Implementation of the Dutch low back pain guideline for general practitioners: a cluster randomized controlled trial.
METHODS
Cluster randomized controlled trial for a multifaceted implementation strategy.


OBJECTIVE
To assess the effectiveness of tailored interventions (multifaceted implementation strategy) to implement the Dutch low back pain guideline for general practitioners with regard to adherence to guideline recommendations.


BACKGROUND
Guidelines for the management of low back pain in primary care have been developed in various countries, but little is known about the optimal implementation strategy. A multifaceted implementation strategy was developed to overcome identified barriers to the implementation of the Dutch low back pain guideline for general practitioners.


METHODS
General practitioners were randomized to an intervention or a control group. The general practitioners in the intervention group (n = 21) received tailored interventions consisting of the Dutch low back pain guideline for general practitioners, a 2-hour educational and clinical practice workshop; two scientific articles on low back pain management; the guideline for occupational physicians; a tool for patient education; and a tool for reaching agreement on low back care with physical, exercise, and manual therapists. The control group (n = 20) received no intervention. The participating general practitioners were asked to recruit consecutive patients with a new episode of low back pain as the main reason for consultation. General practitioners completed registration forms of each individual consultation with regard to the main outcome measures: advice and information, referral to other health-care providers, and prescription of medication.


RESULTS
Forty-one of the 67 randomized general practitioners reported on a total of 616 consultations for 531 patients with nonspecific low back pain. The advice and explanation provided by the general practitioners, the prescription of paracetamol or nonsteroidal anti-inflammatory drugs, and prescription of pain medication on atime contingent or a pain contingent basis showed no statistically significant differences between the intervention and control groups. There were also no differences in overall referral rate. However, in follow-up consultations fewer patients were referred to a physical or exercise therapist by the general practitioners in the intervention group than in the control group.


CONCLUSIONS
The multifaceted intervention strategy modestly improved implementation (for parts of the recommendations in) the Dutch low back pain guideline by general practitioners and produced small concomitant changes in patient management. The implementation strategy produced fewer referrals to therapists during follow-up consultations.
Engers
Arno J
AJ
Center for Quality of Care Research, University Medical Center Nijmegen, The Netherlands. a.engers@planet.nl
Wensing
Michel
M
van Tulder
Mauritis W
MW
Timmermans
Arno
A
Oostendorp
Rob A B
RA
Koes
Bart W
BW
Grol
Richard
R
D000293:Adolescent; D000328:Adult; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D017408:Guidelines as Topic; D006284:Health Plan Implementation / Q000706:statistics & numerical data*; D006801:Humans; D017116:Low Back Pain / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D010147:Pain Measurement; D010821:Physicians, Family