New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 02130-4817, USA.
Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA.
BMC Musculoskelet Disord. 2020 Nov 25;21(1):776. doi: 10.1186/s12891-020-03800-6.
Although risk-stratifying patients with acute lower back pain is a promising approach for improving long-term outcomes, efforts to implement stratified care in the US healthcare system have had limited success. The objectives of this process evaluation were to 1) examine variation in two essential processes, risk stratification of patients with low back pain and referral of high-risk patients to psychologically informed physical therapy and 2) identify barriers and facilitators related to the risk stratification and referral processes.
We used a sequential mixed methods study design to evaluate implementation of stratified care at 33 primary care clinics (17 intervention, 16 control) participating in a larger pragmatic trial. We used electronic health record data to calculate: 1) clinic-level risk stratification rates (proportion of patients with back pain seen in the clinic over the study period who completed risk stratification questionnaires), 2) rates of risk stratification across different points in the clinical workflow (front desk, rooming, and time with clinician), and 3) rates of referral of high-risk patients to psychologically informed physical therapy among intervention clinics. We purposively sampled 13 clinics for onsite observations, which occurred in month 24 of the 26-month study.
The overall risk stratification rate across the 33 clinics was 37.8% (range: 14.7-64.7%). Rates were highest when patients were identified as having back pain by front desk staff (overall: 91.9%, range: 80.6-100%). Rates decreased as the patient moved further into the visit (rooming, 29.3% [range: 0-83.3%]; and time with clinician, 11.3% [range: 0-49.3%]. The overall rate of referrals of high-risk patients to psychologically informed physical therapy across the 17 intervention clinics was 42.1% (range: 8.3-70.8%). Barriers included staffs' knowledge and beliefs about the intervention, patients' needs, technology issues, lack of physician engagement, and lack of time. Adaptability of the processes was a facilitator.
Adherence to key stratified care processes varied across primary care clinics and across points in the workflow. The observed variation suggests room for improvement. Future research is needed to build on this work and more rigorously test strategies for implementing stratified care for patients with low back pain in the US healthcare system.
Trial registration: ClinicalTrials.gov ( NCT02647658 ). Registered January 6, 2016.
尽管对急性腰痛患者进行风险分层是改善长期预后的一种很有前景的方法，但在美国医疗保健系统中实施分层护理的努力收效甚微。本过程评估的目的是：1）检查两个基本过程（对腰痛患者进行风险分层和将高风险患者转介给接受心理知情的物理治疗）的变化；2）确定与风险分层和转介过程相关的障碍和促进因素。
我们采用了一项顺序混合方法研究设计，以评估参与一项大型实用试验的 33 家初级保健诊所（17 家干预诊所，16 家对照诊所）中分层护理的实施情况。我们使用电子健康记录数据来计算：1）诊所层面的风险分层率（在研究期间在诊所就诊的腰痛患者中完成风险分层问卷的比例）；2）不同临床工作流程点（前台、分诊和与临床医生的时间）的风险分层率；3）干预诊所中高风险患者转介给接受心理知情的物理治疗的比例。我们在第 26 个月的第 24 个月对 13 家诊所进行了现场观察，采用了有目的的抽样方法。
33 家诊所的总体风险分层率为 37.8%（范围：14.7-64.7%）。当前台工作人员识别出患者有腰痛时，分层率最高（总体：91.9%，范围：80.6-100%）。随着患者就诊流程的推进，分层率下降（分诊：29.3%[范围：0-83.3%]；与临床医生的时间：11.3%[范围：0-49.3%]）。17 家干预诊所高风险患者转介给接受心理知情的物理治疗的总体比例为 42.1%（范围：8.3-70.8%）。障碍包括员工对干预措施的知识和信念、患者的需求、技术问题、医生参与度不足以及缺乏时间。流程的适应性是一个促进因素。
主要的分层护理流程在各个初级保健诊所和工作流程点的执行情况各不相同。观察到的变化表明仍有改进的空间。未来的研究需要在此基础上进一步探索和严格测试在美国医疗保健系统中为腰痛患者实施分层护理的策略。
临床试验.gov（NCT02647658）。2016 年 1 月 6 日注册。
