Susanne Bernhardsson

Determinants of Guideline Use in Primary Care Physical Therapy: A Cross-Sectional Survey of Attitudes, Knowledge, and Behavior

Background Understanding of attitudes, knowledge, and behavior related to evidence-based practice (EBP) and use of evidence-based clinical practice guidelines in primary care physical therapy is limited. Objectives The objectives of this study were: (1) to investigate self-reported attitudes, knowledge, behavior, prerequisites, and barriers related to EBP and guideline use among physical therapists in primary care and (2) to explore associations of self-reported use of guidelines with these social cognitive factors along with demographic and workplace characteristics. Design This was a cross-sectional survey. Methods A web-based survey of 419 physical therapists in primary care in western Sweden was performed. Multiple logistic regression analysis was performed to examine factors associated with guideline use. Results The response rate was 64.7%. Most respondents had positive attitudes toward EBP and guidelines: 90% considered EBP necessary, and 96% considered guidelines important. Approximately two thirds reported confidence in finding and using evidence. One third reported being aware of guidelines. Thirteen percent knew where to find guidelines, and only 9% reported having easy access to guidelines. Fewer than half reported using guidelines frequently. The most important barriers to using guidelines were lack of time, poor availability, and limited access to guidelines. Young age and brief work experience were associated with positive attitudes toward EBP. A postgraduate degree was associated with higher application of EBP. Positive attitudes, awareness of guidelines, considering guidelines to facilitate practice, and knowing how to integrate patient preferences with guideline use were associated with frequent use of guidelines. Limitations Data were self-reported, which may have increased the risk of social desirability bias. Conclusions Use of guidelines was not as frequent as could be expected in view of the positive attitudes toward EBP and guidelines among physical therapists. Awareness of and perceived access to guidelines were limited. The identified determinants can be addressed when developing guideline implementation strategies.

Guide to Clinical Practice Guidelines: The Current State of Play

Abstract Introduction Extensive research has been undertaken over the last 30 years on the methods underpinning clinical practice guidelines (CPGs), including their development, updating, reporting, tailoring for specific purposes, implementation and evaluation. This has resulted in an increasing number of terms, tools and acronyms. Over time, CPGs have shifted from opinion-based to evidence-informed, including increasingly sophisticated methodologies and implementation strategies, and thus keeping abreast of evolution in this field of research can be challenging. Methods This article collates findings from an extensive document search, to provide a guide describing standards, methods and systems reported in the current CPG methodology and implementation literature. This guide is targeted at those working in health care quality and safety and responsible for either commissioning, researching or delivering health care. It is presented in a way that can be updated as the field expands. Conclusion CPG development and implementation have attracted the most international interest and activity, whilst CPG updating, adopting (with or without contextualization), adapting and impact evaluation are less well addressed.

Evaluation of a tailored, multi-component intervention for implementation of evidence-based clinical practice guidelines in primary care physical therapy: a non-randomized controlled trial.

BackgroundClinical practice guidelines are important for transmitting research findings into practice and facilitating the application of evidence-based practice (EBP). There is a paucity of knowledge about the impact of guideline implementation strategies in primary care physical therapy. The aim of this study was to evaluate the effect of a guideline implementation intervention in primary care physical therapy in western Sweden.MethodsAn implementation strategy based on theory and current evidence was developed. A tailored, multi-component implementation intervention, addressing earlier identified determinants, was carried out in three areas comprising 28 physical therapy practices including 277 physical therapists (PTs) (intervention group). In two adjacent areas, 171 PTs at 32 practices received no intervention (control group). The core component of the intervention was an implementation seminar with group discussions. Among other components were a website and email reminders. Data were collected at baseline and follow-up with a web-based questionnaire. Primary outcomes were the self-reported awareness of, knowledge of, access to, and use of guidelines. Secondary outcomes were self-reported attitudes toward EBP and guidelines. Analyses were performed using Pearson’s χ2 test and approximative z-test.Results168 PTs (60.6%) in the intervention group and 88 PTs (51.5%) in the control group responded to the follow-up questionnaire. 186/277 PTs (67.1%) participated in the implementation seminars, of which 97 (52.2%) responded. The proportions of PTs reporting awareness of (absolute difference in change 20.6%, p = 0.023), knowledge where to find (20.4%, p = 0.007), access to (21.7%, p < 0.001), and frequent use of (9.5%, NS) guidelines increased more in the intervention group than in the control group. The proportion of PTs reporting frequent guideline use after participation in the implementation seminar was 15.2% (p = 0.043) higher than the proportion in the control group. A higher proportion considered EBP helpful in decision making (p = 0.018). There were no other significant differences in secondary outcomes.ConclusionsA tailored, theory- and evidence-informed, multi-component intervention for the implementation of clinical practice guidelines had a modest, positive effect on awareness of, knowledge of, access to, and use of guidelines, among PTs in primary care in western Sweden. In general, attitudes to EBP and guidelines were not affected.

