P.J. van der Wees

Development and Implementation of National Practice Guidelines: A Prospect for Continuous Quality Improvement in Physiotherapy

Summary The development of national practice guidelines (NPGs) is an issue of much concern in healthcare policies world-wide to guarantee and to improve the quality and efficiency of care. The development and implementation of NPGs constitutes an important part of the quality of care policy of the Royal Dutch Physiotherapy Association (KNGF). This interest is due to pressure from society (policy-makers, healthcare managers, financiers and patients) on physiotherapists to ensure quality of care and to justify our position in the healthcare system. The development of NPGs can also be seen as a logical step in the process of professionalisation and quality assurance by physiotherapists. An NPG is described as a systematically developed statement, drafted by experts and directed at one aspect of the treatment of a health problem belonging to the domain of the profession. NPGs are based on the different stages of the physiotherapy care process, the available clinical evidence and expert consensus. Priority is given to a cost-effective approach and multidisciplinary consensus on diagnosis, treatment and primary or secondary prevention. Recommendations are based on the results of new or recorded systematic reviews or meta-analysis. NPGs are important state-of-the-art documents, which can guide professionals in their daily practice and make explicit to other relevant people what professionals can do in a certain situation or with a specific condition, and why they do it. NPGs have important functions, including supporting physiotherapists in their decision-making process; they are a frame of reference for orientation and educational purposes, they provide criteria for self-evaluation and peer review, and can initiate changes in established practice patterns. This paper describes the process and development of NPGs for physiotherapists in the Netherlands. In a companion paper the method and strategies for the implementation of NPGs and the need for evaluation of their outcome will be discussed.

Effectiveness of Peer Assessment for Implementing a Dutch Physical Therapy Low Back Pain Guideline: Cluster Randomized Controlled Trial

Background Clinical practice guidelines are considered important instruments to improve quality of care. However, success is dependent on adherence, which may be improved using peer assessment, a strategy in which professionals assess performance of their peers in a simulated setting. Objective The aim of this study was to determine whether peer assessment is more effective than case-based discussions to improve knowledge and guideline-consistent clinical reasoning in the Dutch physical therapy guideline for low back pain (LBP). Design A cluster randomized controlled trial was conducted. Setting and Participants Ten communities of practice (CoPs) of physical therapists were cluster randomized (N=90): 6 CoPs in the peer-assessment group (n=49) and 4 CoPs in the case-based discussion group (control group) (n=41). Intervention Both groups participated in 4 educational sessions and used clinical patient cases. The peer-assessment group reflected on performed LBP management in different roles. The control group used structured discussions. Measurements Outcomes were assessed at baseline and at 6 months. The primary outcome measure was knowledge and guideline-consistent reasoning, measured with 12 performance indicators using 4 vignettes with specific guideline-related patient profiles. For each participant, the total score was calculated by adding up the percentage scores (0–100) per vignette, divided by 4. The secondary outcome measure was reflective practice, as measured by the Self-Reflection and Insight Scale (20–100). Results Vignettes were completed by 78 participants (87%). Multilevel analysis showed an increase in guideline-consistent clinical reasoning of 8.4% in the peer-assessment group, whereas the control group showed a decline of 0.1% (estimated group difference=8.7%, 95% confidence interval=3.9 to 13.4). No group differences were found on self-reflection. Limitations The small sample size, a short-term follow-up, and the use of vignettes as a proxy for behavior were limitations of the study. Conclusions Peer assessment leads to an increase in knowledge and guideline-consistent clinical reasoning.

