General practitioners knowledge of whiplash guidelines improved with online education.

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1 General practitioners knowledge of whiplash guidelines improved with online education. Rebbeck T, Macedo L, Trevena L, Paul P, Cameron ID. PhD FACP MAppSc(Phty) BAppSc(Phty) Specialist Musculoskeletal Physiotherapist NHMRC Research Fellow Rebbeck T, Macedo L, Paul P, Trevena L, Cameron ID. General practitioners knowledge of whiplash guidelines improved with online education. Australian Health Review 2013.

2 Why guidelines for whiplash? Patients hurt I had a very bad accident 7 months ago..6 weeks to be able to move my neck.and 7 months on after having physio I still have bad neck pain.cant SUFFER LIKE THIS FOR MUCH LONGER. It costs - eg >45% of costs in Australia in compensation schemes 50% of patient don t recover Kamper, Rebbeck et al Pain =373

3 Four target markets for the whiplash guidelines 3

4 Which implementation strategy Active strategies best - Interactive Education (eg Shectman et al 2003, O Brien et al 2001) - Educational Outreach (eg O Brien et al 1997) - Opinion Leaders (eg Soumerai et al 1998) Passive Strategies - Dissemination of printed materials (eg Davis et al 1995) Effect size: Moderate RR Large RR >1.2 (20% change)

5 But what about GP s Profession most consulted Whiplash is a small proportion of workload Time poor unlikely to attend education mtgs Self assessed knowledge poor correlation to actual knowledge Online strategies increasingly beneficial Target one not many behaviours Deliver by GP peer

6 QUESTION? Could we implement guidelines with GP s and achieve a large change in knowledge?

7 Key messages GP version Development of key messages - Focus groups - MAA and steering committes Key messages - When do I X-ray - Who do I worry about - What do I tell my patients - When do I refer

8 Process of producing on-line learning Ethics: University of Sydney Developed template - Researchers - MAA Engaged RACGP - Storyboarding - Peer review - Programming - Media release Live 3 years: - October 2008 October 2011

9 Methods: Baseline assessment Baseline knowledge - Knowledge Q online (/9) - Confidence Q online (/18)

10 Intervention 10

11 Intervention 11

12 Post intervention knowledge - Knowledge Q online (/9) - Confidence Q online (/18) Methods: Post intervention evaluation

13 Methods: Analysis Change in knowledge - ANOVA pre vs post Effect on learning - Proportion of GP s who improved knowledge improved by > 20% from baseline Prediction of learning - Stepwise regression

14 Results: Enrolments Marketing 499 Enrolled in learning activity Consented to participate Completed education 0 Enrolled Oct 08 Dec 10

15 Baseline characteristics Variable Age Mean(SD) 43.4 (10.5) Male/Female 56%/44% Profession ARIA: n(%) Highly accessible Accessible Moderately accessible Remote Very remote 52.6% GP s 43.4% other medical 122 (57%) 19 (9%) 28 (13%) 3 (1.4%) 2 (0.9%) 15

16 Results Knowledge score (Mean /9(SD) Baseline Post P value 5.1 (1.8) 6.9 (1.0) < GPs Non GPs 4.9 (1.8) 4.6 (1.8) 7.1 (1.2) 6.8 (1.5) Confidence (Mean/18 (SD) 11.8 (2.2) 15.9 (1.7) < Effect: % with > 20% improvement in knowledge score: 57.2% 16

17 Multiple linear regression: learning = change in knowledge Results: predictors of learning Factor Adjusted effect estimates T value P value Gender Age Profession Baseline confidence Baseline knowledge Adjusted R 2 = 71% The less they knew the more they learnt 17

18 Conclusions Targeted strategies had a large effect (>57%) in improving knowledge to be more consistent with CPG for whiplash amongst GP s - Best learning in those with poor baseline knowledge - Target behaviour/ learning outcome - Target your strategy Online education achieved its aim - Provided access to all GP s - A large number participated - A large learning effect was demonstrated - Don t know: about behaviour change or health outcomes

19 Lessons learnt and Implications for implementation of 2014 guidelines Motor Accidents Authority of NSW. Guidelines for the management of whiplash associated disorders- for health professionals. Sydney: 3 rd Edition Motor Accident Authority (NSW). Online methods for guideline implementation useful for GP s Target strategy to those in need of learning no need to mandate guidelines Now test with RCT assess health outcomes - Low vs high risk patients may need different strategies 19