Measuring Evidence-Based Practice in Physical Therapy: Translation, Adaptation, Further Development, Validation, and Reliability Test of a Questionnaire

Background Evidence-based practice (EBP) and evidence-based clinical practice guidelines are becoming increasingly important in physical therapy. For the purpose of meeting the goals of designing, implementing, and evaluating strategies to facilitate the development of more EBP in primary care physical therapy, a valid and reliable questionnaire for measuring attitudes, knowledge, behavior, prerequisites, and barriers related to EBP and guidelines is needed. Objective The 3 objectives of this study were: (1) to translate and cross-culturally adapt a questionnaire to a Swedish primary care context for the purpose of measuring various aspects of EBP and guidelines in physical therapy, (2) to further develop the questionnaire to examine more aspects of guidelines, and (3) to test the validity and reliability of the adapted Swedish questionnaire. Design This was an instrument development study with validity and reliability testing. Methods A previously used questionnaire about EBP was translated and cross-culturally adapted to a Swedish primary care physical therapy context. Additional items were constructed. A draft version was pilot tested for content validity (n=10), and a revised version was tested for test-retest reliability (n=42). The percentage of agreement between the 2 tests was analyzed. Results The development process resulted in a first questionnaire draft containing 48 items. The validation process resulted in a second draft with acceptable content validity and consisting of 38 items. The test-retest analysis showed that the median percentage of agreement was 67% (range=41%–81%). After removal or revision of items with poor agreement, the final questionnaire included 31 items. Limitations Only face validity and content validity were tested. Conclusions The final translated and adapted questionnaire was determined to have good face and content validity and acceptable reliability for measuring self-reported attitudes, knowledge, behavior, prerequisites, and barriers related to EBP and guidelines among physical therapists in primary care settings.

Clinical practice in line with evidence? : A survey among primary care physiotherapists in western Sweden

RATIONALE, AIMS AND OBJECTIVES Evidence-based practice is becoming increasingly important in primary care physiotherapy. Clinical practice needs to reflect current best evidence and be concordant with evidence-based clinical guidelines. There is limited knowledge about therapeutic interventions used in primary care physiotherapy in Sweden. The objectives were to examine preferred treatment interventions reported by publicly employed physiotherapists in primary care for three common musculoskeletal disorders (low back pain, neck pain and subacromial pain), the extent to which these interventions were supported by evidence, and associations with demographic variables. METHODS 419 physiotherapists in primary care in western Sweden were surveyed using a validated web-based questionnaire. RESULTS The survey was completed by 271 respondents (65%). Median number of interventions reported was 7 (range 1-16). The most common treatment interventions across the three conditions were advice on posture (reported by 82-94%), advice to stay active (86-92%), and different types of exercise (65-92%). Most of these interventions were supported by evidence. However, interventions with insufficient evidence, such as advice on posture, TENS and aquatic exercise, were also used by 29-96%. Modalities such as laser therapy and ultrasound were sparingly used (<5%), which is in line with evidence. For neck pain, use of evidence-based interventions was associated with gender and for subacromial pain, with work experience. CONCLUSIONS Advice and exercise therapy were the interventions most frequently reported across the three diagnoses, illustrating an active treatment strategy. While most reported interventions are supported by evidence, interventions with unclear or no evidence of effect were also used to a high extent.

Towards evidence-based physiotherapy – research challenges and needs

The evidence-based practice (EBP) movement has gained ground steadily in physiotherapy over the past decade. Influential researchers and clinicians have argued that physiotherapists have a moral and professional obligation to move away from assessment and treatment methods based on anecdotal testimonies or opinion (Grimmer-Somers 2007). However, the growing volume of high-quality clinical research makes it difficult for clinicians to keep pace with the latest evidence. Simultaneously, the practice of physiotherapy has become increasingly complex due to changes in health care systems that entail higher demands on physiotherapists to provide effective and efficient management of patients amidst high patient turnover.

“In the physio we trust” : A qualitative study on patients’ preferences for physiotherapy

ABSTRACT Background: Patients’ preferences should be integrated in evidence-based practice. This study aimed to explore patients’ preferences for physiotherapy treatment and participation in decision making. Methods: A qualitative study set in an urban physiotherapy clinic in Gothenburg, Sweden. Individual, semi-structured interviews were conducted with 20 individuals who sought physiotherapy for musculoskeletal disorders. The interviews were recorded, transcribed, and analyzed with qualitative content analysis. Results: An overarching theme, embracing six categories, was conceptualized: Trust in the physiotherapist fosters active engagement in therapy. The participants preferred active treatment strategies such as exercise and advice for self-management, allowing them to actively engage in their therapy. Some preferred passive treatments. Key influencers on treatment preferences were previous experiences and media. All participants wanted to be involved in the clinical decision making, but to varying extents. Some expressed a preference for an active role and wanting to share decisions while others were content with a passive role. Expectations for a professional management were reflected in trust and confidence in physiotherapists’ skills and competence, expectations for good outcomes, and believing that treatment methods should be evidence-based. Conclusion: Trust in the physiotherapist’s competence, as well as a desire to participate in clinical decision making, fosters active engagement in physiotherapy.