Quality Indicators for Physiotherapy Care in Hip and Knee Osteoarthritis: Development and Clinimetric Properties

OBJECTIVE The aim of the present study was to develop process quality indicators for physiotherapy care based on key recommendations of the Dutch physiotherapy guideline on hip and knee osteoarthritis (OA). METHODS Guideline recommendations were rated for their relevance by an expert panel, transformed into potential indicators and incorporated into a questionnaire, the Quality Indicators for Physiotherapy in Hip and Knee Osteoarthritis (QIP-HKOA). Adherence with each indicator was rated on a Likert scale (0 = never to 4 = always). The QIP-HKOA was administered to groups of expert (n = 51) and general (n = 134) physiotherapists (PTs) to test its discriminative power. Reliability was tested in a subgroup of 118 PTs by computing the intraclass correlation coefficient (ICC). QIP-HKOA items were included if they were considered to be related to the cornerstones of physiotherapy in hip and knee OA (exercises and education), had discriminative power and/or if they were followed by <75% of PTs in both groups. RESULTS Nineteen indicators were derived from 41 recommendations. Twelve indicators were considered to be the cornerstones of physiotherapy care; six indicators had discriminative power and/or were followed by <75% PTs in both groups, resulting in an 18-item QIP- HKOA. The QIP-HKOA score was significantly higher with expert [60.73; standard deviation (SD) 5.67] than with general PTs (54.65; SD 6.17) (p < 0.001). The ICC of the QIP-HKOA among 46/118 PTs was 0.89. CONCLUSION The QIP-HKOA, based on 18 process indicators derived from a physiotherapy guideline on hip and knee OA was found to be reliable and discriminated between expert and general PTs. Its ability to measure improvement in the quality of the process of physiotherapy care needs to be further examined.

Development and Evaluation of an Implementation Strategy for Collecting Data in a National Registry and the Use of Patient-Reported Outcome Measures in Physical Therapist Practices: Quality Improvement Study

Background. In 2013, the Royal Dutch Society for Physical Therapy launched the program “Quality in Motion.” This program aims to collect data from electronic health record systems in a registry that is fed back to physical therapists, facilitating quality improvement. Purpose. The purpose of this study was to describe the development of an implementation strategy for the program and to evaluate the feasibility of building a registry and implementing patient‐reported outcome measures (PROMs) in physical therapist practices. Methods. A stepwise approach using mixed methods was established in 3 consecutive pilots with 355 physical therapists from 66 practices. Interim results were evaluated using quantitative data from a self‐assessment questionnaire and the registry and qualitative data from 21 semistructured interviews with physical therapists. Descriptive statistics and McNemars symmetry chi‐squared test were used to summarize the feasibility of implementing PROMs. Results. PROMs were selected for the 5 most prevalent musculoskeletal conditions in Dutch physical therapist practices. A core component of the implementation strategy was the introduction of knowledge brokers to support physical therapists in establishing the routine use of PROMs in clinical practice and to assist in executing peer assessment workshops. In February 2013, 30.3% of the physical therapist practices delivered 4.4 completed treatment episodes per physical therapist to the registry; this increased to 92.4% in November 2014, delivering 54.1 completed patient episodes per physical therapist. Pre‐ and posttreatment PROM use increased from 12.2% to 39.5%. Limitations. It is unclear if the participating physical therapists reflect a representative sample of Dutch therapists. Conclusion. Building a registry and implementing PROMs in physical therapist practices are feasible. The routine use of PROMs needs to increase to ensure valid feedback of outcomes. Using knowledge brokers is promising for implementing the program via peer assessment workshops.

Psychometric properties of the PROMIS Physical Function item bank in patients receiving physical therapy.

