Measuring Process Adherence with the Low Back Pain Treatment-Based

Measuring Process Adherence with the Low Back Pain Treatment-Based Classification System BACKGROUND The Low Back Pain (LBP) Clinical Practice Guideline recommends that therapists utilize a classification system to subgroup patients in the evaluation and treatment of LBP. Compliance to guidelines in healthcare is generally poor (McGlynn 2003). The purpose of this implementation study was to measure the effect of a regular audit and feedback process on therapist adherence to the TreatmentBased Classification (TBC) system. Significance: Once a classification system for evaluating and directing treatment of low back pain (LBP) is implemented there is limited evidence on therapists’ continued adherence to the system. “Matching” treatment with the classification system can improve patient outcomes (Fritz 2007). METHODS Patients with 3+ visits for LBP were audited for adherence to the TBC system in 2017 Q4 and 2018 Q2-4 (n=749) for 35 outpatient orthopedic clinics. Adherence was defined as a therapist making a correct classification and matching the first treatment to that classification. At the end of each quarterly audit, feedback was provided to each clinic manager for individual clinician performance reviews. Overall adherence was measured each quarter for the health system. The Modified Low Back Disability Questionnaire (MDQ) was measured at every visit and used to determine whether a Minimal Clinically Important Difference (MCID = 6 points) was met during the episode of care. Adherent and Incomplete Charts 80.0% 70.0% 60.0% 50.0% 57.0% 62.0% 62.6% 19.7% 16.5% 68.7% 40.0% 30.0% 20.0% 29.1% 10.0% 8.9% 0.0% 2017 Q4 2018 Q2 2018 Q3 Adherent Incomplete Charts MCID Classification Success 2018 Q4 MCID Failure Total Adherent 337 137 474 Not Adherent 166 109 275 503 246 749 Pearson X2 (1) = 9.09, p = .003 RESULTS TBC adherence increased each measurement quarter: 2017 Q4 = 57.0% (n=151), 2018 Q2 = 62.0% (n=213), Q3 = 62.6% (n = 139), Q4 = 68.7% (n = 246). The difference between the first and last quarters was statistically significant (Pearson X2 (1, n = 397) = 5.56, p=.02) and represents a 11.7% improvement in adherence over the year. Adherent care was associated with achieving an MCID on the MDQ: Pearson X2 (4, n = 749) = 9.09, p=.003. CONCLUSION The initial adherence rate of 57% is consistent with other research auditing adherence to standard care processes. Adherence was successfully increased by 11.7% over 1 year of conducting an audit and feedback process. Improvement in adherence appears to be related to conducting a more complete evaluation. Patients who received adherent care were more likely to achieve an MCID improvement on the MDQ.