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.
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.