consulting chiropractor role in primary care demonstration project · 2020-03-03 · assessment...
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Consulting Chiropractor Role in Primary Care
Demonstration Project
Final Report April 30, 2012
Submitted by:
Jess Rogers Director Centre for Effective Practice 203 College Street, Suite 402 Toronto, Ontario M5T 1P9 T: 647-260-7881 F: 416-352-0109 E: [email protected] www.effectivepractice.org
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TABLE OF CONTENTS Executive Summary ............................................................................................................................................................. 4
Overview ............................................................................................................................................................................... 4
Summary of Findings ..................................................................................................................................................... 4
Summary of Findings Continued ............................................................................................................................. 5
Introduction ............................................................................................................................................................................. 8
Project Overview ................................................................................................................................................................. 8
Scope and Purpose ............................................................................................................................................................. 8
Background and Rationale................................................................................................................................................... 9
Low Back Pain ................................................................................................................................................................. 9
Provincial Interest and Initiatives .......................................................................................................................... 9
DEMONSTRATION PROJECT .......................................................................................................................................... 10
Intervention: Defining the Model of Care .............................................................................................................. 10
Process Map: What did the visit look like? ............................................................................................................. 11
Patient Population: Who was eligible to participate?........................................................................................ 12
Approach ................................................................................................................................................................................. 12
Site Selection: Where would the model be tested? ............................................................................................. 12
Methods .............................................................................................................................................................................. 13
Patient Level Data ............................................................................................................................................................. 14
Support Provided to the Sites ...................................................................................................................................... 15
Tailoring the Approach by Site ................................................................................................................................... 16
Findings .................................................................................................................................................................................... 16
1.0 Patient Recruitment and Referral ................................................................................................................ 16
2.0 Description of Patient Population Referred to the Assessment Clinics ................................... 17
2.1 Consultation Note Findings – Chiropractor Reported .................................................................. 17
2.2 Graded Chronic Pain Scale Findings – Patient Self-Report ........................................................ 21
3.0 Knowledge Translation and Evidence Based Care .............................................................................. 23
3.1 Clinical Practice Guidelines Survey ............................................................................................................... 23
3.2 Reflective Surveys with DCC’s and PCP’s .................................................................................................... 26
4.0 Interviews with DCC’s and PCP’s ................................................................................................................... 31
5.0 Patient Perspectives ............................................................................................................................................. 36
GENERALIZABILITY OF THE ASSESSMENT MODEL .......................................................................................... 38
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Introduction ........................................................................................................................................................................... 38
Literature search methods ....................................................................................................................................... 39
Stakeholder Interviews .............................................................................................................................................. 39
Analysis and Results.......................................................................................................................................................... 40
Findings .................................................................................................................................................................................... 41
Literature ........................................................................................................................................................................... 41
Stakeholder Interviews .............................................................................................................................................. 42
Discussion ............................................................................................................................................................................... 44
Appendices ............................................................................................................................................................................. 45
References .............................................................................................................................................................................. 46
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EXECUTIVE SUMMARY
OVERVIEW In June 2011, the Ontario Chiropractic Association (OCA) was approved by the Ministry of Health
and Long Term Care (MOHLTC) to carry out a demonstration project designed to develop and
evaluate a Consulting Chiropractor Role in Primary Care for Low Back Pain. The model of care being
tested is based on the introduction of an assessment clinic for low back pain in a primary care
physician’s office. The consultant, in this case a chiropractor, performs an assessment of
approximately 30 minutes in length with a patient who has been previously identified as having
acute, recurrent or chronic low back pain and is referred to the clinic by the primary care provider
(this is not a treatment model). The outcome of the assessment is advice and decision support
provided to the physician, and the inherent knowledge transfer that takes place between providers.
Four consulting chiropractors (DCC) were partnered with 4
group primary care practices for a six-month pilot phase. A total
of 9hrs was allocated per month per site for the Assessment
Clinics. Assessment clinics took place in the primary care
practice. The pilot phase began in mid-September 2011 and
ended March, 2012. A total of 213 patients were seen in the
Assessment Clinics across the 4 sites.
A mixed methods approach was used to capture the data required to meet the evaluation objectives
of the project. Data was collected pre-pilot, during the pilot and post-pilot. Methods included, but
were not limited to, interviews, clinical practice guideline and reflective surveys with both the
chiropractors and primary care providers and patient level data (including satisfaction).
SUMMARY OF FINDINGS
The project met the pre-pilot expectation demonstrating the Consulting Chiropractors
ability to contribute positively to the care for patients with Low Back Pain in primary care
settings.
The chiropractor as a consultant appears to have influenced primary care physicians in their
decision making regarding imaging interpretation and in understanding the appropriateness of
exercise or physical activity. There was strong evidence that physicians benefited from the
knowledge transfer as they reported higher levels of confidence in dealing with similar cases in the
future. Most physicians valued the participation and access to the chiropractors.
The objective of the pilot project is to test the feasibility, acceptability and
value of this model of care in the Ontario context.
Hypothesis: This model of care
will demonstrate provider and
patient satisfaction, and
indicate early positive health
system impacts related to the
management of LBP.
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SUMMARY OF FINDINGS CONTINUED
VALUE
o The Assessment Model was a successful knowledge translation and exchange strategy to
address recurrent and chronic low back pain. The findings demonstrate that the
knowledge of both the consulting
chiropractor (DCC) and primary care
provider (PCP) was positively
impacted by the Assessment Model.
This highlights the exchange of
knowledge that occurred between
providers rather than solely
unidirectional knowledge transfer
from the DCC to the PCP.
� Knowledge translation from
DCC to PCP was realized in
clinical practice guideline compliance related to activity prescription (e.g.
exercise, daily activity), identification and management of yellow flags and
appropriate investigations (including when to refer to spinal surgeon and when
to refer for imaging).
� Knowledge translation and exchange from PCP to DCC was realized in clinical
practice guideline compliance related to medication prescriptions and in the use
of evidence based point of care tools (e.g. Opioid Manager).
o The Assessment Model did not appear to be a successful knowledge translation strategy
to impact provider practice for Acute Low Back Pain. Most of the key messages in the
acute low back pain guidelines were already evident for both practitioner groups at
baseline measurements and were sustained through evaluations indicating that this was
not a high-yield target for a knowledge translation intervention.
Quick Look: Primary Care Providers (5 of 7
interviewed) reported:
• A significant increase in their ability
to target treatment.
• Increased confidence around
decision-making for LBP.
• Increased knowledge of community
resources that were available to
providers and patients.
Highlights:
• Increased PCP’s self- reported confidence in assessing and managing LBP patients.
• Increased PCP’s knowledge of appropriate imaging for LBP patients.
• Strengthened PCP understanding of the role of exercise and/or physical activity for
LBP patients.
• Increased DCC’s knowledge of medication management for LBP patients.
• High patient satisfaction
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o All of the PCP’s in the evaluation made reference to the value in referring LBP patients to
the DCC. For example 2 of the PCP’s interviewed, explicitly spoke of their satisfaction
with the assessment resulting in earlier and quicker diagnosis for their patients.
o The majority of patients referred were diagnosed as uncomplicated mechanical back
pain of varying pain intensity. Patient reported pain and disability, although varied by
Site, did reflect typical low back pain patients who continues to challenge the health care
system.
ACCEPTABILITY
o DCC’s were perceived as having expertise in Low Back Pain by PCP’s. Baseline and post
survey data suggests DCC’s are clinical leaders in this clinical area. This was also
supported in the analysis of the DCC’s self-assessments (reflective surveys and CPG
Assessment surveys) completed as part of this project.
o Provider and Patient Satisfaction
� PCP’s reported increased confidence around decision-making for low back pain
and specifically in targeting treatment and an increased understanding of
community resources.
� Overall patient satisfaction was scored at 94.2 out of a 100 scale.
FEASIBILITY
o Considering the nature and type of low back pain patients referred by the PCP to the
DCC, the model appears to address a gap in the primary care setting that may help
address the inherent challenges of managing these patients.
o Data was mixed with respect to defining the role of consultant and in understanding the
support required to ensure consistent approaches. Data in the reflective survey
suggests DCC’s may have had some difficulty in actualizing their role as a consultant
versus a treatment role; whereas in the DCC interviews no concerns were highlighted
with respect to taking on an assessment role. To help ensure consistent application and
impact, future models would likely benefit from identifying the key characteristics for
selection of consultants. This could include an expanded mechanism in the design of
future models to support or train consultants in this role.
o When the OCA Demonstration Model is compared to similar models in the literature and
with lessons from other programs/stakeholders, it is clear that the OCA Demonstration
Model aligns with some identified success factors such as co-location of the providers,
working to the full scope of practice with a shared understanding of competencies
between providers, incorporating ongoing communication between providers, and
encouraging knowledge translation.
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CONCLUSION
This assessment model had a positive impact on knowledge translation and exchange in the care of
chronic and recurrent low back patient where clinical decision-making involved activity
prescription, identification of yellow flags, utilization of imaging investigations and medication
prescriptions. Patients and providers seemed satisfied with the model; however, increased
opportunity to provide more detailed back-related advice would have been helpful. Future studies
may wish modify the model to address the identified opportunities and assess its impact on low
back in primary care.
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INTRODUCTION
PROJECT OVERVIEW In June 2011, the Ontario Chiropractic Association
(OCA) was approved by the Ministry of Health and Long
Term Care (MOHLTC) to carry out a demonstration
project designed to develop and evaluate a Consulting
Chiropractor Role in Primary Care. The model of care
being tested is based on the introduction of an
assessment clinic for low back pain (LBP) in a primary
care physician’s office. The consultant, in this case a chiropractor, performs an assessment of
approximately 30 minutes in length with a patient who has been identified as having acute,
recurrent or chronic low back pain and referred by the primary care provider to the clinic. A total of
9hrs per month per site will be allocated for the Assessment Clinic. It is important to note that this
is not a treatment model the consultant conducts an assessment visit only. The outcome of the
assessment clinic is advice and decision support provided to the physician, and the inherent
knowledge transfer that takes place between providers. The objective of the pilot project is to test
the feasibility, acceptability and value of this model of care in the Ontario context. Four consulting
chiropractors (DCC) were partnered with group primary care practices for a six-month pilot phase.
