1 Rygcenter Syddanmark, Institute of Regional Health Research, Det Sundhedsvidenskabelige Fakultet, SDU2 Center Lillebaelt, Institute of Regional Health Research, Det Sundhedsvidenskabelige Fakultet, SDU3 Monash University4 Clinical Epidemiology Program, Ottawa Health Research Institute5 Health Services Research Unit, University of Aberdeen, Aberdeen6 University College London7 Department of General Practice, School of Primary Health Care, Monash University, Victoria8 Department of Sports Science and Clinical Biomechanics, Det Sundhedsvidenskabelige Fakultet, SDU9 Monash Department of Clinical Epidemiology at Cabrini Hospital, Victoria10 Department of Sports Science and Clinical Biomechanics, Det Sundhedsvidenskabelige Fakultet, SDU
the IMPLEMENT cluster randomised trial
Introduction: This cluster randomised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain (LBP) in general practice. Methods: General practices were randomised to either access to a guideline for acute LBP (control) or facilitated interactive workshops (intervention). We measured behavioural predictors (e.g. knowledge, attitudes and intentions) and fear avoidance beliefs. We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner (GP) level: behavioural simulation (clinical decision about vignettes) and rates of x-ray and CT-scan (medical administrative data). All those not involved in the delivery of the intervention were blinded to allocation. Results: 47 practices (53 GPs) were randomised to the control and 45 practices (59 GPs) to the intervention. The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information; a minimum of 38 GPs were available from the intervention group, and a minimum of 40 GPs from the control group. For the behavioural constructs, although effect estimates were small, the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral. For behavioural simulation, intervention group GPs were more likely to adhere to guideline recommendations about x-ray (OR 1.76, 95%CI 1.01, 3.05) and more likely to give advice to stay active (OR 4.49, 95%CI 1.90 to 10.60). Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear; rate ratio 0.87 (95%CI 0.68, 1.10) for x-ray or CT-scan. Conclusions: The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence-based guideline, but it did not result in statistically significant changes in actual behaviour.