Use of outcome measures improved after a tailored implementation in primary care physiotherapy : a prospective, controlled study

RATIONALE, AIMS AND OBJECTIVES It is important that physiotherapists routinely use outcome measures to evaluate treatment results. There is limited knowledge about effective ways to increase use of outcome measures. The objectives were to investigate the effect of a tailored implementation of guidelines for evaluation of physiotherapy treatment and to explore differences in outcome subgrouped by demographic variables. METHODS A prospective, controlled study was conducted in primary care physiotherapy in western Sweden. 448 publicly employed physiotherapists participated. The intervention comprised a tailored, multi-component implementation of guidelines for treatment and evaluation of musculoskeletal disorders. The core component was a 3-hour implementation seminar. The control group received no intervention. Self-reported attitudes towards, access to and use of outcome measures were assessed with a web-based questionnaire before and after the implementation. RESULTS After the implementation, a significantly higher proportion of physiotherapists in the intervention group than in the control group reported using outcome measures frequently, 54.8% vs. 35.6%, a 19.2% difference. The proportion of physiotherapists who reported that they considered outcome measures important to use and that they had easy access to outcome measures at their workplace, were similar in both groups at follow-up, 92.8% vs. 93.1%, and 95.2% vs. 90.8%, respectively. At follow-up, no differences related to demographic variables were found in the subgroup analyses. CONCLUSIONS The findings suggest that a tailored, multi-component implementation can be effective in increasing use of outcome measures. Although most physiotherapists considered outcome measures important and reported having easy access to them at their workplace, only a little more than half reported using outcome measures after the intervention.

Triage for Patients with Spinal Complaints: A Systematic Review of the Literature.

Background and Purpose. The aim of this study is to provide a systematic overview of the past decade of literature on processes of triage for patients with spinal pain, outcomes measured and markers of effectiveness. Methods. A systematic search of the literature with narrative synthesis of findings was conducted. Studies in English language of any design concerning spinal triage programmes for adults with acute or chronic spinal complaints were considered for inclusion. Electronic database searches were conducted in OVID, Medline, Embase, CINAHL, Health Source Nursing, Scopus and Web of Science. Additional references were sourced through pearling reference lists, and expert input. Findings were synthesized descriptively. Results. Of 216 potentially relevant records, 21 papers (20 studies) were included. There was little commonality in triage activities/programmes and outcomes, although physiotherapists were common members of triage programmes. Positive outcomes were reported most commonly for wait times, with several studies also reporting high levels of patient and physician satisfaction. Outcomes such as surgical conversion rates and selection accuracy were less clear. Discussion. Spinal triage programmes have the potential to improve efficiency of care for outpatients with spinal complaints. The evidence gaps in health outcomes, service models and cost effectiveness should be addressed by more robust prospective research designs.

Carers’ experiences, needs and preferences during inpatient stroke rehabilitation: a protocol for a systematic review of qualitative studies

BackgroundLarge numbers of people provide carer roles for survivors of stroke. Person-centred stroke rehabilitation must consider the perspectives of carers, as stroke affects not only the stroke survivor but also the quality of life and health of the carers. There is little collective knowledge about stroke carers’ experiences, needs and preferences during the inpatient stroke rehabilitation process to then inform person-centred service improvements.Our objective is to report and synthesise experiences, needs and preferences of the carers of stroke survivors undergoing rehabilitation in inpatient settings.Methods/designWe will conduct a systematic review of qualitative studies using a thematic synthesis methodology.We will follow the Enhancing Transparency in Reporting the Synthesis of Qualitative Research Guidelines (ENTREQ) and search the following databases for relevant articles: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Embase, and Web of Science. No language or publication date constraints will be applied. Eligible studies will have to use qualitative methods of data collection and analysis and reported data from the carers of stroke survivors who underwent inpatient stroke rehabilitation. Studies will be eligible for inclusion if they report the experiences, needs and preferences of carers regarding inpatient rehabilitation environments, organisation, care systems, therapeutic interventions, information exchange, carer training, discharge and community service planning and other issues of relevance to their roles as carers. Study selection and assessment of quality will be performed independently by two reviewers. Any disagreement will be resolved by a third reviewer. Data will be extracted by one reviewer, tabled, and checked for accuracy by another reviewer. All text reported in studies’ results, discussion and conclusion sections will be entered into the NVivo software for analysis. Extracted texts will be inductively coded independently by two reviewers and analysed in three phases using thematic synthesis. Descriptive and analytical themes will be developed.DiscussionThis study is expected to provide new insights into the perspectives of stroke survivors’ carers. Increased knowledge about carer perspectives and preferences will inform person-centred improvements in stroke rehabilitation.Study registrationPROSPERO registration number: CRD42015017315.