The pilot phase began in mid-September 2011 and ended March, 2012.
The Centre for Effective Practice (CEP) was commissioned to assist in the design of the pilot, the
development of the evaluation framework and evaluation tools for data collection, and in
conducting an independent evaluation of the project overall.
SCOPE AND PURPOSE This report provides a summary of the approach taken in executing the OCA Demonstration Project
and presents the evaluation findings. This report has been divided into two sections to reflect two
distinct yet complimentary projects that were undertaken:
1. OCA Demonstration Project: Assessment Model for Low Back Pain in Primary Care
Objective: To test the feasibility, acceptability and value of an Assessment Clinic model
of care. Specifically, physician decision support and knowledge transfer.
2. Generalizability of the OCA Assessment Model: Literature search and Stakeholder
Interviews
Objective: To explore the generalizability of the OCA Demonstration Model by
identifying and comparing characteristics of similar models of care both in the literature
and in the Ontario, and in some cases other jurisdictions’ lived experience.
Legend used throughout this report:
(PCP) Primary Care Provider
(DCC) Consulting Chiropractor
(LBP) Low Back Pain
(CPG) Clinical Practice Guideline
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It is the hope of the project team that this report helps to inform future activities undertaken by the
MOHLTC with respect to defining and executing implementation strategies aimed at improving low
back pain assessment and management in Ontario.
BACKGROUND AND RATIONALE
LOW BACK PAIN
Low back pain (LBP) is a major cause of disability and health care expenditure in the developed world and accounts for a significant portion of a primary care physician’s (PCP) practice – Ontario estimated at 8-11% of patient visits.(MOHLTC, 2008) Most LBP patients have an eventual recovery, but some do not and recurrence is common. Chronic, recurrent or non-responsive LBP patients who do not respond to usual physician care are a particular challenge for both PCPs and the health care system and are cited as the most common reason for referrals to orthopedic surgeons and neurosurgeons. (ICES 2004a) This challenge was echoed at the recent MOHLTC Clinical LBP Consultation Sessions held in April 2011. The direct medical costs of LBP exceed $25 billion dollars (US) per year (ICES 2004b).
For those chronic, recurrent or non-responsive patients, PCPs are faced with a variety of options including narcotic medication, conservative care by a physiotherapist, chiropractor or massage therapist, and/or a referral for a surgical consultation to a neurosurgeon or orthopedic surgeon. Wait-times to see a spine surgeon are among the highest in Canada (average wait time is more than 7 months).(Walker 2006) However, as many as 90% of patients who are referred to the surgeon would not benefit from surgical care. In most cases PCPs recognize red flags such as progressive neurologic deficit and fractures among patients presenting with LBP who require urgent referral to a spine surgeon. In the absence of red flags, more difficulty arises when attempting to distinguish patients who may be amendable to surgical intervention from those who are not. Surgery should only be considered for specific diagnoses and under specific circumstances. Except in emergency situations, guideline driven conservative care should be exhausted before surgical consultation. Effective primary care triaging of LBP patients can reduce morbidity related to prolonged waiting times and optimize use of limited resources. For the purposes of this pilot project the Toward Optimizing Practice (TOP) Clinical Practice Guidelines were used as the basis for the curriculum or scope of the project including assessment of both red and yellow flags (TOP guideline).
PROVINCIAL INTEREST AND INITIATIVES
With the strong commitment from the MOHLTC to support a larger scale effort to address current barriers to provision of high quality and appropriate care for LBP in Ontario, the OCA Demonstration Project was an excellent opportunity to test some assumptions, better understand the barriers and enablers in primary care and to evaluate the value and feasibility of an assessment clinic model.
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DEMONSTRATION PROJECT
INTERVENTION: DEFINING THE MODEL OF CARE The model being tested in this Demonstration Project was based on the assumption that
chiropractors can be considered as knowledge experts in LBP and therefore there could be a value
in introducing this expertise to primary care providers in their own setting as a mechanism for
decision support or knowledge translation. The model includes PCP referral of their LBP patients
for consultation by a chiropractor where an assessment is conducted to provide evidence based
recommendations to the PCP. In addition, because of the co-location of the Assessment Clinics,
there may also be an opportunity to discuss those recommendations between the providers to not
only address the management of the case but also the diagnosis, and patient self-
management/education strategies. The model assumes that licensed practicing clinicians, in this
case chiropractors, would base their role and assessment on their usual approach to LBP care – in
that way building from their own experience and knowledge base – direct and ongoing support to
establish a consistent knowledge base among the Chiropractors of evidence based care was not
included in the project’s scope. In the training day curriculum, evidence based recommendations
from CPGs were highlighted and relevant CPGs and tools were provided to the DCC’s for
consideration and reference. The training did not specifically define or have expectations for the
chiropractors to standardize their approach in conducting an assessment or in providing patient
education or recommendations to the PCP’s.
Characteristics of the Low Back Pain Assessment Model of Care for the OCA Demonstration
Project:
Assessment Model provided within the primary care practice setting:
o Patients with low back pain from the primary care providers practice are referred to
the Assessment Clinic
o 30 minute patient assessment visit is conducted by the consulting chiropractor
o 2 half day Assessment clinics per month/per site (target 8 patients per clinic)
o Assessment Clinics take place in the primary care practice of the referring family
physician. Exam room space is provided to the consulting chiropractor
o Same consulting chiropractor at each site for the 6 month pilot
o This is an Assessment Model; treatment was out of scope
Assessment Visit provided to primary care patients by a consulting chiropractor included the
following documentation/tasks:
o Practices determined process for referral (e.g. documentation)
o Patient completed Graded Chronic Pain Scale before the visit
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o Standard template consultation notes were completed by the consulting
chiropractor and provided back to the primary care physician
o Patient completed satisfaction questionnaire following the visit
Role of Consulting Chiropractor:
• Based on established clinical practice guidelines and criteria, DCC will provide advice to the
PCP on:
1. Whether or not the patient is a potential surgical candidate with a
recommendation for referral to a spine surgeon, or other specialist
2. Whether or not the patient has received appropriate and sufficient guideline
driven conservative care and what treatment/referral options, if any,
should be considered. It is important to note that the design of the model
included the creation of a community resource list of diverse providers and
programs that could be offered to the PCP/Patient for care. It was not the
expectation of the model for direct referral to the DCC for treatment.
3. What, if any, advanced diagnostics should be ordered/considered?
This communication was primarily captured through the consultation note completed by the
DCC and provided to the PCP.
• In addition to the documentation provided to the PCP following the assessment clinic
(Consultation Note), the consulting chiropractors were encouraged to communicate with
the PCPs on an ongoing basis to support knowledge translation.
• Consulting chiropractors were identified by the Ontario Chiropractic Association and were
selected based on a convenience model due to timing restrictions. The extremely tight
turnaround time for project design and need to identify pre-existing DCC-PCP relationships
did not allow for a more purposeful selection approach to be considered. All 4 DCC’s
attended a 1 day training session hosted by Centre for Effective Practice in Toronto. The
session included: evidence based recommendations for low back pain assessment, overview
of point of care tools and patient tools, communication skills working within
interprofessional environments (consulting chiropractor and family physician was the
focus), and Knowledge Translation activities [Appendix 1: Training Agenda].
• To encourage initial communication and knowledge translation DCC’s were encouraged to
work with the sites to develop a community resource list to support the pilot sites in
identifying appropriate providers and/or programs for possible referrals. [Appendix 2:
Community Resource List Template]
PROCESS MAP: WHAT DID THE VISIT LOOK LIKE? A process map was used as a starting point for discussion at each site visit to assist each practice to
understand the model and to identify ways in which the model could be applied in the practice.
There were critical components that were deemed necessary but recognizing the diversity of
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primary care practice the sites were encouraged to tailor the way they operationalized the model.
[Appendix 3: Process Map]
PATIENT POPULATION: WHO WAS ELIGIBLE TO PARTICIPATE? The following inclusion/exclusion criteria was developed and communicated to the DCC’s and
PCP’s. Patient recruitment and referral was based on inclusion criteria of patients between ages of
18-80 with new onset acute LBP or chronic or recurrent without surgical opinion of file. Patients
were excluded if they were pregnant, if they had secondary LBP, were opioid dependent, if they
were wheelchair dependent or had a diagnosis of an unrelated psychiatric illness.
APPROACH
SITE SELECTION: WHERE WOULD THE MODEL BE TESTED? An attempt to increase the representativeness of the sample of DCCs and PCPs selected was
somewhat supported in the choice of locations of the sites. The OCA selected primary care practice
sites based on input from the DCC’s selected for the project. An attempt was made to identify
chiropractors with pre-existing relationships with PCP’s or entire Primary Care Practices. Where
this may not have been feasible, effort was made to identify sites that were amenable to
collaborating with the Chiropractor for the project. Although OCA was given specific direction from
the MOHLTC to exclude family health teams, they encouraged the identification of sites that were
diverse both in terms of the existing primary care model (family health organization, family health
group, walk-in clinic etc.) and in terms of geographic representation. 4 sites were identified and
confirmed by OCA in Summer, 2011.
EVALUATION FRAMEWORK: WHAT WERE WE HOPING TO LEARN?
An Evaluation Framework was developed to capture the key themes and evaluation questions of
interest to the OCA and MOHLTC [Appendix 4: Evaluation Framework]. The framework informed
the selection of the evaluation methods (qualitative and quantitative) that would be used during the
project to address the themes and questions.
• Evaluation Framework includes the following themes:
– Feasibility of the model
– Acceptability of the model
– Value of the model
• Analysis aimed to better understand the extent to which the
pilot project impacts Knowledge Translation and/or Exchange
between PCP’s and DCC’s.
Hypothesis: This model of care
will demonstrate provider and
patient satisfaction, and
indicate early positive health
system impacts related to the
management of LBP.
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METHODS While not designed as a formal research
study, effort was made to apply a level of
rigor to the pilot design to identify
important evaluation themes/questions
that would help to increase the
understanding of the feasibility,
acceptability and value an assessment
model. While not all questions contained
in the framework could be addressed to
the same depth, the framework provides
an important start to guide future work in
this area. Based on the above Evaluation
Framework, a mixed methods approach
was determined by the Project Team to be
appropriate to capture the data required to meet the objectives of the project. Effort was also made
to use multiple methods to obtain data to help triangulate the findings to increase the opportunity
to draw conclusions in the final analysis.
