Table 3 Studies that tested ongoing, intermittently re-enforced implementation interventions

Becker et al., 2008 [44]

GPE: 3 MFE sessions with feedback for GPs

MC: 3 MFE sessions with feedback for GPs and motivational counselling training for practice nurses

CG: Postal dissemination of guidelines only

Primary outcome measure:

Primary outcome measure at 6 months:

Primary outcome measure at 12 months:

Partially successful.

There was a statistically significant difference between the MC and CG at 6 months on the HFAQ but not at 12 months

Days in pain at 6 months in the MC and GPE were also statistically less than the CG, with the GPE maintaining that difference at 12 months

Quality of life score was statistically significantly higher in the MC than the CG at 12 months

Mean score on the HFAQ

72.94 GPE v 73.94 MC v 70.29 CG

GPE v CG: CI: −0.704 to 6.007; ρ = 0.12

MC v CG: CI: 0.32 to 6.979; ρ = 0.032*

72.96 GPE v 74.64 MC v 71.56 CG

GPE v CG: CI: −2.224 to 5.017; ρ = 0.446

MC v CG: CI: −0.47 to 6.697; ρ = 0.088

Secondary outcome measures:

Secondary outcome measures at 6 months:

Secondary outcome measures at 12 months:

1. Mean score on the FQPA

1. 36.47 GPE v 36.29 v 33.51 CG

GPE v CG: CI: −1.628 to 7.545; ρ = 0.203

MC v CG: CI: −1.784 to 7.347; ρ = 0.23

1. 46.43 GPE v 45.40 MC v 42.88 CG

GPE v CG: CI: −1.452 to 8.543; ρ = 0.202

MC v CG: CI: −2.476 to 7.495; ρ = 0.396

2. Mean days in pain over the last 6 months.

2. 63.34 GPE v 62.91 MC v 80.78 CG

GPE v CG: CI: −26.833 to −6.034; ρ = 0.002*

MC v CG: CI: −28.183 to −7.553; ρ = 0.001*

2. 58.48 GPE v 61.57 MC v 71.32 CG

GPE v CG: CI: −23.382 to −2.296; ρ = 0.018*

MC v CG: CI: −20.198 to −0.689; ρ = 0.067

3. Mean days of sick leave in the previous 6 months

3.12.99 GPE v 13.05 MC v 14.34 CG

GPE v CG: CI: −5.972 to 3.287; ρ = 0.569

MC v CG: CI: −5.905 to 3.331; ρ = 0.584

3. 6.16 GPE v 6.46 MC v 9.27 CG

GPE v CG: CI: −8.582 to 2.358; ρ = 0.256

MC v CG: CI: −8.463 to 2.837; ρ = 0.32

4. Quality of life score (Euro Qol)

4. 66.59 GPE v 67.53 MC v 66.85 CG

GPE v CG: CI: −2.864 to 2.355; ρ = 0.847

MC v CG: CI: −1.924 to 3.302; ρ = 0.602

4. 68.46 GPE v 70.37 MC v 67.65 CG

GPE v CG: CI: −1.736 to 3.344; ρ = 0.535

MC v CG: CI: 0.185 to 5.26; ρ = 0.036*

5. FABQ

5. Not expressed as a result

5. Not expressed as a result

Bishop & Wing, 2006 [28]

IG1: Copy of the guidelines appropriate to management at that time frame sent at assessment; 0–4 weeks; 5–12 weeks and 12 weeks+

IG2: As the IG1 but with patient educational materials at the same stages. CG: No guidelines sent

Primary outcome measure not specified

Outcome measures:

Largely unsuccessful.

The only statistically significant differences between groups were: recommending aerobic exercise in the IG2 v CG and bed rest=/<4 days recommended in the IG1 v CG.

At assessment:

History of initiating event

Prior history of a similar symptoms

Neurological examination

Regional back examination

Reference to presence or absence of red flags

0-4 weeks:

Exercise and reassurance given

Aerobic exercise promoted

Non-narcotic medication prescription

Physical therapy modalities usage

Spinal mobilisation usage

Bed rest of 4 days or less recommended

5-12 weeks:

Work conditioning programmes utilised

5-12 weeks discordant:

Physical therapy modalities usage.

12 weeks + concordant:

Return to full or modified work.

12 weeks + discordant:

Continued passive therapy or spinal manipulation; recycling through treatments; use of programmes that had previously failed.

Goldberg et al., 2001 [31]

IG: Surgeon study group meetings; use of local opinion leaders; GP education sessions; printed educational materials; audit; patient educational materials; financial data analysis meetings.

CG: Usual care.

Primary outcome measure:

Lumbar spine surgery rate per 100,000 adults.

Successful. The difference between the IG and the CG was statistically significant

Kerry et al., 2000 [22]

IG: Guidelines and a covering letter posted at baseline; revised guidelines at 9 months with feedback on referral rates over previous 6 months

CG: No guidelines sent

Primary outcome measure:

Radiograph request rates.

Successful. The difference between the IG and the CG was statistically significant

Schectman et al., 2003 [23]

E&F: 90-min education session, a copy of the guideline, audit report of patient care during prior year. Follow up at 6 months with a further audit report

E&F&PE: As above but with addition of patient educational materials (printed and audio-visual)

PE: Patient educational materials only

CG: No intervention

Primary outcome measure not specified.

Outcome measures:

Unsuccessful. There were no statistically significant differences between groups.

1. Lumbar spine radiograph request rates

2. CT/MRI request rates

3. Sub-speciality referral rates

4. PT referral rates

Winkens et al., 1995 [47]

IG: Regular feedback (x 5 over 2 yrs 7 months) on audit of quantity and quality of diagnostic test referrals

CG: No feedback.

Primary outcome measures:

Partially successful.

No statistically significant differences between groups in lumbar spine request rate.

There was a statistically significant difference between non-rational requests for lumbar spine radiographs pre and post intervention.

ρ = 0.004*

1. Radiograph request rate

2. Rate of non-rational requests.