Process evaluation of the implementation of an evidence-based model of care for low back pain in Australian emergency departments

Abstract

Introduction: Low back pain (LBP) accounts for a substantial proportion of years lived with disability worldwide, and increasingly patients with LBP are seeking care in emergency departments. In Australia, LBP presentations are among the top 10 reasons for emergency department visits. However, a recognised problem is that the care provided in the emergency department for non-serious LBP seems to conflict with recommendations in clinical practice guidelines. The Sydney Health Partners Emergency Department (SHaPED) trial aims to implement a new model of care developed by the Agency for Clinical Innovation (ACI) in collaboration with policy makers, clinicians, consumers and researchers. This model of care was based on high quality evidence and formulate key messages for practice. In addition to the effectiveness analysis, implementation trials should also conduct a process evaluation of the intervention to explore the differences between the observed and expected results and to identify the factors which influenced the results. Objectives: (a) to investigate the opinions and experiences of emergency clinicians with the implementation process of the ACI model of care (b) to investigate the opinions regarding the material developed for implementation of the ACI model of care; and (c) to assess the barriers and facilitators of the implementation strategies of the ACI model of care in emergency departments. Methods: The emergency departments of three urban hospitals in New South Wales, Australia will participate in the study: Royal Prince Alfred Hospital, Concord Repatriation General Hospital, and Canterbury Hospital. Participants in this process evaluation will be a sample of emergency clinicians (eg physicians, nurses, and physiotherapists) who participated in the Sydney Health Partners Emergency Department (SHaPED) trial. Clinician participants will be invited to participate in the process evaluation considering their availability. We will include clinician participants until saturation is reached in the interviews, that is, when the last interview does not add any relevant information to the study's objectives. Quantitative data will be collected before and after the implementation of the ACI model of care, including the Back Beliefs Questionnaire, and a set of questions measuring their knowledge about the management of LBP and attitudes towards patients. Qualitative data will be collected after the intervention to assess the opinion of emergency clinicians about the strategies used for the implementation of the new model of care. The interviews will be conducted using a set of questions to investigate the interaction of the clinicians with some aspects of the implementation process: instructions during training, research team, training methods, education materials, audio-visual materials, and group discussions. In addition, we will also explore the responses obtained with the Back Beliefs Questionnaire using open-ended questions. Quantitative data will be analysed using paired t tests or Wilcoxon Sign Ranks test to compare pre- and post- treatment scores in the Back Beliefs Questionnaire, depending on data normality. For qualitative data, the transcription and field notes will be transferred to Microsoft Word after the interview. The transcription will be coded in descriptive fragments and, then, grouped in themes. The themes will be combined to obtain relevant information considering the study's objectives. Data saturation will be confirmed by an external investigator after reviewing the data transcribed. A synthesis of the qualitative data will be provided in the final manuscript. (AU)