Abstract
IntroductionThe development and publication of clinical practice guidelines for acute low-back pain has resulted in evidence-based recommendations that have the potential to improve the quality and safety of care for acute low-back pain. Development and dissemination of guidelines may not, however, be sufficient to produce improvements in clinical practice; further investment in active implementation of guideline recommendations may be required. Further research is required to quantify the trade-off between the additional upfront cost of active implementation of guideline recommendations for low-back pain and any resulting improvements in clinical practice.MethodsCost-effectiveness analysis alongside the IMPLEMENT trial from a health sector perspective to compare active implementation of guideline recommendations via the IMPLEMENT intervention (plus standard dissemination) against standard dissemination alone.ResultsThe base-case analysis suggests that delivery of the IMPLEMENT intervention dominates standard dissemination (less costly and more effective), yielding savings of $135 per x-ray referral avoided (-$462.93/3.43). However, confidence intervals around point estimates for the primary outcome suggest that – irrespective of willingness to pay (WTP) – we cannot be at least 95% confident that the IMPLEMENT intervention differs in value from standard dissemination.ConclusionsOur findings demonstrate that moving beyond development and dissemination to active implementation entails a significant additional upfront investment that may not be offset by health gains and/or reductions in health service utilization of sufficient magnitude to render active implementation cost-effective.
Highlights
The development and publication of clinical practice guidelines for acute low-back pain has resulted in evidence-based recommendations that have the potential to improve the quality and safety of care for acute low-back pain
While several studies demonstrate that active implementation of clinical practice guidelines (CPGs) for acute low back pain (LBP) can improve general practitioner (GP) practice and patient health outcomes [5,10], it should be remembered that active implementation typically entails an upfront investment that may not be fully offset by health gains or reductions in health service utilization
Evidence regarding the incremental costs(savings) of active implementation of CGPs for LBP – as well as its effects on clinical practice and health outcomes – is available from one study conducted in an allied health setting [12] and one study conducted in a general practice setting [14]
Summary
The development and publication of clinical practice guidelines for acute low-back pain has resulted in evidence-based recommendations that have the potential to improve the quality and safety of care for acute low-back pain. Further research is required to quantify the trade-off between the additional upfront cost of active implementation of guideline recommendations for lowback pain and any resulting improvements in clinical practice. While several studies demonstrate that active implementation of CPGs for acute LBP can improve GP practice and patient health outcomes [5,10], it should be remembered that active implementation typically entails an upfront investment that may not be fully offset by health gains or reductions in health service utilization. Based on comparison between active implementation plus standard dissemination against standard dissemination of a CPG [15] in a sample of 113 Dutch physiotherapists, Hoeijenbos et al [12] concluded that ‘‘it is very likely that the extended implementation strategy incurs extra costs without producing health gains, it is very likely to be not cost-effective’’ (p93). Becker et al [14] concluded that a trend towards cost-effectiveness is visible in their data but suggest that this trend should be confirmed in future studies
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