Therapeutic Sciences, Trier University of Applied Sciences, Trier, Germany.
Institute of Family Medicine, University of Luebeck, Luebeck, Germany.
BMC Health Serv Res. 2023 Feb 9;23(1):134. doi: 10.1186/s12913-023-09123-1.
Stratified care approach involving use of the STarT-Back tool to optimise care for patients with low back pain is gaining widespread attention in western countries. However, adoption and implementation of this approach in low-and-middle-income countries will be restricted by context-specific factors that need to be addressed. This study aimed to develop with physiotherapists, tailored intervention strategies for the implementation of stratified care for patients with low back pain.
A two-round web-based Delphi survey was conducted among purposively sampled physiotherapists with a minimum of three years of clinical experience, with post-graduation certification or specialists. Thirty statements on barriers and enablers for implementation were extracted from the qualitative phase. Statements were rated by a Delphi panel with additional open-ended feedback. After each Delphi round, participants received feedback which informed their subsequent responses. Additional qualitative feedback were analysed using qualitative content analysis. The criteria for consensus and stability were pre-determined using percentage agreement (≥ 75%), median value (≥ 4), Inter-quartile range (≤ 1), and Wilcoxon matched-pairs test respectively.
Participants in the first round were 139 and 125 of them completed the study, yielding a response rate of 90%. Participants were aged 35.2 (SD6.6) years, and 55 (39.6%) were female. Consensus was achieved in 25/30 statements. Wilcoxon's test showed stability in responses after the 5 statements failed to reach consensus: 'translate the STarT-Back Tool to pidgin language' 71% (p = 0.76), 'begin implementation with government hospitals' 63% (p = 0.11), 'share knowledge with traditional bone setters' 35% (p = 0.67), 'get second opinion on clinician's advice' 63% (p = 0.24) and 'carry out online consultations' 65% (p = 0.41). Four statements strengthened by additional qualitative data achieved the highest consensus: 'patient education' (96%), 'quality improvement appraisals' (96%), 'undergraduate training on psychosocial care' (96%) and 'patient-clinician communication' (95%).
There was concordance of opinion that patients should be educated to correct misplaced expectations and proper time for communication is vital to implementation. This communication should be learned at undergraduate level, and for already qualified clinicians, quality improvement appraisals are key to sustained and effective care. These recommendations provide a framework for future research on monitored implementation of stratified care in middle-income countries.
分层护理方法涉及使用 STarT-Back 工具来优化对腰痛患者的护理，这种方法在西方国家越来越受到关注。然而，在中低收入国家采用和实施这种方法将受到需要解决的特定于背景的因素的限制。本研究旨在与物理治疗师一起制定针对腰痛患者分层护理实施的定制干预策略。
对具有至少三年临床经验、毕业后认证或专科医生的物理治疗师进行两轮基于网络的 Delphi 调查。从定性阶段中提取了 30 条关于实施障碍和促进因素的陈述。Delphi 小组对陈述进行了评分，并附有额外的开放式反馈。在每一轮 Delphi 之后，参与者都会收到反馈，这将为他们的后续回复提供信息。使用定性内容分析对额外的定性反馈进行分析。使用百分比一致性（≥75%）、中位数（≥4）、四分位距（≤1）和 Wilcoxon 匹配对检验分别预先确定了共识和稳定性的标准。
第一轮的参与者为 139 人，其中 125 人完成了研究，应答率为 90%。参与者的年龄为 35.2（6.6）岁，其中 55 人（39.6%）为女性。30 条陈述中有 25 条达成共识。Wilcoxon 检验表明，在 5 条陈述未能达成共识后，反应保持稳定：“将 STarT-Back 工具翻译成洋泾浜语言”71%（p=0.76），“从公立医院开始实施”63%（p=0.11），“与传统整骨师分享知识”35%（p=0.67），“对临床医生的建议进行第二次诊断”63%（p=0.24）和“进行在线咨询”65%（p=0.41）。四项通过额外定性数据得到加强的陈述达到了最高共识：“患者教育”（96%）、“质量改进评估”（96%）、“本科阶段的社会心理保健培训”（96%）和“医患沟通”（95%）。
意见一致认为，应教育患者纠正错误的期望，适当的沟通时间对于实施至关重要。这种沟通应该在本科阶段学习，对于已经合格的临床医生，质量改进评估是持续有效的护理的关键。这些建议为在中等收入国家监测分层护理实施的未来研究提供了框架。
