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Is a government-regulated rehabilitation guideline more effective than general practitioner education or preferred-provider rehabilitation in promoting recovery from acute whiplash-associated disorders? A pragmatic randomised controlled trial.

ABSTRACT: OBJECTIVE:To evaluate the effectiveness of a government-regulated rehabilitation guideline compared with education and activation by general practitioners, and to a preferred-provider insurance-based rehabilitation programme on self-reported global recovery from acute whiplash-associated disorders (WAD) grade I-II. DESIGN:Pragmatic randomised clinical trial with blinded outcome assessment. SETTING:Multidisciplinary rehabilitation clinics and general practitioners in Ontario, Canada. PARTICIPANTS:340 participants with acute WAD grade I and II. Potential participants were sampled from a large automobile insurer when reporting a traffic injury. INTERVENTIONS:Participants were randomised to receive one of three protocols: government-regulated rehabilitation guideline, education and activation by general practitioners or a preferred-provider insurance-based rehabilitation. PRIMARY AND SECONDARY OUTCOME MEASURES:Our primary outcome was time to self-reported global recovery. Secondary outcomes included time on insurance benefits, neck pain intensity, whiplash-related disability, health-related quality of life and depressive symptomatology at 6?weeks and 3, 6, 9 and 12 months postinjury. RESULTS:The median time to self-reported global recovery was 59 days (95%?CI 55 to 68) for the government-regulated guideline group, 105 days (95%?CI 61 to 126) for the preferred-provider group and 108 days (95%?CI 93 to 206) for the general practitioner group; the difference was not statistically significant (?2=3.96; 2 df: p=0.138). We found no clinically important differences between groups in secondary outcomes. Post hoc analysis suggests that the general practitioner (hazard rate ratio (HRR)=0.51, 95%?CI 0.34 to 0.77) and preferred-provider groups (HRR=0.67, 95%?CI 0.46 to 0.96) had slower recovery than the government-regulated guideline group during the first 80 days postinjury. No major adverse events were reported. CONCLUSIONS:Time-to-recovery did not significantly differ across intervention groups. We found no differences between groups with regard to neck-specific outcomes, depression and health-related quality of life. TRIAL REGISTRATION NUMBER:NCT00546806.

SUBMITTER: Cote P

PROVIDER: S-EPMC6347946 | biostudies-literature | 2019 Jan

REPOSITORIES: biostudies-literature

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Is a government-regulated rehabilitation guideline more effective than general practitioner education or preferred-provider rehabilitation in promoting recovery from acute whiplash-associated disorders? A pragmatic randomised controlled trial.

Côté Pierre P Boyle Eleanor E Shearer Heather M HM Stupar Maja M Jacobs Craig C Cassidy John David JD Carette Simon S van der Velde Gabrielle G Wong Jessica J JJ Hogg-Johnson Sheilah S Ammendolia Carlo C Hayden Jill Alison JA van Tulder Maurits M Frank John W JW

BMJ open 20190124 1

<h4>Objective</h4>To evaluate the effectiveness of a government-regulated rehabilitation guideline compared with education and activation by general practitioners, and to a preferred-provider insurance-based rehabilitation programme on self-reported global recovery from acute whiplash-associated disorders (WAD) grade I-II.<h4>Design</h4>Pragmatic randomised clinical trial with blinded outcome assessment.<h4>Setting</h4>Multidisciplinary rehabilitation clinics and general practitioners in Ontario ...[more]

PMID: 30679283

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Project description:BackgroundLow adherence to chronic kidney disease (CKD) guidelines may be due to unrecognized CKD and lack of guideline awareness on the part of providers. The goal of this study was to evaluate the impact of provider education and access to a CKD registry on guideline adherence.MethodsWe conducted a cluster randomized controlled trial at the Louis Stokes Cleveland VAMC. One of two primary care clinics was randomized to intervention. Providers from both clinics received a lecture on CKD guidelines at study initiation. Providers in the intervention clinic were given access to and shown how to use a CKD registry, which identifies patients with CKD and is automatically updated daily. Eligible patients had at least one primary care visit in the last year, had CKD based on eGFR, and had not received renal replacement therapy. The primary outcome was parathyroid hormone (PTH) adherence, defined by at least one PTH measurement during the 12 month study. Secondary outcomes were measurement of phosphorus, hemoglobin, proteinuria, achievement of goal blood pressure, and treatment with a diuretic or renin-angiotensin system blocker.ResultsThere were 418 and 363 eligible patients seen during the study in the control and intervention clinics, respectively. Compared to pre-intervention, measurement of PTH increased in both clinics (control clinic: 16% to 23%; intervention clinic: 13% to 28%). Patients in the intervention clinic were more likely to have a PTH measured during the study (adjusted odds ratio=1.53; 95% CI (1.01, 2.30); P=0.04). However, the intervention was not associated with a consistent improvement in secondary outcomes. Only 5 of the 37 providers in the intervention clinic accessed the registry.ConclusionsAn intervention that included education on CKD guidelines and access to a CKD patient registry marginally improved guideline adherence over education alone. Adherence to the primary process measure improved in both clinics, but no improvement was seen in intermediate clinical outcomes. Improving the care of patients with CKD will likely require a multifaceted approach including system redesign. CLINICALTRIALS.GOV REGISTRATION NUMBER: NCT00921687.