Table A: Description of Evaluation Methods
Baseline
Method Description Appendix
Interviews with PCP and DCC 30-60 minute interviews were conducted at baseline to understand: the current capacity in primary care for LBP assessment and management, current interprofessional collaboration, expected value the model could bring, existing barriers and goals for the project.
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Site Visits OCA and CEP team conducted site visits to provide an overview of the project and expectations to the teams, determine the process tailored to each site, conduct the interviews (when possible in person).
EMR Audit Tool A questionnaire was administered to each site to help capture current capacity in the EMR to document and report on process and outcome indicators related to LBP.
Clinical Practice Guideline Pre-
Assessment PCP and DCC
Case based questions drawn from high quality clinical practice guidelines allow for a comparison of answers to understand the extent of Knowledge Translation related directly to practicing guideline based care for low back pain. (Administered post pilot as well)
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During the Pilot
Method Description Appendix
Reflective Exercise PCP and DCC Intended to
1. capture changes in knowledge of appropriate management of LBP from both the DCC and PCP
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Quick Look: Evaluation Methods
• Provider (DCC/PCP specific)
– Interviews (30-60 minutes pre and
post)
– Clinical Practice Guideline
Assessment Surveys (pre and post)
– Reflective Exercises (2
completed/provider)
– EMR Audit, Site Visit and Monthly
Calls
• Patient Level Data
– Consultation Note
– Patient Assessment Questionnaire
– Patient Satisfaction Survey
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2. capture satisfaction/agreement with the model of care itself from both the DCC and PCP Completed at two time points during the pilot (November 2011 and February 2012)
Monthly Calls with the DCCs Intended to capture the ongoing barriers and enablers to the model of care as they emerge from the perspective of the DCC’s.
Pre-Assessment Patient
Documentation
Patients referred to the Assessment Clinic complete an assessment questionnaire (GCPS) that provides important information on pain and functionality that the DCC will review and consider during the assessment
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Consultation Note The DCC completes the consultation note to capture patient specific data that is communicated back to the PCP and ultimately becomes part of the patient record
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Patient Satisfaction with the
visit
Immediately following the visit, patients are encouraged to complete a patient satisfaction questionnaire.
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Post-Pilot
Method Description Appendix
Interviews with DCCs Post interviews were conducted with the 4 DCC’s using similar questions as the baseline in order to compare.
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Interviews with PCPs Given a lack of response for focus groups with the PCPs, the methodology was adjusted to include post interviews with an aim of including 2 PCP’s from each site. 7 Interviews were conducted in total. Participants were provided a $50 gift certificate for Chapters/Indigo.
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CPG Assessment survey (same
as pre)
The same survey completed by DCC’s and PCP’s at baseline was administered again at project end so answers on CPG based care can be compared to help assess the extent of Knowledge Translation achieved. There was a low response rate from PCP’s limiting the extent of analysis.
PATIENT LEVEL DATA The Project Team discussed the opportunity to capture patient level data and patient reported
satisfaction to enhance the data and analysis. An ethics submission, led by Dr. Silvano Mior, was
prepared for expedited review by the Canadian Memorial Chiropractic College (CMCC). Approval
was received in September 2011. This allowed for the inclusion of a patient completed
questionnaire prior to the visit and a patient satisfaction survey to be administered immediately
following the visit. A detailed description of patient level data is provided below in section (either
5.0 Patient Perspectives OR 2.0 Description of Patient Population Referred to the Assessment
Clinics)
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SUPPORT PROVIDED TO THE SITES Given the nature of this project, Ontario Chiropractic Association provided ongoing project
management support to the four sites throughout the project timeline (August, 2011 – March,
2012). The support included ongoing communication with physician and admin leads to ensure the
assessment clinics were meeting the expectations of the sites, to administer the evaluation methods
(interview schedule, survey distribution etc.). As well as one on one monthly communication (at
minimum) with the DCC’s to troubleshoot any challenges that arose, to help adapt the process map
(e.g. modify patient recruitment/referral approaches) and to follow up on data collection.
Teleconference calls with the 4 DCC’s, OCA Project Lead and the CEP (which included a clinician
team member to offer additional support to the DCC’s specific to patient case examples and
knowledge translation with the PCP’s) were also held monthly to offer ongoing support to the DCC’s
and to also allow for knowledge translation within the group. From the project team’s perspective
these calls were of high value as an opportunity to provide adequate support to the project and
DCC’s. It allowed for important corrections in the approach of the project and encouraged
collaboration between the DCC’s in troubleshooting challenges and in supporting one another.
There were a number of important lessons that emerged in designing and executing this project,
from both the project team and in the meetings notes from the monthly calls with DCC’s, that are
likely relevant to future work:
• Better understanding the necessary characteristics of the consultant role. For example, this
project required a lot of executive function skills from the Chiropractors that may not
always be a strength of health care providers and requires additional time beyond the time
spent in the assessment visit.
• Understanding of how and to what extent the consultant role should be better supported
both in terms of executive function but also with respect to reinforcing the evidence base
messaging, tools and knowledge translation strategies throughout the project should be
further explored.
• It may be useful to explore additional strategies to increase PCP engagement to participate
in both the assessment clinic itself (e.g. referring patients) and in the evaluation methods
(e.g. survey response, participation in interviews etc.). The response rate from the PCP’s for
most of the evaluation methods was a challenge and limited the depth of the analysis and
the ability to draw robust conclusions on the impact of the model.
o Contracts were signed between the OCA and each Primary Care Practice outlining
expectations for participation. Each practice received modest compensation for
participating in the pilot recognizing the expectation for participating in evaluation
type of activities that was beyond their day-to-day clinical practice role.
o In addition, each participating PCP was required to complete a consent form that
also highlighted the expectations of their role for participating.
o Gift certificates were also offered for participation in post-project evaluation
methods.
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TAILORING THE APPROACH BY SITE As noted above, the process map provided the basis for designing and executing the Assessment
Clinics within each practice. To this end the sites were able to modify the approach somewhat both
at the outset of the project and throughout the pilot phase. It was important for the sites to be able
to adapt the approach as they started to learn what was working and where there were barriers.
Examples include:
Patient recruitment or referral: Although in the pre-pilot interviews both the DCC’s and
PCP’s felt that identifying enough patients for two assessment clinics would not be a
challenge, some sites struggled to refer a steady flow of patients to the Assessment Clinics.
The sites used a number of different strategies to recruit patients and encourage providers
to refer patients. One practice proactively searched its electronic medical records (EMRs) to
identify patients with a LBP diagnosis and contacted the patients directly in a ‘blitz’ type
fashion, inviting the patient to come in for the Assessment Clinic. In this example, the
patient did not require seeing the PCP prior to the Assessment Clinic. In other sites, PCP’s
used a more reactive approach waiting for patient appointments for new onset of LBP or for
appointments from pre-existing LBP patients that occurred during the pilot phase.
Frequency of Assessment Clinics: While it was the aim of the project to have consistency
across sites (2 half day assessment clinics per month for a total of 9hrs per month per site),
this was not always feasible or desired at the site. The project team permitted each site to
schedule the Assessment Clinics in a manner that worked best for their practice setting. For
the most part, 2 Assessment Clinics per month was targeted at approximately 2 week
intervals.
Community Resource List: Each DCC created a Community Resource List to help support
their own understanding of available resources, as well as the PCP’s and in some cases the
patients’. The Community Resource List was used in different ways across the pilot sites.
One site chose to update their existing Community Resource List (not specific to LBP) with
LBP specific resources (e.g. expanding the list of Physiotherapists, including Pain
Centres/Specialists). Another created a LBP or Musculoskeletal Disorders Community
Resource List.
FINDINGS
1.0 PATIENT RECRUITMENT AND REFERRAL At baseline, through both the site visits and interviews with DCC’s and PCP’s, all pilot sites reported
that they felt confident they would be able to refer the necessary number of patients to successfully
run the pilot. It is of interest to note the challenges observed in obtaining practice level data from
patient charts regarding LBP diagnostics and follow up. Most physicians were able to recall from
memory a sample of patients to participate in the pilot, or identified that they could take time to
search records by “complaint” in order to obtain a small sample. However, the general inability of
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some sites to pull practice level data or reports from patient charts, specifically from the EMR, may
present a significant challenge to the MOHLTC’s larger goal, under the Excellent Care for All
Strategy, of understanding the experience and best methods of treatment for LBP in Ontario.
Strategies for PCP recruitment and patient referral varied across the 4 sites and were adapted at
each site throughout the project. For example, some sites began with an EMR audit identifying
patients with previous diagnosis of LBP for a select group of PCP’s that was later expanded to
additional PCP’s or new terms to help identify eligible patients. One site limited the number of
referrals per PCP per month to ensure equal access to the assessment clinic across all PCP’s in the
practice.
2.0 DESCRIPTION OF PATIENT POPULATION REFERRED TO THE ASSESSMENT CLINICS
The following is a summary of the data from two data sets: 1. Consultation Notes – completed
by the DCC [Appendix 11] and 2. The Graded Chronic Pain Scale [Appendix 10] – completed by
the patient.
2.1 CONSULTATION NOTE FINDINGS – CHIROPRACTOR REPORTED
The overview of the presenting complaints of the referred patients as reported by the DCC in the
consultation notes is summarized in Table 1. The number of consultation reports completed and
submitted were 213. The number of consultations conducted at each site was about the same
except for Site 3, which had a lower number. Overall, the majority of patients were male of about 43
years of age who presented with chronic low back pain of insidious onset. About 10% of all patients
had previous investigations, and about 30% and 14% had yellow and red flags, respectively.
However, as shown in Table 1, there were obvious differences in the reported patient
demographics and symptoms within Sites. The variables included in Tables 1- 2 were derived from
report of findings in the Consultation Note. Each variable was independently coded for ease of
reporting.
Patient Population Key Findings/Trends:
• 213 Patients participated in the pilot project across the 4 sites
• From the diagnosis reported by the DCC’s, 74.4% of all referred patients were considered to
have uncomplicated, frequent mild low back pain. The allocations of diagnoses of patients
within these classifications appear consistent with reported evidence in other studies.
