focused on reducing central line-associated bloodstream infections in intensive care units.Cost-effectiveness analysis using a decision tree model to compare programme to non-programme intensive care units.USA.Adult patients in the intensive care unit.Economic costs of the programme and of central line-associated bloodstream infections were estimated from the perspective of the hospital and presented in 2013 US dollars.Central line-associated bloodstream infections prevented, deaths averted due to central line-associated bloodstream infections prevented, and incremental cost-effectiveness ratios. Probabilistic sensitivity analysis was performed.Compared with current practice, the programme is strongly dominant and reduces bloodstream infections and deaths at no additional cost. The probabilistic sensitivity analysis showed that there was an almost 80% probability that the programme reduces bloodstream infections and the infections' economic costs to hospitals. The opportunity cost of a bloodstream infection to a hospital was the most important model parameter in these analyses.This multifaceted quality improvement programme, as it is currently implemented by hospitals on an increasingly large scale in the USA, likely reduces the economic costs of central line-associated bloodstream infections for US hospitals. Awareness among hospitals about the programme's benefits should enhance implementation. The programme's implementation has the potential to substantially reduce morbidity, mortality and economic costs associated with central line-associated bloodstream infections.
Project description:BACKGROUND: Systematic planning could improve the generally moderate effectiveness of interventions to enhance adherence to clinical practice guidelines. The aim of our study was to demonstrate how the process of Intervention Mapping was used to develop an intervention to address the lack of adherence to the national CPG for low back pain by Dutch physical therapists. METHODS: We systematically developed a program to improve adherence to the Dutch physical therapy guidelines for low back pain. Based on multi-method formative research, we formulated program and change objectives. Selected theory-based methods of change and practical applications were combined into an intervention program. Implementation and evaluation plans were developed. RESULTS: Formative research revealed influential determinants for physical therapists and practice quality managers. Self-regulation was appropriate because both the physical therapists and the practice managers needed to monitor current practice and make and implement plans for change. The program stimulated interaction between practice levels by emphasizing collective goal setting. It combined practical applications, such as knowledge transfer and discussion-and-feedback, based on theory-based methods, such as consciousness raising and active learning. The implementation plan incorporated the wider environment. The evaluation plan included an effect and process evaluation. CONCLUSIONS: Intervention Mapping is a useful framework for formative data in program planning in the field of clinical guideline implementation. However, a decision aid to select determinants of guideline adherence identified in the formative research to analyse the problem may increase the efficiency of the application of the Intervention Mapping process.
Project description:Background:Non-pharmacological interventions including physical activity programmes, occupational therapy and caregiver education programmes have been shown to lead to better outcomes for people with dementia and their care partners. Yet, there are gaps between what is recommended in guidelines and what happens in practice. The aim of this study was to bring together clinicians working in dementia care and establish a quality improvement collaborative. The aim of the quality improvement collaborative was to increase self-reported guideline adherence to three guideline recommendations. Methods:Interrupted time series. We recruited health professionals from community, hospital and aged care settings across Australia to join the collaborative. Members of the collaborative participated in a start-up meeting, completed an online learning course with clinical and quality improvement content, formed a quality improvement plan which was reviewed by a team of experts, received feedback following an audit of their current practice and were able to share experiences with their peers. The primary outcome was self-reported adherence to their guideline recommendation of interest which was measured using checklists. Data were collected monthly over a period of 18?months, and the study used an interrupted time series design and multilevel Poisson regression analysis to evaluate changes in self-reported adherence. Results:A total of 45 health professionals (78% therapists) from different sites joined the collaborative and 28 completed all requirements. Data from 1717 checklists were included in the analyses. Over the duration of the project, there was a significant increase in clinician self-reported adherence to guideline recommendations with a 42.1% immediate increase in adherence (incidence rate ratio = 1.42; 95% confidence interval = 1.08-1.87; p = 0.012). Conclusion:Health professionals working with people with dementia are interested in and willing to join a quality improvement collaborative with the goal of improving non-pharmacological aspects of care. Participation in the collaborative improved the quality of care for people with dementia as measured through self-reported adherence to guideline recommendations. Although there are challenges in implementation of guideline recommendations within dementia care, the quality improvement collaborative method was considered successful. A strength was that it equipped and empowered clinicians to lead improvement activities and allowed for heterogeneity in terms of service and setting. Trial registration:ACTRN12618000268246.
