Author
Year
Country
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Setting/Allied health
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Strategies
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Outcomes
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Findings
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SIGN
SCORE
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Implementation intervention/strategy
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Control
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Stevenson et al2006 [19]
(UK)
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Community Trust physiotherapy
AH: physiotherapists
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Opinion leader
Educational program administered by local opinion leaders
5 hours
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‘Usual’ in-service training.
A standard in-service training package on clinical management of knee dysfunction and pathology
5 hours
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Patient classification
Classification in three categories: acute low back pain;
subacute low back pain, or chronic low back pain.
Time spent
Rank management approached regarding time spent
Importance
Rank management approaches regarding importance
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- Clinical management: relatively unchanged
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AQ+
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Snooks 2014
(UK) [20]
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Ambulance stations
AH: Paramedics
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Patient mediated intervention
CCDS (Computerised Clinical Decision Support) on hand-held Tablet computers to decide whether to take patients who had fallen to an Emergency Department or leave them at home with referral to a community-based falls service
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Usual care
Paper based protocols to assess patients and make decisions about their care
Care in control group was not standardised.
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Effectiveness
Proportion of participants left at scene without conveyance to an Emergency Department versus proportion referred to falls services
Safety
Proportion of participants with adverse events [20]up to one month (999 call, Emergency Department attendance, emergency admission to hospital, or death)
Cost-effectiveness
Costs of implementation of CCDS for paramedics and its benefits in the form of patient utility modelled over 12 months
Self reported falls
Fall-related self efficacy
Health related quality of life
SF12
Patients satisfaction
Quality of care monitor
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- 17 intervention paramedics used CCDS for 54 (12.4%) of 436 participants.
- 9.6% referred to falls services versus 5.0% in the control group
- Odds ratio (OR) 2.04, 95% CI 1.12 to 3.72.
- No adverse events were related to the intervention
- CCDS is potentially cost-effective, especially with existing electronic data capture.
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AQ+
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Bekkering 2005 (a) [22]
(The Netherlands)
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Physiotherapy practices
AH: physiotherapists
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Educational outreach visit
Audit and feedback
Reminders
Two training sessions
2.5 hours (each)
Supervised by primary investigator and one of two additional trainers with adequate clinical experience in the management of low back pain
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Standard passive method of dissemination
Guidelines are send by mail, along with 4 forms to facilitate use
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Adherence to the guidelines
Individual patients’ forms recording the treatment completed by the physiotherapist.
Forms were assessed using an algorithm based on the number of treatment sessions, treatment goals, interventions, and patient education
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- Correctly limited the number of treatment sessions for patients with a normal course of back pain (OR 2.39; 95% CI 1.12 to 5.12)
- Set functional treatment goals (OR 1.99; 95% CI 1.06 to 3.72)
- Used mainly active interventions (OR 2.79; 95% CI 1.19 to 6.55),
- Gave adequate patient education (OR 3.59; 95% CI 1.35 to 9.55).
- Adhered more to all four criteria (OR 2.05; 95% CI 1.15 to 3.65).
- The active strategy moderately improved adherence to the guidelines.
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HQ++
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Bekkering 2005 (b) [23]
(The Netherlands)
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Physiotherapy practices
AH: Physiotherapists
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Educational outreach visit
Audit and feedback
Reminders
Two training sessions
2.5 hours (each)
Supervised by primary investigator and one of two additional trainers with adequate clinical experience in the management of low back pain
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Standard passive method of dissemination
Guidelines send by mail, along with 4 forms to facilitate use
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Patient outcomes
Self-report questionnaires at baseline and 6, 12, 26, and 52 weeks after baseline
Physical functioning
(QBPDS),19,20
Pain
(11-point numeric rating scale [NRS]),22,23
Sick leave
Number of days off work in the last 6 weeks
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- Physical functioning: 2.83 points difference on QBPDS (95% CI: -.66, 6.31)
- Pain: 0.34 points difference on NRS ((95% CI: -.19, .88)
- Sick leave: no results (only 7% on sick leave at 12 months)
- No additional benefit to applying an active strategy to implement the physical therapy guidelines for patients with low back pain.