• About 10% of all patients had previous investigations, and about 30% and 14% had yellow and
red flags
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The following are some of the key variables identified in the Consultation Note:
• onset (sudden =1, insidious=2, progressive=3);
• duration (acute=1, chronic=2, recurrent=3);
• dominant pain (none=1, low back=2, buttock=3, left leg=4, right leg=5, right and left
legs=6 and mixed=7); and
• other variables were dichotomized as present or absent.
Each variable in the following tables were reported upon based on variable type, i.e. a mean
(standard deviation), median or a percentage (%) of the overall sample size or by site.
In Site 2 the most common reported dominant pain symptom involved the back, buttock and leg
pain (i.e. mixed category). Also, the number of co-morbidities and red flags were notably different
between Site 2 and the other Sites; whereas the percentages of yellow and red flags were almost
non-existent in Site 4. Those reported to having yellow flags, 40% consisted of significant mood
disorders (depression/anxiety), 11% were WSIB claims and 21% were economic-related.
Amongst patients with co-morbidities, DCC’s often reported patients having multiple co-
morbidities. Reported co-morbidities included cardiovascular heat disease, diabetes, arthritis
(spinal and/or lower limb), obesity and mental health disorders (depression/anxiety,
schizophrenia). Of those patients who reported having sustained a spinal trauma in the past, the
majority were secondary to a motor vehicle accident.
Table 1: Demographics of patients referred for consultation to each of the sites.
The noted differences in several of reported symptom-related variables may reflect the
inherent differences in the respective clinic’s case mix, the clinic’s organizational structure
(e.g. walk-in vs. established rural Family Health Organization), age, gender or number of years
in practice of physician, PCP’s referral strategies or the DCC’s reporting accuracy.
Descriptor Site 1 Site 2 Site 3 Site 4 Overall
Number of consultations (n) 58 57 44 54 213
Age (mean, sd) 40.7 (9.9) 44.1(15.4) 44.2(15.4) 44.2(15.38) 42.9(14.7)
Female (%) 56.89 38.59 36.36 38.89 43.90
Duration of complaint (median) 2 2 2 1 2
Dominant pain (median) 2 7 2 2 2
Onset (median) 2 3 2 1 2
Past investigations (% ) 29.2 17.7 34.2 9.4 10.3
Prior spine back surgery (%) 1.7 3.5 2.3 11.3 3.9
Past spine trauma (%) 13.7 15.8 4.5 0 7.2
Co-morbidities (%) 17.0 70.4 38.6 9.5 18.6
Yellow flags (%) 34.48 45.61 38.64 3.70 29.7
Red flags (%) 3.45 40.35 15.90 0 14.2
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Unfortunately, detailed case audits to contrast submitted findings to patient records were
beyond the scope of this project.
In regard to the reported physical examination findings, as expected the majority of patients were found to have a restricted lumbar range of motion and muscle and joint tenderness. (See Table 2) A small percentage of all patients were found to have significant neurological deficits; however, these reported findings were notably different by Site. Interestingly given the reported level and nature of the co-morbidities, there were almost no reported vascular abnormalities in the patients referred to the consultant. Again, confirmation of the accuracy and consistency in reporting of these examination findings was beyond the scope of the project but an important consideration in future model implementation. Table 2: Overview of clinical physical examination findings of patients referred for
consultation by sites and overall. Descriptor Site 1 Site 2 Site 3 Site 4 Overall
Number of consultations (n) 58 57 44 53 212
Restricted ROM (%) 93.1 89.5 88.6 54.7 81.6
Muscle Tenderness (%) JB+ 94.8 98.2 88. 4 58.5 84.9
Joint tenderness (%) 86.2 50.9 61.4 54.7 63.7
Reflex changes (%) 1.7 3.5 4.5 5.7 3.8
Sensory changes (%) 10.3 26.3 2.3 0 10.4
Motor changes (%) 0 14.0 0 0 3.8
Decrease SLR (%) 6.9 12.3 2.3 11.3 8.5
Peripheral vascular (%) 0 1.8 0 0 0.5
The identification of a specific etiology of low back pain is fraught with many challenges. In an effort
to mitigate such challenges, various diagnostic classifications have been proposed that group
various pathologies into symptom related categories (Dagenais and Haldeman, 2012). We used
symptom-based categories to facilitate the classification of presenting complaints. Such a
classification is also useful to contrast the recommended treatment options to available evidence
based guidelines.
20
The classifications used in this project included:
• uncomplicated, frequent mild pain (i.e. non debilitating pain with no significant impact on
activities of daily living (ADL);
• uncomplicated, severe pain (i.e. disabling pain impacting ADL);
• substantial neurological involvement (i.e. demonstrable neurological deficits);
• serious pathology (i.e. serious and often progressive spinal pathology) and
• non-organic (i.e. pain not related to spinal etiology).
In regard to the diagnosis reported by the DCC, 74.4% of all referred patients were considered to
have uncomplicated, frequent mild low back pain. A very small percentage of all patients were
considered to have had substantial neurological involvement and serious pathology (7.1%). (See
Table 3) The allocations of diagnoses of patients within these classifications appear consistent with
reported evidence in other studies. For example, evidence suggests that about 5-10% and 1% of
patients with LBP are estimated to have substantial neurological involvement and serious
pathology (Dagenais and Haldeman, 2012).
As with previously observed Site differences in patient demographics, the allocation of diagnostic
classification did differ by Site. This was particularly apparent in the frequency of reported
classification of uncomplicated with frequent mild pain and with severe pain between Site 2 and the
other Sites. Again, this may be related to differences in the clinic’s case mix, which in part is
supported by the differences in the history and physical examination findings reported in Tables 1
and 2.
Table 3: Frequency of diagnoses made by the DCC by site and overall.
Descriptor Site 1 Site 2 Site 3 Site 4 Overall
Number of consultations (n) 58 57 44 52 211
Uncomplicated: frequent mild pain (%) 84.5 56.1 77.3 80.8 74.4
Uncomplicated: frequent severe pain (%) 10.3 35.1 15.9 7.7 17.5
Substantial neurological involvement (%) 5.2 8.8 4.5 5.8 6.2
Serious pathology (%) 0 0 2.3 1.9 0.9
Non-organic 0 0 0 3.8 0.9
Finally, Table 4 summarizes the treatment options recommended by the DCC to the PCP. Exercise
advice/direction the most frequently overall recommended treatment option. There are obvious
variations within Sites, which would influence the overall frequency of recommended treatment
options. It is unclear if such differences can be explained by the variations in patient history and
clinical examination and diagnoses, DCC preferences, availability of community resources, patient
preference or other reasons. Unfortunately, no follow-up data was available to determine which, if
any recommendations were followed by the PCP.
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Table 4: Frequency of treatments recommended by consulting chiropractor by site and
overall.
Descriptor Site 1 Site 2 Site 3 Site 4 Overall
Number of consultations (n) 58 57 44 54 213
Activities of daily living (%) 10.3 42.1 13.6 5.6 18.4
Manual therapy (%) 94.8 38.6 25.0 35.2 50.5
Soft tissues therapy (%) 94.83 75.4 4.5 37.0 56.6
Exercise advice/direction (%) 79.3 93.0 86.4 46.3 76.4
Ergonomic advice (%) 55.2 26.3 6.8 0 23.6
Back education (%) 48.3 66.7 29.5 1.9 37.7
Counselling (%) 5.2 15.8 6.8 3.8 8.0
Functional restoration program (%) 1.7 29.8 0 3.8 9.4
Specialist referral (%) 1.7 12.3 2.3 7.5 6.1
Other (%) 5.6 0 6.81 3.70 7.9
2.2 GRADED CHRONIC PAIN SCALE FINDINGS – PATIENT SELF-REPORT
In addition to the DCCs’ diagnosis (as above), the patient’s perspective of their perceived level of
pain intensity and disability was also obtained. Each patient was asked to complete the Graded
Chronic Pain Scale (GCPS) prior to seeing the DCC. The GCPS was used to measure the graded levels
of pain disability and intensity in the 6 months prior to attending the consultation. The GCPS is a
valid and reliable self-report measure that captures pain intensity and interference on a numerical
rating scale anchored at either end by descriptors noting no pain or worst pain experienced (von
Korff et al. 1992). The GCPS has been used in general population studies and in primary care and is
considered to be an efficient tool to assess and compare severity of different chronic or recurring
pain conditions (von Koroff et al, 2000).
Table 5 summarizes the GCPS scores by Site and overall. The reported level of pain intensity
supports the DCCs’ categorization of the low back pain from above.
• The average level of reported pain intensity was similar between sites with the overall
rating scored at about 62 out of 100 scale, where 100 would be defined as “pain as bad as it
could be”.
• This was similar for the disability score where the average was about 56 out of 100, where
100 represented inability to carry with ADL, work and social activities during the previous
6 months, except for Site 1.
• The number of patient reported days in the 6 months prior to completing the survey that
patients felt interfered with their work or housework varied by site, with Sites 2 and 3
having higher numbers of disability days compared to Sites 1 and 4.
The scores from each of the questions in the GCPS were then used to transform and grade the
patients’ scores using simple rules to categorize pain severity into 5 hierarchical classes (Grade 0, 1,
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2, 3, 4). This grading system has been found to predict pain-related functional limitations at 3 year
follow-up in longitudinal population-based study (von Korff et al. 1992).
• Grade 0: There were relatively few patients, as one would expect, that were classified at
Grade 0 (no pain prior 6 months).
• Grade 1: One would also presume that the percentage of patients referred would be lower
for Grade 1 (low disability, low intensity pain), which appeared to be the case particularly in
Sites 2 and 3.
• Grade 2 and 3: Overall the most common classification was of patients who graded their
back pain as Grade 2 (low disability, high intensity pain) and Grade 3 (high disability,
moderately limiting).
• Grade 4: There were fewer patients with self-reported Grade 4 (high disability, severely
limiting) who were referred for consultations in Sites 1 and 4 compared to the Sites 2 and 3.
