title: Evaluation of a theory-informed implementation intervention for the management of acute low back pain in general medical practice: the IMPLEMENT cluster randomised trial.
abstract: BACKGROUND
  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.
  
  
  BACKGROUND
  Australian New Zealand Clinical Trials Registry ACTRN012606000098538.
authors.affiliation: School of Public Health and Preventive Medicine, Monash University, Victoria, Australia. s.french@unimelb.edu.au
authors.forename: Simon D
authors.initials: SD
authors.lastname: French
authors.forename: Joanne E
authors.initials: JE
authors.lastname: McKenzie
authors.forename: Denise A
authors.initials: DA
authors.lastname: O'Connor
authors.forename: Jeremy M
authors.initials: JM
authors.lastname: Grimshaw
authors.forename: Duncan
authors.initials: D
authors.lastname: Mortimer
authors.forename: Jill J
authors.initials: JJ
authors.lastname: Francis
authors.forename: Susan
authors.initials: S
authors.lastname: Michie
authors.forename: Neil
authors.initials: N
authors.lastname: Spike
authors.forename: Peter
authors.initials: P
authors.lastname: Schattner
authors.forename: Peter
authors.initials: P
authors.lastname: Kent
authors.forename: Rachelle
authors.initials: R
authors.lastname: Buchbinder
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Page
authors.forename: Sally E
authors.initials: SE
authors.lastname: Green
mesh_terms: D000328:Adult; D001315:Australia; D005194:Family Practice; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D017116:Low Back Pain / Q000000981:diagnostic imaging / Q000534:rehabilitation*; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D011314:Preventive Health Services; D011859:Radiography; D012017:Referral and Consultation