Use of the knowledge to action model improved physical therapist adherence to a common clinical practice guideline across multiple settings: a multisite case series

Five sites with rehabilitation services for patients with peripheral vestibular hypofunction participated in this organizational case series (Table 1). Opinion leaders, from the Academy of Neurologic Physical Therapy Peripheral Vestibular Hypofunction Guideline Dissemination and Implementation Taskforce, served as site leaders for the project. Four site leaders were practicing physical therapists at the participating sites (local opinion leaders), one site (site C) was led by a collaborating academic physical therapist. All sites agreed to participate and secured institutional review board approval. Site leaders and the principal investigator met twice per month from project inception through the completion of data collection to facilitate collaboration and project fidelity across sites.

The Knowledge to Action process model [26] served as the foundation for implementation at each site. The seven phases of the outer circle (‘action cycle’) of the Knowledge to Action model are outlined in Fig. 1. The methods that follow are organized by these phases.

The primary outcome for the case series analysis was difference in adherence to site-specific goals before and after the implementation intervention. Chart review, tally counts, and survey data were collected using REDCap electronic data capture tools hosted at the University of Southern California and reported using descriptive statistics.

Chart reviews (collected for the 6 months before and after the intervention) included patients that: 1) were seen for an initial evaluation during the 6-month time period, and 2) had a diagnosis of peripheral vestibular hypofunction. After identifying appropriate charts to include in the pre or post sample, the medical record was reviewed. Each chart reviewer looked at treating therapist documentation to determine compliance at two levels: 1) adherence across the whole episode of care (defined as the time between initial evaluation and discharge) and 2) adherence at each patient encounter. For example, offering a patient the opportunity to sign up for reminder text messages was expected to occur at one time point across an episode of care, while recording the dose of a patient’s prescribed home exercises was expected to occur at each patient encounter. Chart reviewers also established criteria at their site to determine if a compliance behavior was not applicable to a given patient encounter. For example, a patient without symptoms consistent with anxiety would be excluded from a count for therapist behaviors that should be provided to patients with those symptoms. Patient visits in which the compliance question was not applicable were excluded from that analysis. As a result, the total number of patient records assessed for episode of care level target behaviors and patient visit level target behaviors varied.

Because of the case series nature of the study, separate analyses were conducted for each site to determine change in adherence using chi-square and t-test to measure differences in pre- to post-goal adherence. We used a Bonferroni adjustment based on the number of variables tested per site to mitigate spurious findings due to multiple comparisons. All analyses were conducted using SAS Education edition statistical software.