Objectives The Patient-Reported Outcomes Measurement Information System (PROMIS) is a universally applicable set of instruments, including item banks, short forms and computer adaptive tests (CATs), measuring patient-reported health across different patient populations. PROMIS CATs are highly efficient and the use in practice is considered feasible with little administration time, offering standardized and routine patient monitoring. Before an item bank can be used as CAT, the psychometric properties of the item bank have to be examined. Therefore, the objective was to assess the psychometric properties of the Dutch-Flemish PROMIS Physical Function item bank (DF-PROMIS-PF) in Dutch patients receiving physical therapy. Design Cross-sectional study. Setting and participants 805 patients >18 years, who received any kind of physical therapy in primary care in the past year, completed the full DF-PROMIS-PF (121 items). Methods Unidimensionality was examined by Confirmatory Factor Analysis and local dependence and monotonicity were evaluated. A Graded Response Model was fitted. Construct validity was examined with correlations between DF-PROMIS-PF T-scores and scores on two legacy instruments (SF-36 Health Survey Physical Functioning scale [SF36-PF10] and the Health Assessment Questionnaire Disability-Index [HAQ-DI]). Reliability (standard errors of theta) was assessed. Results The results for unidimensionality were mixed (scaled CFI = 0.924, TLI = 0.923, RMSEA = 0.045, 1th factor explained 61.5% of variance). Some local dependence was found (8.2% of item pairs). The item bank showed a broad coverage of the physical function construct (threshold-parameters range: -4.28–2.33) and good construct validity (correlation with SF36-PF10 = 0.84 and HAQ-DI = -0.85). Furthermore, the DF-PROMIS-PF showed greater reliability over a broader score-range than the SF36-PF10 and HAQ-DI. Conclusions The psychometric properties of the DF-PROMIS-PF item bank are sufficient. The DF-PROMIS-PF can now be used as short forms or CAT to measure the level of physical function of physiotherapy patients.

Characteristics and healthcare utilisation patterns of high-cost beneficiaries in the Netherlands: a cross-sectional claims database study

Objective To determine medical needs, demographic characteristics and healthcare utilisation patterns of the top 1% and top 2%–5% high-cost beneficiaries in the Netherlands. Design Cross-sectional study using 1 year claims data. We broke down high-cost beneficiaries by demographics, the most cost-incurring condition per beneficiary and expensive treatment use. Setting Dutch curative health system, a health system with universal coverage. Participants 4.5 million beneficiaries of one health insurer. Measures Annual total costs through hospital, intensive care unit use, expensive drugs, other pharmaceuticals, mental care and others; demographics; most cost-incurring and secondary conditions; inpatient stay; number of morbidities; costs per ICD10-chapter (International Statistical Classification of Diseases, 10th revision); and expensive treatment use (including dialysis, transplant surgery, expensive drugs, intensive care unit and diagnosis-related groups >€30 000). Results The top 1% and top 2%–5% beneficiaries accounted for 23% and 26% of total expenditures, respectively. Among top 1% beneficiaries, hospital care represented 76% of spending, of which, respectively, 9.0% and 9.1% were spent on expensive drugs and ICU care. We found that 54% of top 1% beneficiaries were aged 65 years or younger and that average costs sharply decreased with higher age within the top 1% group. Expensive treatments contributed to high costs in one-third of top 1% beneficiaries and in less than 10% of top 2%–5% beneficiaries. The average number of conditions was 5.5 and 4.0 for top 1% and top 2%–5% beneficiaries, respectively. 53% of top 1% beneficiaries were treated for circulatory disorders but for only 22% of top 1% beneficiaries this was their most cost-incurring condition. Conclusions Expensive treatments, most cost-incurring condition and age proved to be informative variables for studying this heterogeneous population. Expensive treatments play a substantial role in high-costs beneficiaries. Interventions need to be aimed at beneficiaries of all ages; a sole focus on the elderly would leave many high-cost beneficiaries unaddressed. Tailored interventions are needed to meet the needs of high-cost beneficiaries and to avoid waste of scarce resources.

