Implementation science: reflecting on running an implementation project for low back pain
21 November 2016
When research shows that a new treatment or technique is cheaper and more effective than usual care in the NHS, we want to get that treatment into use in the real-world, into the clinic, as quickly as possible so that patients can benefit from it.
However, exactly how best to achieve this – to implement research findings into standard healthcare practice – isn’t always clear.
BeST is a published, proven and highly effective method for treating low back pain (LBP) – which can be a debilitating and life-changing condition affecting nearly 1 in 10 people.
The BeST Implementation project is broken into two arms. One which evaluates the implementation and one which evaluates how effective the service is (BeST-SE).
For the implementation arm, we have set up an online training website for healthcare professionals (physiotherapists, occupational therapists, nurses, psychologists) who work with low back pain patients. The idea is to provide a cheap, easily accessible and scalable way to train these professionals in how to deliver BeST to their patients.
The website uses written information, combined with videos and knowledge quizzes to communicate cognitive behavioural strategies of how patients with low back pain can increase their physical activity levels and manage their pain and disability.
We used marketing techniques to promote the training, such as hosting a trade stand at the Chartered Society of Physiotherapy (CSP) conference, writing trade press articles (CSP and Nursing Times), blogs (body in mind) alongside more conventional routes, such as academic publications and social media (twitter etc).
The response has been fantastic.
We have more than doubled our anticipated number of enrolments and there continues to be steady traffic to the site.
We are collecting process and implementation intention data from the participants before and after training, and at 4 and 12-months post training completion.
These data will help us estimate how many BeST groups these healthcare professionals have actually set up and how many patients with LBP will have attended. The data will also allow us to identify barriers and facilitators to implementation. Meaning we can improve our approach to implementation in the future.
The Service Evaluation (BeST-SE) arm of the study invites healthcare professionals who have completed the BeST training to join the BeST-SE project.
Once a site has the necessary management sign-off and practicalities in place (e.g. weekly booking of a room to host 6-12 people) we send them a site pack. This pack includes printed versions of the therapist manuals, patient handbooks, attendance records, consent forms, participant assessments (pre-group, post-group) and pre-paid envelopes to return the data to us.
We use participant assessments to measure patient’s pain, disability, recovery, satisfaction, health-related quality of life and service use. We then coordinate collecting 3-month and 12-month follow-up data on the same outcomes from the participants directly. We currently have 28 sites across the UK involved.
This is a fascinating project to work on.
We are, very much, learning from the clinicians and the patients. We collect qualitative feedback from the sites involved in the service evaluation project. Combining and triangulating the qualitative and quantitative data with our developing health economic model is giving us excellent insight into the process of translating an intervention from a clinical trial into a pragmatic tool for use in clinical settings.
A key research activity I have learnt whilst running this project is to perform personal reflexivity tasks.
Working in an academic environment amongst other people who are all invested in your project can sometimes skew your perspective regarding the usefulness/ease for implementing an intervention into a clinical setting – it can be a bit of an echo chamber. I find that writing personal reflections helps me to keep in mind my own biases and to consolidate what I have learnt from talking to site leads.
I believe this has helped me work with sites to help overcome their barriers and to continue with rolling out the BeST groups.
Whilst I will document what I have learnt from this implementation project in a formal process for others, I think some things can only really be properly understood from actually doing personal reflection.