Based on the patient reported levels of pain intensity and disability, Sites 2 and 3 appeared to
provide consultation to a group of patients with reported greater disability who also had a higher
percentage of co-morbidities. This finding is consistent with previous work reporting an increasing
relationship between pain grade and other indicators of pain dysfunction (Von Korff et al, 1992). In
consideration of evidence-based guidelines, one would assume that patients with Grade 0 would
not be referred and few if any, unless for reassurance and provision of exercises, in Grade 1.
However, such decisions especially in a patient-centred environment can be influenced not only by
patient preference but provider experiences in managing low back pain and their perceived
diagnosis. More importantly, the GCPS is a patient reported measure that is theoretically different
from a diagnosis which is the consultants’ interpretation of the clinical history and examination.
Again, further insight into the clinic’s needs and level of understanding of back pain would be
helpful to understand the observed findings.
Table 5: Frequency of patient reported pain intensity and disability using the GCPS.
Descriptor Site 1 Site 2 Site 3 Site 4 Overall
Consultations (n) 58 57 44 54 213
Pain intensity (mean, sd) 58.1(21.94) 62.75(19.04) 64.7(14.15) 63.09(22.31) 61.97(19.9)
Disability score (mean, sd) 43.42(28.78) 59.88(24.36) 59.09(20.36) 61.17(21.30) 55.56(25.12)
Disability days (mean, sd) 3.9(6.4) 24.1(29.83) 17.2(23.45) 7.5 (18.54) 12.8 (22.33)
Graded scores %? Grade 0 1.7 0.0 0.0 0.0 0.5
Grade 1 29.3 14.0 4.5 24.1 18.8
Grade 2 39.7 29.8 34.1 24.1 31.9
Grade 3 27.6 28.1 40.9 44.4 34.7
Grade 4 1.7 28.1 20.5 7.4 14.1
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3.0 KNOWLEDGE TRANSLATION AND EVIDENCE BASED CARE In order to assess the value of this model to the DCC’s and PCP’s a number of methods were used, as
explained above: namely a Clinical Practice Guidelines Survey conducted pre and post, Reflective
Surveys and interviews conducted pre and post.
3.1 CLINICAL PRACTICE GUIDELINES SURVEY
There were 4 chiropractors who completed both the pre and post surveys. There were 13 Primary
Care Practitioners who completed the pre survey and 3 who completed both the pre and post
surveys. A pre and post chiropractic and primary care practitioner comparison was conducted. An
analysis was also conducted on the group who completed the pre-survey to provide an assessment
of guideline compliance.
General Use and Awareness of CPGs and Tools
• At baseline, both DCC’s and PCP’s were aware of some of the clinical practice guidelines related to LBP. At project end, awareness of CPG’s increased for DCC’s as did their use of evidence based websites.
• Most practitioners reported at baseline that they utilized some clinical tools. There were some tools that were unique to each profession. In the post survey, there were no additional tools utilized by the physicians however the DCC’s were now identifying and using the Opioid Risk Tool and the Brief Pain Inventory, tools that the PCP’s reported using in their practice at baseline.
Clinical Practice Guideline Survey Key Findings:
• The impact of the project on the increase in DCC’s knowledge in LBP is a supporting factor for
establishing clinical leaders in low back pain care in primary care.
• The post survey data provides further support that the chiropractors are clinical leaders in the area of low back pain as the baseline data had indicated.
• In the baseline survey, the PCP's identified the next most common reason, after investigations report indicates cord or nerve compression, for referral to a spine surgeon as patient wants a second opinion and this was rated as 50% of PCP responses compared to post survey rate of 33%.
• The low number of PCPs completing the survey post project is a limitation of data analysis.
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Clinical Presentations
Table 6: Clinical Presentations from the CPG Assessment Survey
Patient Type DCC Rating 1-4
(Not very Comfortable - Very
Comfortable)
PCP 1-4
(Not very Comfortable - Very
Comfortable)
Acute Low Back Pain 4.0 3.2
Recurrent Low Back Pain 3.75 3.2
Chronic Low Back Pain 4.0 2.9
Low Back Pain with Neurological
Deficit
3.75 3.10
Low Back Pain with
Radiculopathy
3.75 3.2
Low Back Pain with Depression 3.5 2.8
Average Rating 3.79 3.02
• In the baseline survey, the DCCs were more comfortable with all conditions compared to the primary care physicians as compiled on a self-rating likert scale of 1-4 (4 being Very Comfortable) with varying conditions of low back pain. The average score of professional comfort for the DCC's was 3.79 and for the PCPs the score was 3.02.
• In the post survey, both DCC's and PCP’s were equally comfortable with all population types.
• This data provided suggests that the DCC’s may have been viewed as clinical leaders in the area of low back pain as the baseline indicated but would require future study to confirm.
CLINICAL DECISION MAKING
Reason for Referral to Spinal Surgeon
• Both DCC's and PCP's identified the key reason for referral to a spinal specialist in both the pre and post survey as: � Investigations report indication cord
or nerve compression
• In the baseline survey, the PCP's identified the next most common reason for referral to a spine surgeon as patient wants a second opinion and this was rated as 50% of PCP responses compared to post survey rate of 33%
Quick Look: Patient Expectations
The top patient expectations experienced by all practitioners (self-reported) both pre and post survey were:
• Request for an MRI
• Request for a spinal Surgeon Referral
• Request for an X-ray
• Request for a CT Scan
• Request for Opioid medication (noted increased expectations in post survey)
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• In the baseline survey, the DCC's identified the next most common reason for referral to a spine surgeon as presence of radiating pain and this was rated as 50% of DCC's compared to post survey rate of 33%
• An interesting finding was the increased rate of one of the four DCC's wanting a spine surgeon opinion for chronic back pain not responding to treatment in the post survey. This may be an influence of the PCP's providing knowledge exchange to the DCC’s.
Reason for MRI Request
• In the baseline survey, there was disagreement between the responses of the chiropractor and the primary care physicians on the reasons to recommend a patient undergo an MRI however by the post survey there was good agreement demonstrated and identical core list of reasons for MRI request.
• This is supportive of knowledge translation and exchange between the practitioners based on the current literature and guidelines.
Table 7: Reason for MRI Request CPG Assessment Survey
DCC Baseline DCC Post PCP Baseline PCP Post
Neurological Deficit Neurological Deficit Neurological Deficit Leg Dominant
Red Flags Leg Dominant Red Flags Neurological Deficit
Leg Dominant Red Flags Chronic Pain Red Flags
Chronic Low Back Chronic Low Back Patient Reassurance Chronic Low Back
Yellow Flags Abnormal Xray
Abnormal Xray Leg Dominant Pain
Yellow Flags
Referral to other health care professionals
• The PCP’s identified the following health care professionals as appropriate to provide care to low back pain patients (in alpha order): o Chiropractors o Massage Therapist o Pain Management Physicians o Physiotherapist
• The DCC’s had the same list as the PCP and in addition , the DCC identified (in alpha order): o Massage Therapist o Personal Trainers o Sport Medicine Physicians
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• Given the health care professionals identified by both the DCC’s and PCP’s for appropriate referrals, the project model could be piloted in future with those Ontario licensed health care professionals from above as the consultants in an assessment model.
GUIDELINE COMPLIANCE
Application of Guidelines to decision-making in Patient Scenario
• In the comparison between DCC and PCP for guidelines compliance, there was compliance at baseline and maintained in post survey on bed rest, red flags and activity prescription indicating that this is NOT an area requiring knowledge translation intervention.
• In the area of medication prescription and X-ray requisition, there was a shift to guideline compliance in both practitioner groups with the greatest impact on new knowledge of the chiropractor
• In the area of lumbar supports, 50% of the DCC’s did not have full compliance to the evidence based recommendations and the impact to shift the PCP to guideline compliance was not realized.
Use of Goal Setting in patient care
• Both DCC and PCP set goals with their patients for care most of the time at baseline and at post survey
• At baseline, the DCC (100% frequently- always) were more likely to set patient goals with other health care professionals than the PCP (30% frequently) this did not shift in the post survey.
3.2 REFLECTIVE SURVEYS WITH DCC’S AND PCP’S
Reflective Surveys were administered at two points in time during the pilot phase (November 2011
and February 2012) to both the DCC’s and PCP’s. The full analysis has been included below. The
Reflective Survey Key Findings:
• The CPG and Reflective survey has identified Chronic Medical Conditions as an educational
gap for future guidelines
• Findings demonstrate a change in knowledge and behavior for PCP’s toward guideline based
care (e.g. better understanding of exercise and a greater confidence in managing LBP)
• Findings, from the Reflective Survey, may suggest a conflict of interest for using a model
where treatment providers may benefit from relationship referrals
• Inteprofessional collaboration between the DCC’s and PCP’s did occur as a result of the
Assessment Model
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following scale was used when analyzing the data: The word “some” is used if a comment appeared
1-2 times in the data, the word “good” is used if a comment appeared 3-4 times and the word
“strong” is used if there were more than 4 comments.
Table 8: Reflective Survey Comparison
DCC’S PCP’S 1. What issues made this patient more challenging to manage?
SUMMARY: The DCC’s identified past treatment
issues as main challenges to initial care versus
patient issues with the exception of identification
of chronic medical factors. The CPG and Reflective
survey has identified Chronic Medical Conditions
as an educational gap for future guidelines in the
CPG surveys. The issues did not change over the
course of project.
DETAILED:
• In some cases, the lack of understanding about chiropractic services was a challenge.
• In one case a prior unsatisfactory exposure to chiro services was a hurdle.
• In some other cases, the patient's lack of insurance coverage (personal cost) was seen as a barrier for the referral process.
• Prior unsuccessful treatments were also seen as barriers in some cases.
• The cases referred to were for the most part complicated by other chronic clinical issues / factors.
DETAILED:
• The PCP’s saw patients with a variety of MSK problems.
• The mix of patients selected for the study did not change in any significant way throughout.
2. New info that made a difference in patient management.
SUMMARY: Over time, the DCC’s continued to
identify areas of patient management that was
consistent with the clinical practice guidelines
key messages.
DETAILED:
• There was strong suggestions that guidelines (e.g. Clinical Practice Guidelines for chronic low back pain) made a difference.
SUMMARY: Guideline Comfort scores, from
CPG Survey, which had indicated that PCP’s
were very comfortable with key messages
regarding red flags, activity and pain
management was confirmed.
