Evaluation of practice guideline implementation in the Army Medical Department

Preface ......................................... iii Figures ......................................... ix Tables .......................................... xi Summary ....................................... xiii Acknowledgments ................................. xxix Acronyms and Abbreviations ......................... xxxi Chapter One INTRODUCTION .............................. 1 The DoD/VA Guideline Adaptation Process ........... 3 Overview of the Practice Guideline for Low Back Pain .... 4 Expected Effects on Health Care Practices ............ 4 A Systems Approach to Implementation ............. 8 Basic Implementation Strategy ................... 9 Six Critical Success Factors ..................... 10 The AMEDD/RAND Guideline Implementation Project .. 11 The Demonstration Sites ......................... 13 The RAND Evaluation ........................... 15 The Process Evaluation ........................ 15 Analysis of Guideline Effects .................... 16 Chapter Two METHODS AND DATA .......................... 17 Process Evaluation Methods ...................... 18 Outcome Evaluation Methods ..................... 19 Choice of Demonstration and Control Groups ....... 20 vi Evaluation of the Low Back Pain Practice Guideline Implementation Data Sources ................................ 21 The Low Back Pain Population ................... 21 Indicators for Demonstration Effects .............. 22 Definition of Key Variables ...................... 24 Analysis Methods ............................ 26 Chapter Three BASELINE PERFORMANCE OF THE STUDY SITES ...... 29 Distributions of MTFs on Low Back Pain Measures ...... 30 Discussion ................................... 34 Chapter Four INFRASTRUCTURE FOR GUIDELINE IMPLEMENTATION ............................ 37 MEDCOM Support ............................. 37 The Kickoff Conference ........................ 38 The Low Back Pain Toolkit ...................... 39 Information Exchange ......................... 43 Structure and Support at the MTFs ................. 45 Command Support and Accountability ............. 45 The Champions .............................. 46 The Facilitators .............................. 47 The Implementation Teams ..................... 47 Lessons Learned ............................... 48 MEDCOM Support ........................... 48 Support at the MTF ........................... 50 Chapter Five IMPLEMENTATION ACTIONS BY THE DEMONSTRATION SITES ........................ 53 The MTF Environment .......................... 54 MTF Service Capabilities ....................... 54 Climate for Guideline Implementation ............. 55 Implementation Activities and Progress .............. 57 Implementation Strategies ...................... 58 The Implementation Process and Activities ......... 61 Lessons Learned ............................... 66 Flexibility Versus Consistency ................... 67 Monitoring and Accountability .................. 67 Coding and Data Retrieval ...................... 68 Ongoing Provider/Staff Education ................ 68 Patient Education ............................ 68 Contents vii Defining New Procedures and Responsibility for Them ................................. 69 Integrating New Practices ...................... 69 Chapter Six EFFECTS OF GUIDELINE IMPLEMENTATION ........ 71 Provider Knowledge and Acceptance of the Guideline ... 71 Provider Knowledge and Views of the Low Back Pain Guideline ................................. 71 Effects of the Guideline on Providers’ Behavior ....... 73 Reported Changes in Clinical Practices .............. 73 Primary Care Services ......................... 74 Change in Patterns of Referrals ................... 75 Change in Prescription of Pharmaceuticals .......... 75 Staff Perceptions of Patient Satisfaction ............ 76 Analysis of Effects on Clinical Practices .............. 76 The Study Population ......................... 77 Measures and Methods ........................ 78 Referrals to Physical Therapy or Manipulation ....... 79 Follow-Up Primary Care Visits ................... 82 Referrals to Specialty Care ...................... 84 Prescription of Muscle Relaxants ................. 87 Prescription of Narcotics ....................... 90 Prescription of High-Cost NSAIDs ................ 92 Discussion ................................... 95 Chapter Seven LESSONS FROM THE LOW BACK PAIN DEMONSTRATION ............................. 97 Performance on Six Critical Success Factors ........... 97 Some Perspectives for the Treatment Facilities ......... 101 The Corporate Perspective ....................... 102 Appendix A. EVALUATION METHODOLOGY ................... 107 B. REPORTS FROM THE FINAL ROUND OF SITE VISITS ... 117 C. MULTIVARIATE ANALYSES OF LOW BACK PAIN METRICS .................................... 153 References ...................................... 163