Alan K Novick MD Rehabilitation Medical Director Memorial Rehabilitation Institute Objectives Develop a basic understanding of the Agree II tool with respect to Applicability Develop an understanding of potential barriers and obstacles to application of LBP clinical guidelines inclu ID: 783371
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Slide1
Facilitators and Barriers to Application of Low Back Pain Clinical Guidelines
Alan K. Novick, MDRehabilitation Medical DirectorMemorial Rehabilitation Institute
Slide2ObjectivesDevelop a basic understanding of the Agree II tool with respect to “Applicability”
Develop an understanding of potential barriers and obstacles to application of LBP clinical guidelines including financial and societalDevelop a knowledge of potential facilitators to apply LBP clinical guidelines
Slide3DisclosuresI have no financial disclosures
Slide4AGREE II Tool
Score 1 to 71= Strongly Disagree7= Strongly Agree23 Items6 Domains
Slide5AGREE II Tool
Slide6AGREE II Domain 5: Applicability
Guideline1819
2021
Avg
NASS
Spinal Stenosis
2.25
2.25
2.0
2.75
5.5
NASS Deg
Spondylolithesis
1.8
1.2
1.0
3.4
6.0
AAOS Symptomatic Osteoporosis comp
fx
1.33
3.0
1.33
2.33
6.0
APT: LBP CPGs linked to the ICF
1.6
2.8
.8
2.2
3.2
Slide7Cabana MD, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999 Oct 20;282(15):1458-65.
Review of 78 published studies describing at least 1 barrierKnowledgeLack of awareness n=46AttitudesLack of agreement n=33Lack of self-efficacy n=19
Lack of outcome expectancy n=8Lack of motivation n=14BehaviorExternal Barriers n=34Patient
Guideline
Enviromental
Slide8Cabana MD, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999 Oct 20;282(15):1458-65.
Lack of awarenessVolume of informationLack of agreementToo cookbook, Too rigidInterpretation of evidenceLack of self-efficacy
Belief that physician can’t perform CPGLack of outcome expectancy Belief that CPG will not lead to desired outcomeLack of motivation
Inertia of previous practice habits
Slide9Cabana MD, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999 Oct 20;282(15):1458-65.
External Barriers PatientInability to reconcile patient preferencesGuidelinePresence of contradictory guidelinesEnvironmentalLack of time, resources
organizational constraintsPerceived increase in malpractice liability
Slide10Ayres CG, Griffith HM. Perceived barriers to and facilitators of the implementation of priority clinical preventive services guidelines. Am J Manag Care. 2007 Mar;13(3):150-5.
Focus groups from health plan providersBarriersPayment and CostTimeLegal IssuesInconsistency among HP toolsLack of internalization
Patient-clinician relationshipFacilitators
HP support
Patient Materials
Clinician awareness
HP tool consistency
Slide11Légaré F, et al. Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals' perceptions.
Patient Educ Couns. 2008 Dec;73(3):526-35.38 studies, 3231 participants, 89% physiciansBarriers
Time constraints (22/38)Lack of applicability due to patient characteristics (18/38)Clinical situations (16/38)Facilitators
Provider Motivation (23/38)
Positive impact on the clinical process (16/38)
Patient outcomes (16/38)
Slide12Barriers: LBP CPG’sLack of defined group of practitionersOrtho, Neurosurgery, PM&R, Rheumatology, Anesthesiology and Primary Care may all treat back pain
Different clinical approachesChallenging to get consensus or distribute CPGs
Slide13Barriers: LBP CPG’sFinancialCost of treatment
Resource Utilization HMO may require conservative treatment prior to diagnostic testing
Slide14NASS Spinal Stenosis CPG
Slide15Barriers: LBP CPG’sFinancial
Cost of treatmentResource Utilization HMO may require conservative treatment prior to diagnostic testingEvidence inconclusive for pharmacologic or therapeutic treatmentsMRI appropriate diagnostic testMay be unable to order MRI until fails conservative treatmentEconomic IncentivesPhysician ownership/profitability
Imaging & therapy centers, dispensary
Slide16Barriers: LBP CPG’sResource AvailabilitySufficient practitioners with skills to deliver the recommended care
Sufficient equipmentClinical Practice GuidelineStructure variabilitySize
Slide17Barriers: LBP CPG’sSocietal
Patient expectationsPatients often want certain treatments/testing (MRI, medications, etc.)Patient satisfaction May impact physician scorecard/reviewsWeb based physician rating sitesEmployed physician compensation
Slide18Barriers: LBP CPG’sSocietal
LiabilityDefensive medicine
Slide19Facilitators: LBP CPG’s
Slide20Facilitators: LBP CPG’sResearch
Consensus between specialtiesInput from all stakeholdersPatientsMultiple specialistsImaging centers/therapy centersStandardization of CPGsTools for implementationDistribution of InformationWebsite postings of CPGs
Slide21Conclusion