Implementing Evidence-Based Treatments for Persistent Back Pain into Primary Care

描述（由申请人提供）：本提案回应了国家补充和替代医学中心的兴趣，即确定有效的方法来实施基于证据的干预措施，以“提供结合补充和替代医学方法的疼痛管理策略的卫生保健机构”。它解决了持续背痛的有效治疗知识和实践中实施这一知识之间的实质性差距。高质量指南目前推荐的8种治疗方法主要是补充和替代医学（CAM）和身心技术（即脊柱推拿、针灸、按摩、瑜伽、认知行为疗法、渐进式放松）。临床医生对这些治疗方法缺乏了解，这对鼓励患者使用它们提出了一个特别的挑战。此外，人们对在实践中实施任何循证辅助医学干预措施的挑战或如何应对这些挑战知之甚少。为了帮助克服这些障碍，我们建议正式评估在初级保健实践中实施背痛指南的过程，包括CAM和慢性背痛的身心治疗。由于背痛在美国造成了巨大的个人、社会和经济成本，因此改善背痛的临床护理的潜在好处是巨大的。我们提出了一个形成性的评估试点实施的证据为基础的指导方针的持续性背部疼痛进入集团健康（GHC）初级保健诊所。形成性评价认识到，卫生保健组织是复杂的适应系统，以不可预测的方式不断变化。因此，我们的评估方法将包括持续监测和修改，以识别障碍、促进因素和其他可能影响项目成功的适应性因素。具体目标：在实施之前，我们将识别、探索和描述在初级保健试点诊所实施指南的障碍和促进因素，并相应地修改计划（目标1）。在实施过程中，我们将确定计划与其运作之间的差异，并监测实现预期结果的影响和进展指标（目标2）。实施后，我们将分析前几个阶段的经验教训和利益相关者的汇报，以确定对结果的替代解释（目标3）。这些信息将用于最终确定实施计划，然后将其传播给其他GHC诊所，并传播给其他有兴趣在其他环境中实施循证治疗的人。鉴于之前实施背痛指南的努力令人失望的结果，以及缺乏评估在医疗保健环境中实施循证CAM和身心治疗效果的研究，我们的研究结果将为未来努力的成功提供至关重要的信息

DESCRIPTION (provided by applicant): This proposal responds to the National Center for Complementary and Alternative Medicine's interest in identifying effective ways to implement evidence-based interventions into "health care settings that deliver pain management strategies which incorporate complementary and alternative medicine approaches. It addresses the substantial gap between knowledge of effective treatments for persistent back pain and implementation of this knowledge into practice. The 8 treatments now recommended for persistent back pain by high quality guidelines are mostly complementary and alternative medical (CAM) and mind-body techniques (i.e., spinal manipulation, acupuncture, massage, yoga, cognitive behavioral therapy, progressive relaxation). Clinicians' lack of knowledge about these treatments presents a particular challenge for encouraging their use by patients. Furthermore, little is known about the challenges of implementing any evidence-based CAM interventions into practice or how these challenges might be addressed. To help overcome these obstacles, we propose to formally evaluate the process of implementing back pain guidelines including CAM and mind/body treatments for chronic back pain into primary care practice. Because of the large personal, social, and economic costs of back pain in the U.S., the potential benefits of improvements in clinical care for back pain are enormous. We propose a formative evaluation of the pilot implementation of evidence-based guidelines for persistent back pain into a Group Health (GHC) primary care clinic. Formative evaluation recognizes that health care organizations are complex adaptive systems which are constantly changing in unpredictable ways. For this reason, our evaluation method will include ongoing monitoring and modification to identify barriers, facilitators and other adaptable factors that could influence th program's success. Specific Aims: Prior to implementation, we will identify, explore, and describe the barriers and facilitators to implementing the guidelines in a primary care pilot clini and modify the plan accordingly (Aim 1). During implementation, we will identify discrepancies between the plan and its operationalization and monitor the impacts and indicators of progress toward desired outcomes (Aim 2). After implementation, we will analyze the lessons from the previous stages and from a debriefing of the stakeholders to identify alternative explanations for the results (Aim 3). This information will be used to finalize the implementation plan before spreading it to other GHC clinics and disseminated to others interested in implementing evidence-based treatments into other settings. In view of the disappointing results of previous efforts to implement back pain guidelines and the lack of research evaluating the effect of implementing evidence-based CAM and mind-body treatments into medical care settings, our findings will provide information that will be critical for the success of future efforts to bridge these gaps between research and practice. PUBLIC HEALTH RELEVANCE: This proposal addresses the substantial gap between knowledge of effective treatments for persistent back pain (most of which are complementary and alternative and mind/body techniques) and implementation of this knowledge into practice. Formal evaluation of the process of implementing back pain guidelines into practice will provide information critical for the success of future efforts to bridge the gap between research and practice.