20 Development and proposed implementation of a guideline based clinical pathway of care to improve health outcomes following whiplash injury. Trudy Rebbeck 1, Simon Willcock 1, Justin Kenardy 2, Luke Connelly 2, Ian Cameron 1, Kathryn Refshauge 1, Geoffrey Mitchell 2, Andrew Leaver 1, Michele Sterling 3. 1 University of Sydney, Australia 2 University of Queensland, Australia 3 Griffith University, Australia Background: a problem A collaboration with potential 3 Figure 1: A novel clinical pathway of care for whiplash Whiplash injuries are an Australian health burden, comprising over 75% of road traffic injuries. 1 At least 50% of people with whiplash proceed to chronicity 2 with current treatment showing only modest effects for this group 3,4. Recently a validated clinical prediction rule (CPR) enables identification of those at risk of non-recovery soon after injury 5. These together with updated clinical guidelines for whiplash 6 have been developed into a novel clinical pathway of care. This will be the first study to implement and evaluate a clinical pathway of care for whiplash. It has created a partnership amongst: Health policy makers (Motor Accidents Authority (MAA) of NSW and Motor Accident Insurance Commission (MAIC) of Queensland) University Researchers (Griffith, Sydney and Queensland Universities) Service providers (Physiotherapists, General practitioners, Chiropractors, Clinical Specialists) The pathway has the potential to improve service delivery, health outcomes and cost w e e k s 6 w e e k s Usual care Low risk Assessment of risk Randomisation Guideline based advice and exercise by primary carer: 1-2 sessions Clinical pathway 1. Continue current care monitored by specialist Medium/ high risk 2. Specialist provides care: physical and psychological approach 3. Specialist refers for alternate care Method: A solution References A randomized controlled trial comprising Connelly L, Supangan R. The economic costs of road traffic crashes: Australia, states and acute whiplash participants will be conducted territories. Accident Analysis and Prevention. across NSW and QLD. Participants will be 2006; 38: Kamper SJ, Rebbeck TJ, Maher CG, McAuley randomized to either usual care or the clinical JH, Sterling M. Course and prognostic factors pathway (Figure1). Key processes in the clinical of whiplash: A systematic review and metaanalysis. Pain. 2008; 138(3): pathway include early screening in primary care 3. Jull G, Kenardy J, Hendrikz J, Cohen M, to stratify patients into low, medium and high Sterling M. Management of acute whiplash: A risk groups. The pathway matches interventions randomized controlled trial of multidisciplinary stratified treatments. Pain to these groups based on the guideline 4. Rebbeck T, Maher CG, Refshauge KM, recommendations. The low risk groups will Rebbeck T, Maher CG, Refshauge KM. receive minimal intervention in primary care Evaluating two implementation strategies for whiplash guidelines in physiotherapy: a cluster whilst the medium and high risk groups will be randomised trial. Australian Journal of referred to a specialist clinician. The specialist Physiotherapy. 2006; 52(3): Ritchie C, Hendrikz J, Kenardy J, Sterling M. will direct the patient into one of 3 pathways Development and validation of a screening tool (Figure 1), matched to their detailed physical to identify both chronicity and recovery and psychological assessment findings. following whiplash injury. Pain Motor Accidents Authority of NSW. Guidelines for the management of whiplash associated disorders- for health professionals. Sydney: 3 rd Edition Motor Accident Authority (NSW). 3 m o n t h s Follow up assessment: 3, 6 and 12 Months Primary outcome: Global rating of change, Neck related disability Secondary outcomes: Generic health and disability (WHODASII), Patient self efficacy, pain intensity and Cost (Direct and per QALY saved) Acknowledgements: This project is funded by a NHMRC partnership grant APP CI s: Sterling, Rebbeck, Willcock, Kenardy, Connelly, Cameron, Refshauge, Mitchell. AI Leaver. Industry partners are the Motor Accidents Authority of NSW (project manager Mr David Andrews) and Motor Accidents Insurance Commission of Queensland (project manager Dr Natalie Spearing).

21 Thank-you and Acknowledgements Research Team - Trudy Rebbeck - Lyndal Trevena - Ian Cameron - Luciana Macedo - Placid Paul Funding RACGP MAA Project Management - Liz Gee - Leonie McDonald - Darnel Murgatroyd Rebbeck T, Macedo L, Paul P, Trevena L, Cameron ID. General practitioners knowledge of whiplash guidelines improved with online education. Australian Health Review 2013.

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