Project description:Background:Parent carers of disabled children are at increased risk of mental and physical health problems. They often experience challenges to maintaining good health which have implications for their well-being and their ability to care for their children. In response to these needs, researchers and parent carers developed the Healthy Parent Carers (HPC) programme. It is a peer-led, group-based intervention that promotes behaviours associated with health and well-being. The aims of this trial are to assess the acceptability of the HPC programme and the feasibility of its delivery in the community and to assess the feasibility and acceptability of the design of the definitive trial to evaluate the programme's effectiveness and cost-effectiveness. Methods:We will establish six research sites and train facilitators to deliver the manualised intervention. Parent carers of children with special educational needs and disabilities will be individually randomised, stratified by group delivery site, to either take part in a group programme and online resources (intervention) or to receive access to the online resources only (control). Measures of mental health; well-being; health-related quality of life; health behaviours; patient activation; protective factors such as resilience, social connections, and practical support; and use of health care, social care, and wider societal resources will be collected before randomisation (baseline), immediately post-intervention, and 6 months later. Recruitment of participants, adherence to the programme, and the dose received will be assessed. Group sessions will be audio-recorded to evaluate the fidelity of delivery and participant engagement. Participants' and facilitators' feedback on the programme content and delivery, their experience, and the acceptability of the outcome measures and trial design will be collected through feedback forms, interviews, and focus groups. Discussion:This trial will assess whether the programme delivery and evaluative trial design are feasible, to inform whether to progress to a definitive randomised controlled trial to test the effectiveness and cost-effectiveness of the Healthy Parent Carers programme. Trial registration:ISRCTN, ISRCTN151144652, registered on 25 October 2018; ClinicalTrials.gov, NCT03705221, registered on 15 October 2018.
Project description:BACKGROUND:Evidence suggests people with axial spondyloarthritis (axial SpA) should exercise up to five times per week but lack of time, symptoms, cost and distance are barriers to regular exercise in axial SpA. Personalised exercise programmes delivered via the internet might support people with axial SpA to reach these exercise targets. The aim of this study is to investigate the effect of, and adherence to, a 12 month personalised web-based physiotherapy programme for people with axial SpA. METHODS:Fifty people with axial SpA will be recruited to this prospective, interventional cohort study. Each participant will be assessed by a physiotherapist and an individualised exercise programme set up on www.webbasedphysio.com . Participants will be asked to complete their programme five times per week for 12 months. With the exception of adherence, data will be collected at baseline, 6 and 12 months. DISCUSSION:The primary outcome measure is adherence to the exercise programme over each four week cycle (20 sessions maximum per cycle) and over the 12 months. Secondary measures include function (BASFI), disease activity (BASDAI), work impairment (WPAI:SpA), quality of life (ASQoL, EQ5D), attitude to exercise (EMI-2, EAQ), spinal mobility (BASMI), physical activity and the six minute walk test. Participants will also be interviewed to explore their adherence, or otherwise, to the intervention. This study will determine the adherence and key clinical outcomes of a targeted web-based physiotherapy programme for axial SpA. This data will inform clinical practice and the development and implementation of similar programmes. TRIAL REGISTRATION:ClinicalTrials.gov: NCT02666313 , 20th January 2016.
Project description:BACKGROUND:The evidence-based guideline entitled guideline evidence-based health information emerged from the German Network for Evidence-based Medicine (DNEbM) and was published in February 2017. The guideline addresses providers of health information and its goal is to improve the quality of health information. In addition, we explored the competences of providers of health information and developed a training programme. The aim of this study is to evaluate the efficacy of a training programme addressing providers of health information to support the application of the guideline evidence-based health information. We expected the intervention to improve the quality of health information in comparison to the provision of the guideline on its own. METHODS/DESIGN:The trial uses a superiority randomised control group design with 10 months' follow-up. Twenty-six providers of health information (groups with up to ten members) will be enrolled to compare the intervention (guideline and training programme) with usual care (a publicly available guideline). The 5-day training programme comprises an evidence-based medicine training module and a module to prepare the application of the guideline. The primary outcome parameter is the quality of the health information. Quality is operationalised as the extent of adherence to the guideline's recommendations. Each provider will prepare a single health information item informing a health-related decision on a topic freely chosen before randomisation. The quality of this information will be rated using the Mapping Health Information Quality (MAPPinfo) Checklist. An accompanying process evaluation will then be conducted. DISCUSSION:The study results should show whether the efficacy of the intervention justifies implementation of the training programme to enhance health information developers' competences in evidence-based medicine and to ensure high-quality evidence-based health information (EBHI) in the long term. TRIAL REGISTRATION:ISRCTN registry, ID: ISRCTN96941060. Registered on 7 March 2019.