title: Cost-effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for nonspecific low back pain: design of a stepped-wedge cluster randomised controlled trial.
abstract: BACKGROUND
  Low back pain (LBP) is one of the most prevalent and expensive health care problems in industrialised countries. LBP leads to high health care utility and productivity losses; leaving the individual, the employer, and society with substantial costs. To improve the care for LBP patients and reduce the high societal and financial burden of LBP, in 2010 the 'Multidisciplinary care guideline for nonspecific low back pain' was developed in the Netherlands. The current paper describes the design of a study aiming to evaluate the (cost-) effectiveness of a multifaceted strategy to implement this guideline.
  
  
  METHODS
  In a cluster-randomised controlled trial, the (cost-) effectiveness of a multifaceted implementation strategy will be compared to passive guideline dissemination. Using a stepped-wedge approach, participating general practitioners, physiotherapists, and occupational physicians are allocated into clusters and will attend a multidisciplinary continuing medical education training session. The timing these clusters receive the training is the unit of randomisation. LBP patients visiting the participating health care providers are invited to participate in the trial and will receive access to a multimedia intervention aimed at improving beliefs, cognitions, and self-management. The primary outcome measure of this study is patient back beliefs. Secondary outcome measures on patient level include pain, functional status, quality of life, health care utility, and productivity losses. Outcome measures on professional level include knowledge and attitude towards the guideline, and guideline adherence. A process evaluation for the implementation strategy will be performed among the health care providers and the patients. Furthermore, a qualitative subgroup analysis among patients with various ethnic backgrounds will be performed.
  
  
  CONCLUSIONS
  This study will give insight into the (cost-) effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for non-specific back pain to improve outcomes on patient and professional level. The valuable information gained with this study may prove useful for policy-makers, health care providers, and researchers who are in the process of reducing the burden of back pain on individuals and society.
  
  
  BACKGROUND
  Netherlands Trial Register (NTR): NTR4329. Registered December 20th, 2013.
authors.affiliation: Department of Public and Occupational Health, VU University medical centre, EMGO+ Institute for Health and Care Research, PO Box 7057, 1007 MB, Amsterdam, The Netherlands. a.suman@vumc.nl.
authors.forename: Arnela
authors.initials: A
authors.lastname: Suman
authors.affiliation: Department of Public and Occupational Health, VU University medical centre, EMGO+ Institute for Health and Care Research, PO Box 7057, 1007 MB, Amsterdam, The Netherlands. f.schaafsma@vumc.nl.|Research Centre for Insurance Medicine, Collaboration between AMC-UMCG-UWV-VUmc, Amsterdam, The Netherlands. f.schaafsma@vumc.nl.
authors.forename: Frederieke G
authors.initials: FG
authors.lastname: Schaafsma
authors.affiliation: Department of General Practice and Elderly Care Medicine, VU University medical centre, EMGO+ Institute for Health and Care Research, Amsterdam, The Netherlands. p.elders@vumc.nl.
authors.forename: Petra J M
authors.initials: PJ
authors.lastname: Elders
authors.affiliation: Department of Health Sciences, Section Health Economics and Health Technology Assessment, VU University, Amsterdam, The Netherlands. maurits.van.tulder@vu.nl.
authors.forename: Maurits W
authors.initials: MW
authors.lastname: van Tulder
authors.affiliation: Department of Public and Occupational Health, VU University medical centre, EMGO+ Institute for Health and Care Research, PO Box 7057, 1007 MB, Amsterdam, The Netherlands. h.anema@vumc.nl.|Research Centre for Insurance Medicine, Collaboration between AMC-UMCG-UWV-VUmc, Amsterdam, The Netherlands. h.anema@vumc.nl.
authors.forename: Johannes R
authors.initials: JR
authors.lastname: Anema
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003362:Cost-Benefit Analysis; D004496:Education, Continuing / Q000458:organization & administration; D005260:Female; D019983:Guideline Adherence / Q000191:economics; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel / Q000193:education*; D006296:Health Services / Q000706:statistics & numerical data; D006304:Health Status; D006801:Humans; D017116:Low Back Pain / Q000191:economics* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D017410:Practice Guidelines as Topic; D011788:Quality of Life; D012107:Research Design; D012648:Self Care / Q000191:economics; D055815:Young Adult