1. LEARNING TO IMPROVE THE MANAGEMENT OF BACK PAIN IN THE COMMUNITY (THE LIMBIC PROJECT) Eloise C. Carr 1, Jennifer Langworthy 2, Alan Breen 2, Charles Campion-Smith 1, Peter Wilcock 3, Louise Worswick 1 Dawn Jackson 1 1. Bournemouth University, Bournemouth, Dorset, UK, 2. Institute of Musculoskeletal Research & Clinical Implementation, Bournemouth, Dorset, UK, 3. Salisbury NHS Foundation Trust, Salisbury, Wiltshire, UK Methods This study uses a mixed method design which includes a quantitative and qualitative component. The quantitative element comprises a baseline study of 64 prospective patients attending a primary care consultation for back pain across 9 participating practices. This took place prior to commencement of 8 half-day workshops in 2008 and again 8 weeks later. Patient data: Patients; demographic information, Roland and Morris Disability Questionnaire (Roland and Morris 1983), Deyo’s Back Pain Symptom Frequency and ‘Bothersomeness Index’ (Deyo 1988), The Medical Outcomes Study SF-12 questionnaire, the Patient Satisfaction Scale (Cherkin and Deyo 1991). Practice process data referral for investigations, NHS services, and visits to General Practitioner/Family Physician (GP) Professional Practice teams will be evaluated in terms of their own learning and changes in their delivery of care around back pain using questionnaires and focus group interviews. Preliminary results Patient data (baseline) Mean age: 45.39yrs (range 22-69yrs) Gender: 52% (n=33) female 48% (n=30) male Duration of current episode: Mean 3.84wks (SD 2.88) (range 1-12wks) Chronicity: LBP on <50% of days in past 12mths 60% (n=3) LBP on >50% of days in past 12mths 16% (n=10) First ever episode 25% (n=16) Mean severity score over past week (1=no pain 10=worst possible pain): 7.36 (SD 1.82) Mean disability score (0=no disability 24=severe disability): 11.16 (SD 5.60) Mean LBP bothersomeness score over past wk (1=not at all bothersome 5=extremely bothersome): 3.84 (SD 0.96) Mean score for Interference with normal work (inside & outside the home (0=not at all 4=extremely): 2.94 (SD 1.11) Mean number of days cut down normal activity over past 4wks: 8.13 (SD 7.37) Mean days of work/school absence over past 4wks due to LBP: 4.91 (SD 5.93) Mean score for self-rated general health (0=poor 4=excellent) 2.61 (SD 0.90) Mean interference over past 4wks with social activities due to physical or emotional problems (0=none of the time 4=all of the time): 1.48 (SD 1.18) Practice data Process data has been received from 7 of the practices and data is available for a total of 351 patients. Referral (diagnostics) and costs Professional data Preliminary analysis on the Attitudes to Back Pain Questionnaire for General Practitioners (ABQ-GP) has been undertaken on a returned sample of 21/42 (50%). GPs in this sample were found to have, a moderately positive (61%, SD 2.13) outlook with regard to the management of patients with non-resolving low back pain. Expectations of interprofessional education from focus group interviews The practice improvement projects selected by the Practices: “Quality improves as we improve the match between our services and the care needs of the people who depend on them” 9 practice teams are following an improvement framework that helps plan and test changes on a small scale. Improvement projects to date are: Exercise and information leaflets Laminated information card Laminated information card Receptionists giving information Patient telephone reminder for physiotherapy appointments Information giving via TV in patient waiting area 1. Picavet HSJ & Schouten J (2003) Musculoskeletal pain in the Netherlands: prevalence, consequences and risk groups, the DMC(3) study. Pain;102:167-178 2. Breen A, Campion-Smith C, Austin H. Carr ECJ & Mann E (2007) “You feel so hopeless”: a qualitative study of GP management of acute back pain. European Journal of Pain 11(1):21-29. 3. Grimshaw, J. M., R. E. Thomas, et al. (2004). "Effectiveness and efficiency of guideline dissemination and implementation strategies." Health Technology Assessments ;8(6): 1-102 Conclusion and next steps: The preliminary findings illustrate the complexity of back pain management in the primary care setting. It illuminates how practices teams use improvement knowledge and apply this to their own learning and practice. Using collaborative action learning groups supporting practice staff who are using ‘improvement methodologies’ to improvement involving general practice staff as well as patients is seen as a worthwhile approach to the management of back pain. So I am looking forward to it [Receptionist] Further information: Dr Eloise Carr ecarr@bournemouth.ac.uk 1 Acknowledgements The LIMBIC project Steering group. This project is funded by the Health Foundation as part of their funding scheme ‘Engaging with Clinicians in Primary Care’ www.health.org.uk I would really like to hear what the patients say, in a safe environment. I would really like to hear what they want [GP] interesting…exciting…[ Practice Manager] the initial contact is important There are long waits for referral.. Workshops 9 practices are participating; each represented by a GP, practice nurse, practice manager, a physical therapist, either a receptionist or further nurse, and a patient. Participants from each practice form an ‘Action Learning Group’ (ALG). Workshops include; back pain topics identified by participants, improvement methodology. Each practice works on an ‘improvement project’ between workshops Workshop evaluation: rapid feedback questionnaires completed at the end of each workshop, ABQ-GP questionnaires completed at the beginning and end of the project. Expectations from patient representatives Some practice teams were initially uncertain about the importance of the role of the patient representative on the team. Most however, were keen to involve a patient in the baseline focus groups which aimed to identify any current concerns. All patients said they “look forward to understanding more” but…. they didn’t recognise my need for knowledge Introduction Non-specific low back pain is common with an estimated 12 month prevalence rate of 44% in the general population1. When seeing patients with back pain, GP’s have reported feelings of frustration, lack of time, conflict with the patients expectations, difficulties negotiating sick certification and inadequate local resources2. The challenge when evaluating an educational intervention is to develop a coherent evaluation which includes patient outcomes, health professional and organisational change3. Aim of Investigation The aim of the project is to document baseline data evaluating an inter-professional learning approach (8 workshops) which links practice based learning with the principles and methods of healthcare improvement. Key objectives Improve clinical outcomes for the treatment of low back pain. Improve practice (e.g. implementation of national guidelines, team working, decision-making, improving quality and reducing costs). Improve understanding and develop capacity for continuous improvement learning and develop participating practices’ capability to reduce gaps in other clinical areas for the future.