DETAILED:
• Exercise, physical activity was noted in a number of the responses. With respondents appearing to embrace this in their
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• The special skills and knowledge of the chiropractors appears to have helped provide more insight for patients in a good number of cases – e.g. in interpreting x-ray results, in explaining the nature of patient conditions and in recommending specific courses of action. These explanations were provided both to physicians and their patients (directly).
recommendations for patients. The reporting of this was strong.
• Even when physicians felt no new information was provided; they was good evidence they saw value in the confirmation received through the consultation.
• In some cases, patients who were reluctant previously had doubts or concerns dealt with (good).
• Messaging regarding “hurt vs. Harm” was picked up most strongly in one clinic over the others.
• Surgery recommendations were reinforced in some cases by the consultation (good).
• “Reassurance” was noted several times in the response to this question. There was strong support for a “reassurance” effect.
• There was some influence and support for surgical recommendations.
3. How will management of next patient change?
SUMMARY: The CPG survey and Reflective
Surveys supported change in DCC knowledge
based on PCP knowledge exchange in imaging
and medication issues.
DETAILED:
• In some cases, the DCC’s reported that the guidelines and patient handouts would help future patients in similar situations.
• In a good number of cases, DCC’s themselves noted this interaction with the PCP would change their use of imaging technologies (x-rays and MRIs).
SUMMARY: The reflections are consistent with
the CPG Survey findings demonstrating change in
knowledge and behaviour in guideline key
messages.
DETAILED: There was
• strong evidence that the consultation strengthened the PCP’s understanding of and use of exercise or physical activity.
• good evidence that PCP’s knowledge levels were improved and they could make better treatment decisions on their own.
• good evidence that PCP’s would reduce the use of imaging as a result of acquiring better knowledge through these consultations.
• good evidence that PCP’s would utilize checklists and guidelines provided through these consultations.
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• strong evidence that PCP’s benefited from the knowledge transfer as they reported higher levels of confidence in dealing with similar cases in the future.
4. What are you doing now that you didn't before?
SUMMARY: The Reflective survey results support
the development of interprofessional
relationships between the DCC’s and PCP’s.
DETAILED:
• There was strong evidence that the DCC’s found their interaction with family physicians beneficial.
• The frequency of interaction was greater than before in a good number of cases.
• This interaction was seen by some as helpful in removing the anticipation that DCC’s were to be criticized by the PCP’s or that patients would be counseled against returning to them.
• There were a good number of cases where handouts were referred to as more important and the emphasis on these was improved.
• In some cases, the DCC’s noted they were not doing anything different.
SUMMARY: The findings suggest increased
referrals to chiropractors which is consistent
with the findings of the CPG Survey. We do not
know the nature of the referral. Future studies
may help to provide information on the reasons
of referrals. Referrals may be for ongoing
treatment or for education and exercise we were
unable to discern reason for referral or
appropriateness of referral.
• Physicians indicated that they would consider earlier referrals – to chiropractors or physiotherapists.
• There was strong support for increased referrals to chiropractors.
• There was good support for earlier referral to physiotherapists.
• Overall, this consultation would result in more referrals to chiropractors.
• There was good indication that physicians would perform a more thorough physical examination.
• Some physicians reported no change to their practice habits.
5. How could the assessment clinic be modified?
SUMMARY: The model requires more support in
providing patient self-management tools to
DCC’s.
DETAILED:
• There was very strong support for better follow up to assess patient progress and compliance.
• Additional handouts were suggested as a result of the assessment clinics by some DCC’s.
DETAILED:
• There was strong support for the model – with access to chiropractic services at the clinic level – concurrently or to support (second opinion) patient recommendations.
• Most PCP’s valued the participation and access to the DCC’s and would continue with the model as they experienced it in this project.
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• Some DCC’s saw short term opportunities to offer similar clinics to other family physicians.
• No modifications were suggested to the current model.
• One PCP indicated that they did not need diagnostic assistance; but rather, saw the role of the DCC for treatment only.
6. What are clinical questions have emerged from discussions and the clinics?
SUMMARY: The findings support the knowledge
exchange identified in the CPG survey regarding
imaging and medications.
DETAILED:
• A good number of the DCC’s noted that drugs and medications were an issue for patients. Specific mention was made of opioids by some of the DCC’s.
• Specific mention was made by some DCC’s of the financial considerations guiding treatment for patients.
• Some DCC’s noted that they spend time discussing the costs of various imaging technologies, the appropriateness and when these tests were indicated.
DETAILED:
• Some PCP’s were still unsure when to send to physiotherapy and or chiropractic treatments and for how long (duration).
• A few PCP’s answered this question from a fiscal not a clinical perspective. It appears that for a good part of the PCP participants questions arose as to what would be covered by OHIP.
• One PCP wanted to understand better how a chiropractor classifies degree and etiology of pain.
• One PCP indicated that where there were multiple positive findings it was hard to prioritize these and to focus on the important clinical issues.
• One PCP wanted guidance on “Benefit of pain management strategies ...” including “... psychological or Cognitive Behavioural Therapy.”
GENERAL COMMENTS
• Some barriers appear to exist in referring to and using chiropractic services. This was perceived as being either a historical or social bias.
• There were some comments received about the initiative (good / excellent)
• One respondent suggested that having the DCC enter clinical findings directly into the EMR would have been better and would have eliminated problems interpreting hand written notes. There were 2 pilot sites that were not using
an EMR in their practice and 2 pilot sites there
were on an EMR.
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4.0 INTERVIEWS WITH DCC’S AND PCP’S
Interviews were conducted pre-pilot and post-pilot with both the DCC’s and PCP’s. Both pre and
post semi-structured interviews were recorded and transcribed for data analysis. The full analysis
is available in Appendix 15 and 16. Additional data from the pre-pilot interviews is available in the
Interim Report: Consulting Chiropractor Role in Primary Care Demonstration Project January 2012
submitted to the Ontario Chiropractic Association. Below is a summary of the findings with emphasis
on post-interviews. All 4 DCC’s were interviewed post and 7 PCP’s were interviewed post.
Table 9: DCC and PCP Comparison of Post-Interviews
EXPECTATIONS
DCC’S PCP’S Knowledge Translation
• DCC’s generally felt that they were able to transfer their knowledge of low back pain assessment and treatment to primary care physicians through this model.
• There was agreement among DCC’s that there were few challenges for them in assuming the assessment role
• This model had an impact for one DCC in terms of allowing him/her to better deal with short term medications and better decide on the appropriate time to send the patient out for imaging studies.
• Further, participation in the model had a positive impact for another DCC in terms of monitoring and discussing the yellow flag
There were several indicators that confirm knowledge translation did occur between the DCC and PCP:
• PCP’s (5 of 7) reported a significant increase in their ability to target treatment
• PCP’s (5 of 7) reported increased confidence around decision-making
• PCP’s (5 of 7) reported increased knowledge of community resources that were available to patients
• PCP’s (3 of 7) reported an increased understanding of the DCC skills in the assessment of LBP
However, PCP’s did not consistently identify increased awareness or use of LBP guidelines in their practice
Interview Key Findings/Trends:
• PCP’s reported increased confidence around decision-making for low back pain and
specifically in targeting treatment and increased understanding of community resources
• All PCPs made reference to the value in referring LBP patients to the DCC.
• DCC’s were generally positive about the OCA Demonstration Model in terms of the
acceptability, value and impact of the model. They saw their role as valuable, they felt valued
by primary care providers and patients, there was value in this model to patients outside of
any other factors being considered, and they enjoyed the assessor role. These perceptions
were held in spite of some lack of clarity around the benefit of this model to primary care
providers as well as funding sustainability.
32
patients.
• Yet another DCC said that participation in this model also allowed for an opportunity to update his or her research knowledge base and to streamline the information that was given to the primary care physicians.
• The above reported knowledge translation is supported by the findings of both the CPG Assessment Survey and Reflective Survey.
Notable Quotes
“[Sometimes] we had, we referred patients for, like um, physiotherapy. And then I spoke with [DCC]
about where, where the place – the best place would be, or who would be best – more suitable for this
patient and that. And indirectly I – I learned some things. About the resources in community so I can
use that information for patients.” [PCP Interview]
“I have certainly have learned now to pay a little more attention to the assessment that does outside
my office, and I actually get reports from the chiropractors more often. Because I ask for them.” [PCP
Interview]
“As a consultant I was able to . . . some knowledge base …to the physicians, to make them a better
understanding of their management ‘cause they’re technically managing and I’m consulting. So they
knew what questions to ask and they knew that if you referred out to a physio, or chiro or massage,
they knew to ask for what are they doing.” [DCC Interview]
Communication • DCC’s felt that the assessment role either
maintained their already high communication levels or increased and enhanced their communication with primary care physicians.
• Informal face-to-face discussions, the electronic medical record (EMR), texts and emails, as well as the consultation note were all mentioned as effective and satisfying communication methods.
• The consultation note was mentioned as a particularly efficient method of communication as it was seen as concise and clear in providing pertinent information to the PCP’s.
• Prior to taking part in the demonstration project, while there was strong agreement that communication would be the key to the success of the model, there appeared to be
• All PCPs expressed an overall satisfaction with their communication with DCCs.
• The majority of PCPs identified the DCC Consultation Note included in their patient records was a key benefit to the model
• All PCPs had a positive perception of their collaboration with DCCs, using keywords such as helpful “second opinion” or reinforcement to describe the collaboration
33
little agreement as to which communication methods would work best. After taking part in the model, chiropractors’ perceptions remain mixed with no consensus on the most effective communication method.
Notable Quotes
“It’s nice to have another therapist using the same chart, so we can refer to the notes [...] especially for
on-going treatment, that was a benefit” [PCP Interview]
“[The] notes were easy to use [...] and incorporate into my own practice. It was recorded in, in our
Electronic Medical Records, so it came in sequence, umm with my notes and so on. And so it was quite
easy to use, yeah.” [PCP Interview]
VALUE
DCC’S PCP’S Roles
• DCC’s felt that this model was helpful in terms of providing a second opinion for the diagnoses that the PCP’s were giving their low back pain patients.
• It was also helpful from an educational perspective, providing some PCP’s with more knowledge on how to assess and treat low back pain as well as educating them on the skill set of chiropractors and physiotherapists.
