Clinicians believed that guidelines were categorical , prescriptive , and constrained professional practice ; however , popular clinical practice s superseded the guidelines .
Imaging referrals were used to manage consultations and to obtain definitive diagnoses .
Clinicians ' perceptions reflected a lack of content knowledge and underst and ing of how guidelines are developed .
DISCUSSION Addressing misconceptions and other barriers to uptake of evidence -based guidelines for managing LBP is needed to improve knowledge transfer and close the evidence - practice gap in the treatment of this common condition
INTRODUCTION Despite the availability of evidence -based guidelines for the management of low back pain ( LBP ) that contain consistent messages , large evidence - practice gaps in primary care remain .
OBJECTIVES To perform a systematic review and meta synthesis of qualitative studies that have explored primary care clinicians ' perceptions and beliefs about guidelines for LBP , including perceived enablers and barriers to guideline adherence .
The Effect of Adherence to Practice Guidelines on Depression Outcomes
Context Do clinicians who follow  depression practice guidelines have better patient outcomes ? Contribution This observational study from 45 primary care practice s found that clinicians adhered well to only one third of the guideline recommendations for depression . Most clinicians initially recognized and treated depression ; however , they often did not address suicide risk , assess alcohol use , adjust treatment appropriately , or follow through on long-term treatment plans . Better clinician adherence to recommendations was associated with a lower probability of persistent depressive symptoms among patients . Caution Data on depression-related care were based on patients ' self-report . Implication Clinicians should try harder to deliver guideline -concordant depression care . The Editors Depression practice guidelines for primary care represent expert consensus , based on systematic review of several r and omized clinical trials and other relevant literature , on how depression should be diagnosed and treated . Guidelines provide guidance for depression assessment , referral to mental health specialists , and follow-up in primary care ( 13 ) . Numerous studies document low rates of adherence to guideline recommendations on antidepressant use or psychotherapy ( 46 ) and less-than-optimal outcomes in usual care ( 7 ) . Far fewer studies have assessed adherence to the broader set of recommendations on additional aspects of care ranging from detection of depression symptoms to treatment discontinuation . National efforts to improve care ( 8) rely substantially on 1 or 2 guideline recommendations ( for example , completion of a short-term care course of antidepressant medication ) . Knowing the strengths and gaps in care for primary care patients with depression could provide a stronger basis for quality improvement . We sought to determine whether adherence to the broader set of depression guideline recommendations improves depression outcomes and , if so , to identify which guideline recommendations are most and least likely to be followed . To achieve these aims , we used expert panel methods to develop 20 guideline -based quality indicators for depression care ( 9 , 10 ) . We applied the indicators to secondary data from surveys of 1131 representative depressed patients from 45 diverse and geographically dispersed primary care practice s. We analyzed the link between performance on our measure and depression outcomes at 12 , 18 , and 24 months and assessed the level of performance on each of our indicators to identify which aspects of depression care were most and least in need of improvement . Methods We performed secondary analysis of data collected through the Quality Improvement for Depression ( QID ) collaboration ( 11 ) between 1996 and 1998 . The 4 studies in this collaboration used cluster r and omized design s to evaluate encouragement strategies for implementing Agency for Healthcare Research and Quality guidelines for depression ( 13 ) in primary care . One QID study used self-administered surveys ( 12 ) , which had some questions that were worded differently from questions in the other 3 studies . We included only the 3 QID studies that used virtually identical telephone-administered surveys . Among these 3 studies , only 1 showed statistically significant improvement in depression-specific outcomes ( 13 , 14 ) . In the QID studies , experimental-group clinician leaders were given training , material s , and protocol s to encourage them to provide collaborative care for depression-based quality improvement ( Figure ) . Additional details on the encouragement approach used by each study are published elsewhere ( 1114 ) . For our observational analyses , we combined the usual care and experimental groups . The study was approved by the institutional review board at each study site . Figure . Quasi-experimental design of studies in the Quality Improvement for Depression collaboration . Setting Patients and clinicians were recruited from 45 primary care practice s within 4 health care organizations in 13 states . Organizations included a multistate family practice network ( 11 ) , 2 staff-model managed care organizations ( Kaiser Permanente and Veterans Affairs [ 14 ] ) , and a network model managed care organization whose patients were cared for in private practice s throughout Maryl and ( 11 , 15 ) . Sample Research ers consecutively approached patients visiting participating practice s to identify those with symptoms of depression on a brief self-report depression screening instrument derived from the World Health Organization Composite International Diagnostic Interview ( CIDI ) ( 16 ) . Telephone interviewers used the full CIDI for Affective Disorders to assess consenting patients who tested positive on the CIDI screening instrument . We included 1019 patients who were positive for a major depressive disorder or dysthymia on the CIDI and 112 patients who were negative despite reporting at least 5 of 9 depression criteria ( 17 ) at recruitment ( 18 ) . In the QID