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HQ++
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Pennington et al 2005 [18]
(UK)
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Management of post stroke dysphagia
AH: Speech language therapists
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Educational meetings
Five days training once per fortnight at Manchester University from April to June 2002.
Same as control group with
2,5 days of additional training on the diffusion of innovation, using the model developed by Rogers.
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2,5 days training over seven weeks (April to May 2002)
Manchester University.
Introduction to clinical governance and evidence-based health care, critical appraisal of systematic reviews, randomized controlled trials, cohort and quasi experimental studies and evidence-based guidelines
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Adherence to practice guidelines Using a process-based audit tool, developed by the researchers and a consensus group
Cost effectiveness
3 categories of costs: providing the two training strategies, attending the two training strategies and rolling out the training to the rest of the SLT department
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- No significant effect on initial compliance (F=0.16, df 1, 15, p=0.9)
- No significant overall response to training (F= 1.33, df 1, 1436, p 0.25)
- No effect of training strategy on post-intervention compliance (F 2.80, df 1, 15, p =0.12)
- Departments' rating of research culture included in model improved the significance of the effect of strategy on response to training (F 3.66, df 1, 11, p 0.08)
- Increased dissemination activities and awareness of research information
- No changes in clinical practice within six months of training.
- Costs of the roll out of training for both strategies
- No relationship between costs and clinical outcome.
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HQ++
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Rebbeck 2006 [21]
(Australia)
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Physiotherapy clinics
AH: physiotherapists
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Distribution of educational materials
Opinion leaders
Follow-up education
Educational meetings (workshops)
Educational outreach visits
8 h workshop including interactive sessions outlining the content of the guidelines, practical sessions covering the treatments endorsed in the guidelines
Local opinion leaders delivered some of the program content.
Algorithms outlining the process of care, appointment cards, and marketing material to be used for general practitioners who usually refer to the practice
Follow-up educational outreach visit (2 hours) 6 months later: problem solving regarding use of the guidelines in clinical practice and update of the evidence
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Dissemination of guidelines
By mail
Physiotherapists were given but not directed to use the guidelines.
Both groups were given the same information regarding the trial and its outcome measures
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Patient outcomes: disability, disability due to acute whiplash, whiplash, clinically important change, patient satisfaction
Functional Rating Index, adapted version of the 7-item Core Outcome Measure for neck pain, 5item questionnaire ‘symptom bothersomeness’, Global Perceived Effect, 5-point Likert scale ranging from 1 (extremely dissatisfied) to 5 (extremely satisfied)
Physiotherapist outcomes: knowledge, clinical practice, physiotherapists satisfaction
custom-made questionnaire, percentage prescribing guideline recommendations before and after the trial (from responses to the questionnaire) and during the trial (audited from patient notes), 7-point Likert scale ranging from –3 (extremely unhelpful) to +3 (extremely helpful)
Cost of care
Median cost per patient for each physiotherapist.
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- No significant difference for any of the patient outcomes
- Increased their knowledge of the guidelines by 5.5 points (95% CI 2.5 to 8.4) (p = 0.001)
- Increased self-rated understanding of the guidelines by 1.5 points (95% CI 0.7 to 2.3) (p = 0.001).
- Increased ability to identify yellow flags (p = 0.02)
- Increased self-reported use of functional outcome measures (p = 0.01)
- 2/5 guideline recommendations were identified by more ‘reassure patient’ (p = 0.05) and ‘advise to act as usual’ (p = 0.02).
- Recommendations prescribed more (p = 0.04 and 0.02)
- Equal satisfaction with the guidelines (p = 0.29) or the consumer version of the guidelines (p = 0.20)
- More satisfied with implementation package (p = 0.07)
- Cost of care not significantly different (p = 0.67)
- Cost per one point improvement not significantly different (p = 0.55)
- Median of 13 treatments to patients in the implementation group not significantly different (p = 0.75)
- Improved knowledge and clinical practice more consistent with the guidelines
- Patient outcomes and cost of care were not affected.
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HQ++
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