• It allowed DCC’s to help PCP’s to identify the more complex “yellow flag” patients with greater confidence, in chiropractors’ view.
• Finally, the model allowed for DCC’s to perform a more extensive examination than PCP’s usually had the time for.
• All PCPs made reference to the value in referring LBP patients to DCC. o 2 explicitly spoke of their satisfaction
with the DCC assessment resulting in earlier and quicker diagnosis
• The majority of PCPs perceived the DCC assessment and management of LBP as being of higher quality than PCPs
• This confirms the pre-pilot expectation of DCCs ability to contribute positively to the care for patients with LBP in primary care settings
Notable Quotes
“I actually think the chiropractors do a really good job of full back pain, probably a lot better than
doctor[s] do. “ [PCP Interview]
“I actually think, and you can put this on the record: I think that chiro – most chiropractors I know are
much better at doing an initial assessment than, sort of, risk stratification for patients presenting with
low back pain than most primary care physicians that I know.” [PCP Interview]
34
Referrals • DCC’s generally felt that their role within the
model gave them the added benefit (to PCP’s) of being viewed as a resource. Their value as a resource ranged from providing a second opinion to the patient to prescribing MRIs.
• PCPs (5 of 7) reported a decrease in referrals to specialists. The remaining 2 PCPs reported no changes in their rate of referrals
• PCPs (3 of 7) reported a decrease in referrals for diagnostic imaging. None reported any increases in referrals to specialists or for advanced imaging during the study
Notable Quotes
“Less visits for reinforcement. I have patients they, [...] didn’t have time or they didn’t want to go for
the project...for the pilot. And then I had to see them again and again. To reinforce, you know [...] And
eventually to send them to specialist. I mean during, this [...] time. To send them to specialist to do the
test and then to come back to reach the same conclusion that could have been reached by one simple
visit.” [PCP Interview]
“. . . a lot of times they [patients] get sent simply to the spinal surgeon because the physician wants
that MRI or wants to know, ‘should I prescribe an MRI?’ or ‘should I order an X-ray?’ . . . Whereas
oftentimes a chiropractor deals with that imaging on a daily basis, they’re fully equipped to turn
around and say, ‘Okay, this person does need an MRI’ or ‘this person doesn’t need an MRI and this is
why because they don’t fit the criteria or they do fit the criteria.” [DCC Interview]
Collaboration • The community resource list was a tool that the
DCC’s used in their assessment of patients’ low back pain. DCC’s all said that they used the list in referring patients out into the community. This list grew during the project for at least one DCC as she/he was able to see referrals to chiropractors and physiotherapists in the electronic medical record, and add them to this list.
• PCPs (3 of 7) identified establishing relationships and being familiar with the DCC’s work as success factors for the pilot
• One PCP expressed a reluctance to refer patients to the DCC for an Assessment given the time between their own visit with the patient compared to the timing of the next assessment clinic
Notable Quotes
“It’s very useful that I knew [DCC] [...] So that made it easy – I don’t know – so for to start with a fairly
new, or like [...] a fresh relationship – I think would take some time...and [wouldn’t] be the same
thing.” [PCP Interview]
“...for me to see a patient one week, only to have to wait 10 days to see the chiropractor...is not timely.
And so I would revert back to my previous...if they needed therapy, it was a quick and easy to say
listen remember you did this before...and that’s what I suggest again, rather than involving, you know,
the chiropractor that was coming here [...] By the time the second week rolled around the DCC was out
of your memory” [PCP Interview]
“. . . it shows collaborative care and this is a good thing . . . I think it’s the way the future is going to be.
It’s something we should all strive to kind of work through and work with each other instead of
fighting against one another.” [DCC Interview]
35
Perceptions of Value to Patients • DCC’s agreed that this model was beneficial
for the patient as this model provided an in-depth opportunity for patients’ to have their low back pain assessed in a manner not normally done by their primary care provider. It was generally thought that an in-depth condition-specific assessment would allow for a greater understanding of the issue.
• Two DCC’s mentioned that this model was an opportunity to demonstrate their skills to the patients in a different way than through usual chiropractic appointments.
• PCPs reported that patients were very satisfied with the Assessment Visit
• From the perspective of the PCPs quick turnaround between PCP referrals to the Assessment clinic resulted in: o Increased reassurance for the patient o Increased patient confidence in diagnosis
and treatment options; and o Decrease in patients requesting specific
referrals
• One PCP did identify that one of his/her patients was dissatisfied with the Assessment Visit because the patient was uninsured and did not find the assessment only useful as opposed to having both assessment and treatment as part of the model at no cost to the patient
“I think it’s good just in terms of . . . belief of the public in terms of what chiropractic is. I think it
shows that we’re evidence-based practitioners, that we do more than just crack backs, we do have the
information that can be used to assess and to treat patients. So, I think if anything, it’s good for the
profession.” [DCC Interview]
FEASIBILITY
DCC’S PCP’S Roles
• There were mixed thoughts on how the model could work in the future. For some DCC’s, the model could work with the same components as used in the pilot. For one DCC, using the same model was logical as it was only an extension of the model that he/she was already working within. There was mention by others that for the model to be sustainable and accessible going forward, it would need to be modified. One modification was an increased frequency of the assessment clinic so that the DCC would be more likely seen and used as a specialist.
• Other modifications suggested were to position the model in emergency departments or walk-in clinics in order to increase the patient volumes.
• Generally DCC’s felt that physiotherapists could be included in this model in the role currently filled by DCC’s.
• When asked if they were satisfied with the model, 5 of 7 PCPs expressed that they would continue to support the model if the assessment was covered.
• PCPs identified a barrier to the feasibility of this model beyond the pilot for patients without employer benefits or medical coverage
• Some PCPs indicated they would continue to refer insured patients to Chiropractors for LBP assessment post pilot
36
Notable Quotes
“I actually think, and you can put this on the record: I think that chiro – most chiropractors I know are
much better at doing an initial assessment than, sort of, risk stratification for patients presenting with
low back pain than most primary care physicians that I know.” [PCP Interview]
“I think you can use physiotherapists in this role as well just as easily . . . the education level is the
same . . . a lot of the treatments they can offer is the same, their knowledge base is the same in a lot of
cases or very similar.” [DCC Interview]
5.0 PATIENT PERSPECTIVES
The full analysis is available in Appendix 17. Below is a summary of findings from the patient
satisfaction questionnaire. Patient satisfaction is considered an important dimension in the
assessment of quality of care (Hutchison et al, 2003). In consideration of the nature of this
demonstration project, the Visit Satisfaction Questionnaire-9 (VSQ-9), as modified by Kennedy et al.
(2010), was selected (Used with permission of authors). The author’s modified the original VSQ-9
to capture unique patient experiences that assessed process and provider-based items and overall
satisfaction.
• Overall satisfaction was scored at 94.2 out of a 100 scale, where a score of 100 was defined
as excellent. There were no significant differences between the four sites.
• In reviewing the specific questions comprising this score, Sites 2-4 all had significantly
lower satisfaction scores for Q2 assessing wait time in the office compared to Site 1.
• In regard to provider-based outcomes, the patients in all sites rated the level of satisfaction
with their consultant similarly, with all being greater than 93 out of 100.
In reviewing the mean scores and the 95% confidence intervals of the individual survey questions,
the patient reported scores were similar for each site. The lower process score noted in Sites 2-4
may have been attributed to the limited appointment scheduling allocated to each chiropractor,
unlike that in Site 1 where the chiropractor was co-located and with their own practice.
However, the high satisfaction scores reported herein may have been influenced by various factors,
such as social desirability bias and the method of dissemination and collection of the survey tool.
Ideally the survey should be distributed and collected by independent assistants; however, in our
project due to inherent limitations in project oversight and availability of research personnel, such
Patient Perspectives Key Findings/Trends:
Findings suggest that patients were satisfied with almost all measured components of the
interaction with the consultant in this model.
37
was not always the case. Yet when the qualitative data from the chiropractic consultants and the
physicians were analyzed, similarly high satisfaction was reported by patients. Therefore, the
findings suggest that patients were satisfied with almost all measured components of the
interaction with the consultant in this model.
38
GENERALIZABILITY OF THE ASSESSMENT MODEL
INTRODUCTION The following content analyzes the generalizability of the OCA Demonstration Model by identifying
and comparing characteristics of similar models of care both in the literature and in the Ontario,
and in some cases other jurisdictions’, lived experience. The objectives and therefore methodology
for this work is complimentary to that of the preceding content on the execution and evaluation of
the OCA Demonstration Project however, it was conducted in parallel to the Demonstration Project
it did not inform the development and execution of the OCA Demonstration Project.
To support this objective, both primary and secondary data were collected.
The primary data was collected through qualitative interviews conducted with 17 key informants,
physicians and sector opinion leaders, to assess the appropriateness of this care model to other
health care providers and other complex conditions that are costly and challenging for the primary
care system. [Appendix 18: List of Stakeholders]
Secondary data analysis was conducted through a comprehensive literature review to identify
similar models and examine details of their components for key learning that could be applied to
enhance the understanding of the feasibility, potential benefit and generalizability of the OCA
Demonstration Model.
The stakeholders interviewed were not specifically aware of the OCA Demonstration Project (there
were a few individuals that were somewhat aware of the project but indirectly). The OCA
Demonstration Project was not explained in detail to the stakeholders as part of the interview
process. Developing an understanding of the applicability or generalisability of the OCA
Demonstration Project was developed during the analysis of the information gathered through both
the primary and secondary data. That is to say, stakeholders were not directly asked to comment on
the appropriateness or applicability of the OCA Demonstration Project and the model of care being
pilot tested. The intent of the interviews was to illicit the stakeholders own experience developing
and executing a model of care to better understand barriers and enablers.
39
METHODS
Two separate and distinct methodologies were used to gather the primary and secondary data
analyzed in this report.
LITERATURE SEARCH METHODS
Appendix 19: Literature Search Strategy and Appendix 20: Literature Search Results):
A medical librarian executed a literature search in
December 2011 to identify studies evaluating
interprofessional collaboration health care
models, more specifically consultation-liaison
approaches. Inclusion criteria consisted of setting
(primary health care, primary care and
ambulatory care), terms attempting to capture
characteristics of the model of care (e.g. patient
care team, shared care, referral, consultation,
assessment), health care professionals and was
limited to publication type: journal articles.