Project description:Whiplash injuries are an important public health problem that is associated with significant disability and high health care utilization. Recent cohort studies suggest that physician care may be the most effective treatment for patients with whiplash-associated disorders. However, these findings have not been tested in a randomized controlled trial. The purpose of this study is to determine which of physician care or two rehabilitation programs of care is most effective in improving recovery of patients with recent whiplash associated disorders.We designed a pragmatic randomized clinical trial. A total of 444 participants (148 in each of three arms) who reside in Southern Ontario, Canada will be recruited from a large insurer. We will include individuals who are 18 years of age or older and who are diagnosed with Grade I or II Whiplash-associated Disorders. Participants will be randomized to physician-based education and activation or one of two rehabilitation programs of care currently in use in Ontario. Our primary outcome, self-rated global recovery and all secondary outcomes (neck pain intensity, whiplash disability, health-related quality of life, depressive symptomatology and satisfaction with care) will be measured at baseline by a trial coordinator and at 6 weeks, 3, 6, 9 and 12 months follow-up by an interviewer who is blind to the participants' baseline characteristics and treatment allocation. We will also collect information on general health status, other injuries, comorbidities, expectation of recovery, work status, pain coping, legal representation, and co-interventions. The primary intention-to-treat analysis will compare time to recovery between the three interventions. This trial will have 90% power at an alpha of 0.05 to detect a 20% difference in the rate of perceived recovery at one year. Secondary analyses will compare the health outcomes, rate of recurrence and the rate of adverse events between intervention groups.The results of this study will provide the public, clinicians and policy makers much needed evidence on the effectiveness of common approaches used to manage whiplash-associated disorders.ClinicalTrials.gov identifier NCT00546806.

Project description:BackgroundAdherence and completion of programmes in educational and physical exercise sessions is essential in cardiac rehabilitation (CR) to obtain the known benefits on morbidity, mortality, risk factors, lifestyle, and quality of life. The patient education strategy "Learning and Coping" (LC) has been reported to positively impact adherence and completion in a hospital setting. It is unknown if LC has impact on adherence in primary healthcare settings, and whether LC improves self-management. The aim of this pragmatic primary healthcare-based study was to examine whether patients attending CR based on LC had a better adherence to patient education and physical exercise, higher program completion rate, and better self-management compared to patients attending CR based on a consultation program Empowerment, Motivation and Medical Adherence (EMMA).MethodA pragmatic cluster-controlled trial of two types of patient education LC and EMMA including ten primary healthcare settings and 514 patients (LC, n = 266; EMMA, n = 248) diagnosed with ischaemic heart disease discharged from hospital and referred to CR between August 1, 2018 and July 31, 2019. Adherence was defined as participation in ≥ 75% of provided sessions. Completion was defined as patients attended the final interview at the end of the 12-weeks programme. Patient Activation Measure (PAM) was used to obtain information on a person's knowledge, skills and confidence for self-management. PAM questionnaire was completed at baseline and 12-weeks follow-up. Multiple and Linear regression analyses adjusted for potential confounder variables and cluster effect were performed.ResultPatients who followed CR based on LC had a higher adherence rate to educational and physical exercise sessions compared to patients who followed CR based on EMMA (p < 0.01). High-level of completion was found at the end of CR with no statistically significant between clusters (78.9% vs. 78.2%, p > 0.05). At 12-weeks, there was no statistical differences in PAM-score between clusters (p > 0.05).ConclusionThis study indicates that the LC positively impacts adherence in CR compared to EMMA. We found non-significant difference in completing CR and in patient self-management between the two types of patient education. Future studies are needed to investigate if the higher adherence rate achieved by LC in primary healthcare settings translates into better health outcomes.

Dataset Information

Is a government-regulated rehabilitation guideline more effective than general practitioner education or preferred-provider rehabilitation in promoting recovery from acute whiplash-associated disorders? A pragmatic randomised controlled trial.

Publications

Is a government-regulated rehabilitation guideline more effective than general practitioner education or preferred-provider rehabilitation in promoting recovery from acute whiplash-associated disorders? A pragmatic randomised controlled trial.

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