studies , follow-up surveys were completed by 85 % of the enrolled patients at 12 months , 77 % at 18 months , and 78 % at 24 months . Measures We measured the process of care , case mix ( based on prognosis ) , and outcomes for depression ( Figure ) . Process-of-care measures included 139 self-report items ( 19 ) . Case-mix measures ( 20 ) included 70 items used to create 5 scales ( baseline severity of depression on the modified Center for Epidemiologic Studies Depression [ CES-D ] scale , severity of physical symptoms common among people with depression , social support , number of depression symptoms lasting 2 years , and appropriate antidepressant use during 3 months in the past 6 months ) that formed the basis for a vali date d depression prognostic index ( DPI ) ( 14 , 21 , 22 ) . Higher DPI scores indicate worse prognosis . Outcome measures included depression symptoms ( continuous ) and persistent depression ( dichotomous ) at 12 , 18 , and 24 months after baseline ( the date of study enrollment ) . We measured depression symptoms by using a modified version of the CES-D scale ( 23 , 24 ) that more closely approximates criteria from the Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition ; lower scores on the modified CES-D scale reflect fewer depression symptoms ( range , 0 to 100 ) . We measured the presence or absence of persistent depression by using a previously vali date d measure ( 25 ) that approximates current major depression . We defined persistent depression as scores that fell in the depressed range ( according to previously established cutoff values ) on each of 3 measures : the modified CES-D scale ( score 20 , equivalent to 16 on the original CES-D ) , the mental health composite score of the Short Form-12 ( 26 ) ( score 1 SD below the general population mean of 50 ) , and stem items from the CIDI screening instrument that identifies current probable depression ( 16 ) . Unlike the CIDI structured diagnosis instrument , the CIDI screening instrument requires the presence of depressed mood and anhedonia in the past month . Because patients must score in the depressed range on all 3 measures according to st and ard depression cutoffs ( the measures map closely to diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition ) and major symptoms must be current , the patients identified by the composite measure for persistent depression are substantially and currently impaired . Development of the Depression Quality Index We developed preliminary quality review criteria based on Agency for Healthcare Research and Quality guidelines ( 13 ) and refined them through an expert panel process . We translated quality review criteria into scored , survey-based quality indicators , without testing any indicators against outcome until the index was complete . We vali date d the index by evaluating the relationship between quality scores and depression outcomes , adjusting for case mix . We developed clinical algorithms for identifying st and ard , above-st and ard , or below-st and ard care relative to guideline statements . In st and ard care , a care process would be likely to ensure good to excellent outcomes for most patients , whereas below-st and ard care would lead to poor outcomes among some patients and above-st and ard care would have a high likelihood of leading to optimal outcomes . We then su bmi tted preliminary quality review criteria to an independent group of depression care experts ( 5 primary care practitioners and 2 mental health specialists ) from the MacArthur Foundation Initiative on Depression and Primary Care , using a modified Delphi process ( 27 ) . Seven experts participated in 3 rounds of review and revision of the criteria and 1 final round of review to assess consensus on the final measure . The consensus process result ed in 20 quality review criteria ( 19 ) . A strength of these criteria is that they account for the complexity of care decisions made over time on the basis of response to treatment . We translated the final quality review criteria into measurable quality indicators based on survey variables . Each indicator identifies a patient population ( for example , patients with persistent symptoms at 6 months ) to which a care process or processes identified by the quality review criterion applies ( for example , the patient should be seen by a mental health specialist ) . Scoring further divides the indicator into st and ard , above-st and ard , or below-st and ard care subsets on the basis of additional conditions specified in the quality review criterion ( for example , per our panel 's recommendations , care is below st and ard for suicide assessment only when the patient came for a scheduled visit with no new medical problems ) . Each indicator generates a raw score of 9 to 9 , with st and ard care as zero . Statistical Analysis We used weighting and multiple imputation to account for difficult-to-survey sub population s ( such as ethnic minority groups ) . Weighting accounted for the probability of enrollment and attrition at each step , beginning with data on patients approached for screening
Clinicians believed that guidelines were categorical , prescriptive , and constrained professional practice ; however , popular clinical practice s superseded the guidelines .
Imaging referrals were used to manage consultations and to obtain definitive diagnoses .
Clinicians ' perceptions reflected a lack of content knowledge and underst and ing of how guidelines are developed .
DISCUSSION Addressing misconceptions and other barriers to uptake of evidence -based guidelines for managing LBP is needed to improve knowledge transfer and close the evidence - practice gap in the treatment of this common condition
INTRODUCTION Despite the availability of evidence -based guidelines for the management of low back pain ( LBP ) that contain consistent messages , large evidence - practice gaps in primary care remain .
OBJECTIVES To perform a systematic review and meta synthesis of qualitative studies that have explored primary care clinicians ' perceptions and beliefs about guidelines for LBP , including perceived enablers and barriers to guideline adherence .