From this search 59 articles were returned. Titles
and abstracts were then reviewed by the Project
Team. Only eight articles were identified for
retrieval. Due to the small number of appropriate
articles, the medical librarian then conducted a
second search (January 2012), removing the
publication-type limit. The results included more examples of assessment and referral models. The
results were again reviewed independently by 3 members of the project team. A total number of 12
articles were included in the final data abstraction table. [Appendix 21: Data Abstraction]
STAKEHOLDER INTERVIEWS
A targeted list of key informants (stakeholders) was
developed through the knowledge and experience of the
CEP research team, input from OCA Project Advisory
Committee (including MOHLTC and OMA
representation) and through snow ball sampling
informed by the literature search, the stakeholders
themselves and website searching (see criteria inset).
Key informants were determined to be experts in their
field who could speak knowledgeably about the model
of care which they had created or worked in. It was
Data Abstraction table (Appendix 21)
designed in Excel to capture the
salient points of the studies
including:
• An overview of the model;
• The practice setting;
• Region;
• Health professionals
involved;
• Gap in care the model
addressing;
• Barriers identified;
• Intervention used;
• Success factors; and
• Results and conclusions
Criteria for Stakeholder Selection:
• Patient based/Clinical Program
(not limited to Primary Care)
• Experience designing/executing
the assessment model(s)
• Completed evaluation of the
program/project
• Ontario (preferable)
• Involved teams of practitioners
(loosely defined)
• Not limited to a clinical condition
40
hoped to obtain data on a cross-section of models across a variety of health care areas as well as to
have some key informants speak to relevant assessment models at a higher and more wide-ranging
level.
Twenty-one potential key informants were contacted over a two-week period. From this list, 17
interviews were conducted. Semi-structured interviews were conducted by telephone between
February 27th and March 30th, 2012. The interview guide was sent to key informants prior to the
interview; interviews lasted an average of 45 minutes, with a range of between 32 minutes and 61
minutes. See Appendix 22 for a copy of the interview guide. Informed consent was obtained for the
audio-recording of the interviews as well as the use of aggregated data. While the interviews were
not transcribed, notes were taken during the interviews and subsequently reviewed in conjunction
with the recordings at the conclusion of the interview. Stakeholders were offered a stipend of $150
for their participation.
The interviews provided in-depth information on the stakeholder’s role, the model in which they
worked, the gap in the health care system that the model addressed, the skills needed and displayed
by the team working in the model, the successes and challenges in executing the model, the factors
that could or did lead to success in the model. As well, stakeholders were asked to describe how the
model in which they worked would impact primary care providers in the community, patients, and
the health care system at large. They were also asked about the model’s reproducibility in different
settings and whether or not they thought it could be integrated into different aspects of the health
care system.
ANALYSIS AND RESULTS
The interview data was analyzed with a thematic analysis
approach, identifying key themes within the evaluation
framework.
A list of stakeholders and their role or experience in the health
care profession is presented in Appendix 18 In short,
stakeholders had a great breadth and depth of experience
across the health care profession. As well, stakeholders often
had held or were holding multiple roles related to overseeing
or working in the model as a health professional and teaching.
They often had their own private practice, and spent time
advocating for the model. Many were involved in
interprofessional education at a macro level, designing courses,
training modules and activities for students as well as fully
licensed health care professionals. Most stakeholders
interfaced with primary care through team grants, through
managing a model that connects with a family practice from a
Table 10 Stakeholders and
Health Profession Focus
Health System
Interprofessional Care
4
Health System Wait
Times/Design
1
Spine 1
Cardiovascular 1
Diabetes 2
Arthritis 1
Mental Health 3
Osteo (hip and knee) 2
Geriatrics 2
41
hospital, working with the Ontario College of Family Physicians, and other related areas, but were
not directly involved with primary care.
FINDINGS The literature review and stakeholder interviews were conducted in order to provide some
understanding as to the generalizabillity of the OCA Demonstration Model to other providers and
for complex conditions.
LITERATURE Due to the small number of published articles on the subject, generalizations of findings are limited,
especially with two articles assessing models used in academic hospital settings. Study objectives ranged
from reducing patient wait times and improving access to specialists for diagnosis or treatments; or
reducing unnecessary referrals, interventions or hospitalization of specific patient populations. Five of the
studies were concerned with improving primary care for patients with mental health issues.
Though limited in its generalizability, the literature reviewed did identify some overarching success
factors that have bearing on the model evaluated in the OCA Demonstration Project.
The majority of barriers reported in the published literature was specific to the study’s design and
patient population, and therefore do not have relevance on the OCA Demonstration Project.
However some studies identified interpersonal skills, including communication and strained
relationships between health providers, as challenges to the models. Vierhout, Knottnerus, Ooij, et
al. (1995) recognized the expectation of general practitioners changing their practice behaviours,
such as their referral patterns, within a short time period as being a study limitation.
Identified Success Factors for Assessment Models from the Literature:
• Models require flexibility from health providers, while also establishing a well-
defined consultant-liaison relationship.
• Agreed upon referral criteria and protocol prior to model implementation.
• Ongoing training to primary care physicians on referral options.
• Opportunities to establish positive interpersonal relationships (i.e., meetings, joint
consultations)
• Clear communication between health professionals, especially access to consultation
notes and/or electronic patient records
42
STAKEHOLDER INTERVIEWS
Additional Findings from Stakeholder Interviews:
• Communication:
o A few stakeholders mentioned that they used an electronic medical record (EMR) in
their model and that this assisted in facilitating communication among the various
health care providers. The EMR facilitated knowledge sharing and awareness of the
full scope of the patients care.
o Several stakeholders mentioned team meetings as a critical part of their model. As
well, informal communication between health care practitioners in hallways and
lunchrooms was seen as a critical communication pathway.
• Funding:
o Many models were funded through MOHLTC either through pilot funds or specific
funding streams tied to MOHLTC initiatives.
o Organization funding (hospital, family health team) supported several models.
Stakeholders supported this funding approach because it was seen as being fairly
sustainable.
o There were a few other funding mechanism mentioned including fee for service or
services covered by provincial programs, research funding to support particular
health care provider roles.
• Health Care Professional Roles:
o Many stakeholders mentioned that specific health care professionals were not as
important to the success of the model as was the specific skill set or characteristics
brought to the model which were not necessarily dependant on the type of health
care professional.
o Most key informants mentioned that the health care professionals in their model
required additional training and support to participate successfully. At a minimum,
Success Factors from Other Models
When the interprofessional models examined through the interviews were unpacked
element by element, across the models, as was done in the full analysis report Appendix 23,
it is clear that the OCA Demonstration Model includes some of the success factors
identified through the stakeholder interviews such as:
• co-location of the providers,
• working to the full scope of practice with a shared understanding of competencies
between providers,
• incorporating ongoing communication between providers, and
• strategies that encourage knowledge translation.
43
the training appeared to help team members understand their respective roles and
to help build trusted relationships.
• Challenges
o Funding, as noted above, is a critical component to exploring and then sustaining
new models of care.
o Many stakeholders discussed the importance of recognizing different practice
cultures and scopes of practice across different professional groups and therefore
practice approaches can be diverse and need to be addressed or considered in
designing new models.
o A few stakeholders identified barriers in interprofessional models in providing
equitable access of services to populations typically under-served (e.g. women,
minorities and/or patients with lower socio economic status (SES).
• Evaluation
o Overall it was consistently reported by the stakeholders that measures of success
were tailored specifically to the goals of the specific model.
o A large proportion of models included a formal evaluation, many on a prospective
basis. A small number were informally evaluated with plans to conduct a more
formal evaluation in the near future or dependent on funding.
• Impact
o Primary Health Care Setting
� Most of the models were not specifically focussed on the primary health care
setting although many stakeholders did speak to the relevance their model
could have to primary care providers.
� Stakeholders felt that communication methods and collaboration
approaches from their models were likely the most transferable elements
into the primary care context.
� In those models that did interact with primary care providers many were
limited to a referral model with very little expected or targeted knowledge
transfer back to the primary care provider.
� In those models that directly focussed on primary care, specifically
interprofessional approaches to complex disease in the primary care setting
discussed the opportunity to apply similar models to other clinical topic
areas (generally the trend was toward chronic diseases).
o Patients
� Overall, these models were perceived to be positively received by patients.
Stakeholders generally said that patients saw a savings in their time, an
ability to have a unique treatment, an improvement in their self-
efficacy/self-management and overall quality of life.
o Health Care System
� All stakeholders discussed the cost savings that their respective
interprofessional models provided to the system. There was a large
proportion who felt that their models’ impact was overwhelmingly positive,
44
and felt that there was support for reproducing the model in other sites and
settings.
� Many felt that while their models might not demonstrate clear cost savings
due to a number of challenges (the model may not be designed to capture
cost analysis, expensive start up costs, data collection and analysis, or due to
pilot nature of the model), the other benefits to the health system
demonstrated by the model were important to consider.
There are some areas of the OCA Demonstration Model that cannot be properly examined. The
potential cost and savings of the model to the health care system are unclear at this time as is the
funding sustainability of the model. While these are critical pieces, a few of the models outlined by
stakeholders also included some lack of clarity in this area, which did not detract from their
perceived success. In contrast however, the OCA Demonstration Model was a six-month pilot while
the shortest duration for any of the models examined here was a year and a half year, suggesting
that there are learnings from the OCA Demonstration Model that can potentially take place in the
longer term.
DISCUSSION
Looking at the surface, because the OCA model includes some success factors seen in other
successful models, it should be able to be scaled up for LBP in particular and possibly generalized to
other relevant providers and more complex conditions. As key informants suggested, models
should be evaluated to ensure they support a new context, when they are being initiated in new
sites and settings. The OCA Demonstration Model would be no different in this regard. Further,
changes such as the inclusion of other health care providers and location outside of primary care,
would call for a new evaluation of the model’s efficacy to ensure that it continued to function on a
clear evidence base.
Given the positive perceptions of interprofessional models among these stakeholders, and the
assertion among many that this is the way health care should be delivered in the future, the OCA
Demonstration Model, if not perfectly appropriate in its current form, represents a forward-
thinking direction in health care.
46
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