HEALTH PRACTITIONERS' PERCEPTIONS OF ADOPTING CLINICAL PREDICTION RULES IN THE MANAGEMENT OF MUSCULOSKELETAL PAIN: A QUALITATIVE STUDY

Kelly J.^1,2, Sterling M.^1,2, Rebbeck T.^2,3, Bandong A.N.^3,4, Leaver A.³, Mackey M.³, Ritchie C.^1,2

¹Recover Injury Research Centre, Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia, ²NHMRC Centre of Clinical Research Excellence in Recovery Following Road Traffic Injuries, Gold Coast, Australia, ³University of Sydney, Faculty of Health Sciences, Sydney, Australia, ⁴University of the Philipines, Department of Physical Therapy, Manila, Philippines

Background: Clinical prediction rules (CPRs) have the potential to improve the management of individuals with musculoskeletal pain by assisting health practitioners to make more accurate judgments of diagnosis, prognosis or likely response to a specific intervention. Although several appropriately developed CPRs exist, evidence suggests that clinical adoption of these tools is poor. Determining the influencing factors health practitioners' use to decide whether or not to adopt a CPR is important given tool development is time consuming and costly, and the value of these tools relies on routine implementation by clinicians.

Purpose: To explore health practitioners' understanding and practice behaviours in regards to CPRs, and to investigate their perceptions of adopting a newly validated prognostic whiplash CPR.

Methods: Six semi-structured focus groups were conducted in Sydney and Brisbane, Australia. Participants were recruited using a purposive sampling framework and comprised physiotherapists (n = 19), chiropractors (n = 6) and osteopaths (n = 3) who provide routine treatment to people with whiplash associated disorders. Discussions were audio-recorded, transcribed verbatim and analysed using an inductive thematic approach. Credibility of the inquiry was enhanced through research team and member subjectivity checks of findings.

Results: Health practitioners’ understanding and clinical use of CPRs was mixed. Participants considered components relating to acceptability (‘whether I agree with it’) and implementation (‘how I’ll use it’) when deciding on whether or not to adopt a new CPR. Acceptability was informed by four themes: knowledge and understanding, CPR type, congruence and weighted value. Consideration of matters that promote implementation occurred once a CPR was deemed to be acceptable. Three themes were identified as having potential to enhance implementation of the whiplash CPR: an external driver of adoption, flexibility in how the CPR could be administered, and guidance regarding communication of CPR output to patients.

Conclusion(s): Multiple factors underpin the decision-making process of health practitioners when considering whether or not to adopt a CPR. Assessment of adequate acceptability or ‘agreement in general’ was an essential first step in the adoption process. Acceptability was impeded by misunderstanding of CPR purpose and perceived fit with practice, and facilitated where the CPR was of diagnostic or prognostic type, was perceived to be congruent with clinicians’ personal experiences, and was anticipated to provide positive value to patient management.

Implications: General education on CPR purpose and fit with practice is needed so that health practitioners are better able to judge the merits of available CPRs. Researchers developing future CPRs should prioritise diagnostic and prognostic tools and ensure a level of congruence is possible between the CPR and current clinical reasoning frameworks. A whiplash CPR impact-analysis study that includes situated learning opportunities for clinicians, an external source of motivation, administrative flexibility, and appropriate guidance to support communication of the CPR’s output is necessary to address identified barriers to change, whilst progressing the CPR’s stage of development to one that supports more widespread implementation.

Funding acknowledgements: This project was funded by Motor Accident Insurance Commission Queensland (MAIC) and State Insurance Regulatory Authority New South Wales (SIRA)

Topic: Musculoskeletal: spine

Ethics approval: Approved by the University of Sydney (2015/444) and Griffith University (2015/707) Human Research Ethics Committees

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