Compliance with clinical guidelines for whiplash improved with a targeted implementation strategy: a prospective cohort study

Clinical guidelines for whiplash were developed in Australia [1, 2] for the purpose of improving professional practice, and ultimately changing health outcomes for people with whiplash. Allied health professionals such as physiotherapists, chiropractors and osteopaths were one of the key targets for implementation of the Australian whiplash guidelines, because they are the most commonly consulted health practitioners for the management of whiplash. It is widely reported that dissemination of clinical guidelines alone is unlikely to change health professional’s knowledge or practice [3]. Rather it is suggested that targeted and active implementation strategies need to be used, and barriers to implementation identified, in order to change both professional knowledge and practice.

Active implementation strategies have been effective in changing health professional’s knowledge and practice, however only moderate effects are reported. For example, the most successful implementation strategies identified in Cochrane systematic reviews have reported an absolute risk difference of 6% (95% CI 1.8-15.9) for improving use of endorsed professional practices with a continuing education intervention [4] and 12% (CI 6-14.5) for the use of opinion leaders [5]. To date there is only one systematic review that has examined the effect of active implementation strategies amongst allied health professionals including physiotherapists and chiropractors [6]. This systematic review reported similarly modest effects [6] suggesting room for improvement. Given this, it appears an examination of factors that may improve guideline adherence is warranted.

To date only a few studies have examined barriers to implementation of guidelines amongst health professionals such as physiotherapists and chiropractors. The beliefs of health professionals have been suggested as a factor that would influence behaviour change. Most whiplash guidelines [7‐10], including the Australian guidelines [1, 2] advocate for an active and behavioural approach to management. It has been suggested that when health professionals have a strong biomedical belief system, health practices are less likely to change to align with a more behavioural approach, such as those endorsed in the guidelines [11‐14]. Furthermore, professional background may explain the differences in these belief systems [13]. Professional background and the belief system of the health professional are therefore potential factors that may arise as barriers to implementation.

Other factors have been identified as effect modifiers to compliance with guidelines amongst allied health professionals. These include the experience of the health professional [15], whether the implementation strategy focuses on changing simple or complex behaviours [4, 16], perceived advantage of using the guideline [17] and compatibility between current practice and recommendations [14]. In our previous cluster randomised controlled trial (RCT) [18] implementing guidelines for whiplash, we found that both knowledge and clinical practice were largely consistent with guideline recommendations at baseline, with most physiotherapists already using active treatments. We hypothesised, therefore, that if health professional knowledge and practice were less compliant with guidelines at baseline, the effect on learning should be improved. In order to test this hypothesis, it would be necessary to include a sample of participants whose knowledge and practice was identified as non-compliant with guidelines at baseline.

The primary aim of this study was therefore, to describe and evaluate the effect of a targeted implementation strategy on the knowledge, practice and beliefs of allied health professionals managing patients with whiplash. In addition, this study aimed to identify factors that predicted learning in relation to clinical guidelines for whiplash.

Following a targeted implementation strategy there were large improvements in health professional’s knowledge of whiplash management, beliefs about pain and clinical practice so that it aligned more closely with recommendations in guidelines for whiplash. As hypothesised, knowledge improvement was greatest in practitioners with low baseline knowledge and those whose professional background was physiotherapy. This information may be useful for organisations that implement guidelines, suggesting that educational resources may be best directed at practitioners whose knowledge of the guidelines is poor at baseline. It remains to be tested, whether this strategy would in turn result in greater health outcomes for patients with whiplash.

The improvement in knowledge and clinical practice after the active implementation strategy used in this study would be considered large, when considering previously published effect sizes. It should be remembered that this study in not an RCT, so direct comparisons of effect sizes cannot be made. However, the aim of this study was to prove a concept, namely that those with poor baseline knowledge and compliance would learn more. The proven concept was that low baseline knowledge significantly contributed to the size of the learning effect. Identifying such practitioners is practical in whiplash, because it is a condition primarily arising from a motor vehicle accident and treatment is commonly regulated by insurers, where information regarding health professional knowledge about guidelines can be easily obtained. The results of this study therefore have implications for organisations implementing guidelines for whiplash. They suggest that by measuring baseline knowledge through a questionnaire, implementation costs could be saved by directing education at practitioners with low knowledge, rather than attempting to educate all practitioners.

A key difference in this study to the previous RCT conducted by the authors [18] was the recruitment strategy, aimed to include practitioners whose baseline compliance with guidelines was low. The current strategy appeared effective, given that a considerable proportion (46%) of our participants were assessed as non-compliant at baseline. We hypothesised, however, that non-compliance at baseline would be a predictor of learning, and did not find this. Explanations for this may be statistical, namely we classified people dichotomously as compliant or non-compliant, rather than using a continuous variable that may be more responsive or predictive, as suggested by systematic reviewers [4]. Alternatively, it may be that other factors are more predictive of outcome, such as baseline knowledge and professional background proved to be in this study. In Forsetlund et al's (2009) systematic review, which reviewed the effect of interventions most like ours, significant effect modifiers included the intensity of the education, attendance at education, complexity of the targeted behaviours and seriousness of the outcome. The interpretation of our results together with that of Forsetlund et al (2009) would suggest that known effect modifiers should be considered in future implementation strategies, and that measures of baseline compliance should be a continuous rather than dichotomous variable.

Barriers to implementation have been identified and addressed in order to improve compliance with guidelines in the medical field [21, 22]. However, only recently have data been available for allied health professions such as physiotherapy in terms of implementation strategies. Authors of these studies suggest that clinicians use guidelines if recommendations are similar to their usual practices [14] and beliefs [12] or they can perceive an advantage from using them [17] and note deviation from guidelines if practitioners have little experience with managing the condition [15]. However to date such factors have only accounted for a small percentage of the variance in predicting guideline adherence. For example practitioner factors including perceived advantage accounted for 5.6% of the variance in a model to explain determinants of guideline adherence by physiotherapists to the Dutch guidelines for LBP [17]. The two factors found to predict knowledge to be more consistent with guideline recommendations in our study were low baseline knowledge and profession, accounting for 35% of the variance. Because these data predict a high variance, they suggest that our identified factors should be considered when designing future implementation strategies.

The finding that profession predicted learning in our study warrants further discussion. We found that physiotherapists learned more than chiropractors or osteopaths. These results may reflect the fact that opinion leaders providing the education program were mainly physiotherapists and could have added their experiences and perspectives to the program. However, the content of the clinical guidelines advocate more active (exercise) approaches that may be more familiar to physiotherapists than chiropractors. Recent debates have suggested that if practitioners have more biomedical beliefs that they are less likely to advocate for an active approach than practitioners that have more behavioural beliefs [11, 12]. Therefore, we measured the beliefs of practitioners using the PABS [11] questionnaire, but did not find beliefs to be a predictor of learning. However when we compared beliefs between practitioners, we found that whilst behavioural orientation was similar between professionals, chiropractors and osteopaths had statistically higher biomedical scores than physiotherapists (p = 0.01) which may explain our data. This finding is similar to that reported by Pincus et al. [13] where chiropractors were found to have a more biomedical approach to managing low back pain than physiotherapists [13]. Implementation scientists therefore may need to consider professions and their beliefs when developing an implementation strategy.

In conclusion, factors including low baseline knowledge and profession should be considered when designing future implementation strategies for whiplash guidelines. Based on these data, it is recommended to target the strategy to the identified gaps in the knowledge and to the specific profession. It is hypothesised and remains to be tested as to whether such a strategy will in turn improve health outcomes for patients with whiplash.