Effectiveness of strategies for implementing guideline-concordant care in low back pain: a systematic review and meta-analysis of randomised controlled trials

Abstract

Background: International low back pain guidelines recommend providing education/advice to patients, discouraging routine imaging use, and encouraging judicious prescribing of analgesics. However, practice variation occurs and the effectiveness of implementation strategies to promote guideline-concordant care is unclear. This review aims to comprehensively evaluate the effectiveness of implementation strategies to promote guideline-concordant care for low back pain.

Methods: Five databases (including MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL) and Physiotherapy Evidence Database (PEDro) were searched from inception until 22nd August 2024. Randomised controlled trials (RCTs) that evaluated strategies to promote guideline-concordant care (providing education/advice, discouraging routine imaging use, and/or reducing analgesic use) among healthcare professionals or organisations were included. Two reviewers independently conducted screening, data extraction, and risk of bias assessments. The primary outcome was guideline-concordant care in the medium-term (>3 months but <12 months), measured by the rate of patients receiving such care. The taxonomy recommended by the Cochrane Effective Practice and Organisation of Care (EPOC) group was used to categorise implementation strategies. Meta-analysis with a random effects model was conducted where possible. This systematic review was prospectively registered in PROSPERO (registration number: CRD42023452969).

Findings: Twenty-seven RCTs with 32 reports were included. All strategies targeted healthcare professionals (7796 health professionals overseeing 34,890 patients with low back pain), and none targeted organisations. The most commonly used implementation strategies were educational materials (15/27) and educational meetings (14/27), although most studies (24/27) used more than one strategy ('multifaceted strategies'). In the medium-term, compared to no implementation, implementation strategies probably reduced analgesic use (number of studies [N] = 4, odds ratio [OR] = 1.21, 95% confidence interval [CI]: 1.05-1.40, I 2 = 0%, moderate certainty evidence), but probably made little to no difference in reducing the use of routine imaging (N = 5, OR = 1.16, 95% CI: 0.95-1.41, I 2 = 41%, moderate certainty evidence). Further, implementation strategies may make little to no difference in improving the rate of providing education/advice (N = 3, OR = 2.40, 95% CI: 0.89-6.49, I 2 = 95%, low certainty evidence). However, this should be interpreted with caution as the sensitivity analysis indicated a positive effect, albeit with low certainty evidence, suggesting that the results are unstable and may change with future research (N = 2, OR = 3.59, 95% CI: 1.68-7.69, I 2 = 75%). There was insufficient evidence to indicate one implementation strategy was superior to another in the medium-term.

Interpretation: Implementing guideline recommendations delivered mixed effects in promoting guideline-concordant care for low back pain management. Further research is needed to establish the effectiveness of implementation strategies for specific guideline-concordant care practices in low back pain.