Facilitators and Barriers to Application of Low Back Pain Clinical Guidelines

Alan K. Novick, MD

Rehabilitation Medical Director

Memorial Rehabilitation Institute

ObjectivesDevelop 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 societal

Develop a knowledge of potential facilitators to apply LBP clinical guidelines

Disclosures

I have no financial disclosures

AGREE II Tool

Score – 1 to 7

1= Strongly Disagree

7= Strongly Agree

23 Items

6 Domains

AGREE II Tool

AGREE II Domain 5: Applicability

Guideline 18 19 20 21 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

Cabana 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 barrier

Knowledge– Lack of awareness n=46

Attitudes– Lack of agreement n=33– Lack of self-efficacy n=19– Lack of outcome expectancy n=8– Lack of motivation n=14

Behavior– External Barriers n=34

Patient

Guideline

Enviromental

Cabana 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 awareness– Volume of information

Lack of agreement– Too cookbook, Too rigid– Interpretation of evidence

Lack of self-efficacy– Belief that physician can’t perform CPG

Lack of outcome expectancy – Belief that CPG will not lead to desired outcome

Lack of motivation– Inertia of previous practice habits

Cabana 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 – Patient

Inability to reconcile patient preferences– Guideline

Presence of contradictory guidelines– Environmental

Lack of time, resources

organizational constraints

Perceived increase in malpractice liability

Ayres 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 providers– Barriers

Payment and Cost

Time

Legal Issues

Inconsistency among HP tools

Lack of internalization

Patient-clinician relationship

– FacilitatorsHP support

Patient Materials

Clinician awareness

HP tool consistency

Légaré 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% physicians– Barriers

Time constraints (22/38)

Lack of applicability due to patient characteristics (18/38)

Clinical situations (16/38)

– FacilitatorsProvider Motivation (23/38)

Positive impact on the clinical process (16/38)

Patient outcomes (16/38)

Barriers: LBP CPG’s

Lack of defined group of practitioners– Ortho, Neurosurgery, PM&R, Rheumatology,

Anesthesiology and Primary Care may all treat back pain

Different clinical approaches

Challenging to get consensus or distribute CPGs

Barriers: LBP CPG’s

Financial– Cost of treatment– Resource Utilization

HMO may require conservative treatment prior to diagnostic testing

NASS Spinal Stenosis CPG

Barriers: LBP CPG’sFinancial– Cost of treatment– Resource Utilization

HMO may require conservative treatment prior to diagnostic testing

– Evidence inconclusive for pharmacologic or therapeutic treatments

– MRI appropriate diagnostic test– May be unable to order MRI until fails conservative

treatment

– Economic IncentivesPhysician ownership/profitability

– Imaging & therapy centers, dispensary

Barriers: LBP CPG’s

Resource Availability– Sufficient practitioners with skills to deliver the

recommended care– Sufficient equipment

Clinical Practice Guideline– Structure variability– Size

Barriers: LBP CPG’s

Societal– Patient expectations

Patients often want certain treatments/testing (MRI, medications, etc.)

Patient satisfaction – May impact physician scorecard/reviews

Web based physician rating sites

Employed physician compensation

Barriers: LBP CPG’sSocietal– Liability

Defensive medicine

Facilitators: LBP CPG’s

Facilitators: LBP CPG’sResearch

Consensus between specialties

Input from all stakeholders– Patients– Multiple specialists– Imaging centers/therapy centers

Standardization of CPGs

Tools for implementation

Distribution of Information– Website postings of CPGs

Conclusion