Stewardship of primary care physicians to contain cost in health care: an international cross-sectional survey

Purpose Physician stewardship towards cost control is potentially important in enhancing the financial sustainability of health care systems. Objective Aim of this study was to identify the level of stewardship of cost containment of primary care physicians (PCPs) and to assess the associations between stewardship and characteristics of PCPs and health care systems. Methods Secondary analysis of data from a cross-sectional survey among 10 countries: Australia, Canada, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, UK and USA. Participants were a random sample of 33312 PCPs with 11547 responses (34.7%). Outcome measure was a stewardship scale addressing cost-awareness and cost-consideration. Results Across countries, 41.6% and 45.7% of the PCPs responded that they often were aware of treatment costs and considered cost, respectively. Female PCPs were less aware of costs (OR: 0.75; 95% CI: 0.69-0.81) and considered costs less frequently in making treatment decisions (OR: 0.82; 95% CI: 0.76-0.89). Older PCPs were more aware of the costs than younger PCPs for all age categories compared to those <35 years (P < 0.001). PCPs older than 65 years (OR: 0.64; 95% CI: 0.54-0.78) and 55-64 years (OR: 0.84; 95%CI: 0.73-0.97) were less likely to consider costs than the youngest age group. Cost-consideration of PCPs residing in countries with a single payer system was lower (OR: 0.58; 95% CI 0.35-0.95) than their colleagues in multiple payer systems. Conclusion PCPs show moderate stewardship of health care resources with large intercountry differences. Cost-awareness may not be a necessary precondition for cost-consideration, and policies aimed at raising cost-consideration may be more important.

The reasons behind the (non)use of feedback reports for quality improvement in physical therapy: A mixed-method study

Objectives To explain the use of feedback reports for quality improvements by the reasons to participate in quality measuring projects and to identify barriers and facilitators. Design Mixed methods design. Methods In 2009–2011 a national audit and feedback system for physical therapy (Qualiphy) was initiated in the Netherlands. After each data collection round, an evaluation survey was held amongst its participants. The evaluation survey data was used to explain the use of feedback reports by studying the reasons to participate with Qualiphy with correlation measures and logistic regression. Semi-structured interviews with PTs served to seek confirmation and disentangle barriers and facilitators. Results Analysis of 257 surveys (response rate: 42.8%) showed that therapists with only financial reasons were less likely to use feedback reports (OR = 0.24;95%CI = 0.11–0.52) compared to therapists with a mixture of reasons. PTs in 2009 and 2010 were more likely to use the feedback reports for quality improvement than PTs in 2011 (OR = 2.41;95%CI = 1.25–4.64 respectively OR = 3.28;95%CI = 1.51–7.10). Changing circumstances in 2011, i.e. using EHRs and financial incentives, had a negative effect on the use of feedback reports (OR = 0.40, 95%CI = 0.20–0.78). Interviews with 12 physical therapists showed that feedback reports could serve as a tool to support and structure quality improvement plans. Barriers were distrust and perceived self-reporting bias on indicator scores. Conclusions Implementing financial incentives that are not well-specified and well-targeted can have an adverse effect on using feedback reports to improve quality of care. Distrust is a major barrier to implementing quality systems.

SP0250 Implementing Non-Pharmacological Guidelines in Clinical Practice

Clinical practice guidelines are “statements that include recommendations intended to optimize patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options”. In health care services, clinical guidelines are considered important instruments to improve and manage the care process. Important goals in developing and implementing guidelines are higher quality and improved cost-effectiveness of interventions, ideally resulting in improved health outcomes. The growing body of knowledge in the field of clinical guidelines has provided opportunities for international collaboration. In 2002, the Guidelines International Network (G-I-N) was founded to provide a network and partnerships for guideline organizations, implementers, researchers and other stakeholders in health care. G-I-N seeks to improve the quality of health care by promoting the systematic development of guidelines and their application to practice. Despite a multitude of implementation strategies, research has demonstrated that guidelines are not readily implemented in every day clinical practice. The main bottlenecks for practitioners are attributable to knowledge, attitudes and factors concerning social, organizational and societal support. Because education is assumed to be the first step to behavioral change in clinical practice, a variety of educational interventions have been designed addressing knowledge, skills, and attitudes. Peer Assessment is an implementation strategy that aims at developing mutually accepted performance standards and realistic perceptions of actual performance. We will present the effectiveness of peer assessment strategies to enhance the implementation of clinical practice guidelines based on the results of two cluster-randomized clinical trials. Disclosure of Interest None declared