1. Facilitators and Barriers to Application of Low Back Pain Clinical Guidelines Alan K. Novick, MD Rehabilitation Medical Director Memorial Rehabilitation Institute

2. Objectives Develop a basic understanding of the Agree II tool with respect to “Applicability” Develop an understanding of potential barriers and obstacles to application of LBP clinical guidelines including financial and societal Develop a knowledge of potential facilitators to apply LBP clinical guidelines

3. Disclosures I have no financial disclosures

4. AGREE II Tool Score –1 to 7 1= Strongly Disagree 7= Strongly Agree 23 Items 6 Domains

5. AGREE II Tool

6. AGREE II Domain 5: Applicability Guideline18192021Avg NASS Spinal Stenosis2.25 2.02.755.5 NASS Deg Spondylolithesis1.81.21.03.46.0 AAOS Symptomatic Osteoporosis comp fx1.333.01.332.336.0 APT: LBP CPGs linked to the ICF1.62.8.82.23.2

7. Cabana MD, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999 Oct 20;282(15):1458-65. –Review of 78 published studies describing at least 1 barrier Knowledge –Lack of awareness n=46 Attitudes –Lack of agreement n=33 –Lack of self-efficacy n=19 –Lack of outcome expectancy n=8 –Lack of motivation n=14 Behavior –External Barriers n=34 PatientGuidelineEnviromental

8. Cabana MD, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999 Oct 20;282(15):1458-65. Lack of awareness –Volume of information Lack of agreement –Too cookbook, Too rigid –Interpretation of evidence Lack of self-efficacy –Belief that physician can’t perform CPG Lack of outcome expectancy –Belief that CPG will not lead to desired outcome Lack of motivation –Inertia of previous practice habits

9. Cabana MD, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999 Oct 20;282(15):1458-65. External Barriers –Patient Inability to reconcile patient preferences –Guideline Presence of contradictory guidelines –Environmental Lack of time, resources organizational constraints Perceived increase in malpractice liability

10. Ayres CG, Griffith HM. Perceived barriers to and facilitators of the implementation of priority clinical preventive services guidelines. Am J Manag Care. 2007 Mar;13(3):150-5. Focus groups from health plan providers –Barriers Payment and Cost Time Legal Issues Inconsistency among HP tools Lack of internalization Patient-clinician relationship –Facilitators HP support Patient Materials Clinician awareness HP tool consistency

11. Légaré F, et al. Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals' perceptions. Patient Educ Couns. 2008 Dec;73(3):526-35. 38 studies, 3231 participants, 89% physicians –Barriers Time constraints (22/38) Lack of applicability due to patient characteristics (18/38) Clinical situations (16/38) –Facilitators Provider Motivation (23/38) Positive impact on the clinical process (16/38) Patient outcomes (16/38)

12. Barriers: LBP CPG’s Lack of defined group of practitioners –Ortho, Neurosurgery, PM&R, Rheumatology, Anesthesiology and Primary Care may all treat back pain Different clinical approaches Challenging to get consensus or distribute CPGs

13. Barriers: LBP CPG’s Financial –Cost of treatment –Resource Utilization HMO may require conservative treatment prior to diagnostic testing

14. NASS Spinal Stenosis CPG

15. Barriers: LBP CPG’s Financial –Cost of treatment –Resource Utilization HMO may require conservative treatment prior to diagnostic testing –Evidence inconclusive for pharmacologic or therapeutic treatments –MRI appropriate diagnostic test –May be unable to order MRI until fails conservative treatment –Economic Incentives Physician ownership/profitability –Imaging & therapy centers, dispensary

16. Barriers: LBP CPG’s Resource Availability –Sufficient practitioners with skills to deliver the recommended care –Sufficient equipment Clinical Practice Guideline –Structure variability –Size

17. Barriers: LBP CPG’s Societal –Patient expectations Patients often want certain treatments/testing (MRI, medications, etc.) Patient satisfaction –May impact physician scorecard/reviews Web based physician rating sites Employed physician compensation

18. Barriers: LBP CPG’s Societal –Liability Defensive medicine

19. Facilitators: LBP CPG’s

20. Research Consensus between specialties Input from all stakeholders –Patients –Multiple specialists –Imaging centers/therapy centers Standardization of CPGs Tools for implementation Distribution of Information –Website postings of CPGs

21. Conclusion