Implementing BetterBack – a Best Practice Physiotherapy Healthcare Model for Low Back Pain : Clinician and Patient Evaluation

Sammanfattning: Background: Low back pain (LBP) occurs in all ages, and first-line treatment by physiotherapists (PTs) is common. However, national evidence-based LBP clinical guidelines are still lacking in Sweden. To facilitate guideline uptake, we developed and with a multifaceted strategy implemented a best practice physiotherapy healthcare model (BetterBack MoC) with the aim of supporting management of LBP in primary care.The overall aim of this thesis was to evaluate a multifaceted implementation strategy and a best practice physiotherapy healthcare model for LBP. Methods: This thesis is based on one methodological study and three experimental trials with PTs and patients with LBP. In Paper I a mixed method design was used to translate, tailor, validate and feasibility-test the Determinants of Implementation Behaviour Questionnaire (DIBQ). This tailored DIBQ Questionnaire (DIBQ-t) was used to evaluate potential barriers/facilitators during the implementation process together with evaluation of PTs’ confidence, attitudes and beliefs in managing LBP. In a stepped cluster randomised controlled trial, PTs and their patients in three clusters were allocated to intervention (after implementation of BetterBack MoC) or routine physiotherapy care (control group). In Paper III the proportions of guideline-adherent care were compared between groups in Paper III. This evaluation was based on PTs’ adherence to eight clinical practice recommendations and three clinical practice quality indices (CPQI). The overall CPQI containing the five most prioritised recommendations are: no referral to specialist care; no referral to medical imaging for benign LBP during PT treatment period; use of educational interventions; use of exercise interventions; and no use of non-evidence-based physiotherapy. Finally, in Paper IV patient-reported outcome measures (PROMs) were compared between intervention (after the implementation of BetterBack MoC) and routine care. In Paper IV an additional secondary analysis was performed, comparing PROMs based on whether or not PTs had delivered care that met all five criteria of the overall CPQI or not. Results: A tailored feasible and valid questionnaire was developed, DIBQ-t to be used for evaluation of the implementation of LBP primary care programmes. After implementation workshop, PTs’ (n = 116) confidence increased, and PTs’ attitudes and beliefs shifted towards a more biopsychosocial orientation. PTs had high expectations of the BetterBack MoC, which decreased after using the MoC. When evaluating received treatment for 500 patients with LBP, a more frequent delivery of guideline-adherent care was seen after implementation (n = 278) compared to routine care (n = 222). The overall CPQI containing the five prioritised recommendations was fulfilled in 59% of all patients in intervention versus 26% in routine care group. Analysis of adherence to specific recommendations showed a significantly improved use of stratification of number of PT visits and patient educational interventions, frequent use of exercise was maintained, and use of non-evidence-based treatment and medical imaging decreased after implementation. The primary outcome, i.e. referral to specialist consultation, was low in both groups, with no between-group differences. After implementation of the BetterBack MoC, no between-group differences in PROMs were seen except for greater satisfaction with LBP care, greater improvement in illness perception and better health-related quality of life, compared with routine care. However, when PTs’ care adhered to all five CPQI criteria, a greater improvement of most patient-reported outcomes was seen compared to patient care that did not adhere to all five CPQI criteria.  Conclusions: The implementation of a best practice physiotherapy healthcare model (BetterBack MoC) for LBP improved both clinician and patient outcomes. PTs increased use of guideline-adherent care, confidence and biopsychosocial orientation in managing LBP. Patients reported improved satisfaction, illness perception and health-related quality of life. The implementation did not decrease referral to specialist consultation from an initial low level; nor did it improve patients’ disability and pain more than routine care. However, when guideline-adherent care was fulfilled, most PROMs improved. It is therefore important to highlight the importance of guideline-based primary care for improving patient-reported LBP outcomes.