van der Wees Philip J, Hendriks Erik J M, Jansen Mariette J, van Beers Hans, de Bie Rob A, Dekker Joost
Department of Epidemiology, Center for Evidence Based Physiotherapy and Caphri Research Institute, Maastricht University, The Netherlands.
BMC Musculoskelet Disord. 2007 May 22;8:45. doi: 10.1186/1471-2474-8-45.
Clinical guidelines are considered important instruments to improve quality in health care. In physiotherapy, insight in adherence to guidelines is limited. Knowledge of adherence is important to identify barriers and to enhance implementation. Purpose of this study is to investigate the ability to adherence to recommendations of the guideline Acute ankle injury, and to identify patient characteristics that determine adherence to the guideline.
Twenty-two physiotherapists collected data of 174 patients in a prospective cohort study, in which the course of treatment was systematically registered. Indicators were used to investigate adherence to recommendations. Patient characteristics were used to identify prognostic factors that may determine adherence to the guideline. Correlation between patient characteristics and adherence to outcome-indicators (treatment sessions, functioning of patient, accomplished goals) was calculated using univariate logistic regression. To calculate explained variance of combined patient characteristics, multivariate analysis was performed.
Adherence to individual recommendations varied from 71% to 100%. In 99 patients (57%) the physiotherapists showed adherence to all indicators. Adherence to preset maximum of six treatment sessions for patients with severe ankle injury was 81% (132 patients). The odds to receive more than six sessions were statistically significant for three patient characteristics: females (OR:3.89; 95%CI: 1.41-10.72), recurrent sprain (OR: 6.90; 95%CI: 2.34 - 20.37), co-morbidity (OR: 25.92; 95% CI: 6.79 - 98.93). All factors together explained 40% of the variance. Inclusion of physiotherapist characteristics in the regression model showed that work-experience reduced the odds to receive more than six sessions (OR: 0.2; 95%CI: 0.06 - 0.77), and increased explained variance to 45%.
Adherence to the clinical guideline Acute ankle sprain showed that the guideline is applicable in daily practice. Adherence to the guideline, even in a group of physiotherapists familiar with the guideline, showed possibilities for improvement. The necessity to exceed the expected number of treatment sessions may be explained by co-morbidity and recurrent sprains. It is not clear why female patients were treated with more sessions. Experience of the physiotherapist reduced the number of treatment sessions. Quality indicators may be used for audit and feedback as part of the implementation strategy.
临床指南被视为提高医疗保健质量的重要工具。在物理治疗领域，对指南依从性的了解有限。了解依从性对于识别障碍和加强实施至关重要。本研究的目的是调查对《急性踝关节损伤指南》建议的依从能力，并确定决定对该指南依从性的患者特征。
在一项前瞻性队列研究中，22名物理治疗师收集了174名患者的数据，对治疗过程进行了系统记录。使用指标来调查对建议的依从性。患者特征用于识别可能决定对指南依从性的预后因素。使用单变量逻辑回归计算患者特征与对结局指标（治疗次数、患者功能、完成目标）依从性之间的相关性。为了计算综合患者特征的解释方差，进行了多变量分析。
对个别建议的依从性从71%到100%不等。在99名患者（57%）中，物理治疗师对所有指标均表现出依从性。对于重度踝关节损伤患者，遵循预设的最多六次治疗疗程的依从率为81%（132名患者）。对于三个患者特征，接受超过六次治疗的几率具有统计学意义：女性（比值比：3.89；95%置信区间：1.41 - 10.72）、复发性扭伤（比值比：6.90；95%置信区间：2.34 - 20.37）、合并症（比值比：25.92；95%置信区间：6.79 - 98.93）。所有因素共同解释了40%的方差。在回归模型中纳入物理治疗师特征表明，工作经验降低了接受超过六次治疗的几率（比值比：0.2；95%置信区间：0.06 - 0.77），并将解释方差提高到45%。
对《急性踝关节扭伤临床指南》的依从性表明该指南适用于日常实践。即使在一组熟悉该指南的物理治疗师中，对指南的依从性仍有改进的空间。治疗疗程超过预期次数的必要性可能由合并症和复发性扭伤来解释。尚不清楚女性患者接受更多疗程治疗的原因。物理治疗师的经验减少了治疗次数。质量指标可作为实施策略的一部分用于审核和反馈。
