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Using Technology to Close the Evidence-Practice Gap: A South Australian Experience

Ensuring health care is underpinned by quality and safety principles, within the framework of evidence-based practice (EBP), remains as an important priority for health care stakeholders. This has been driven by consistent research evidence to indicate that current health care practices may not adhere to quality and safety principles, which result in overuse, underuse or misuse of health care. This is partly due to persistent evidence-practice gaps in health care. Evidence-practice gaps are gaps between what is known from research evidence and actual clinical practice. By reducing these gaps, there are increased opportunities to improve health care processes and health outcomes.

Recently, I have had the opportunity to work with allied health colleagues from a large metropolitan tertiary hospital, the Royal Adelaide Hospital (RAH), in Adelaide, South Australia. These allied health professionals, along with their medical colleagues, identified an opportunity to close an historical evidence-practice gap. It was identified that there was ongoing inadequacy to meet the high demand for spinal outpatient services. Despite the availability of consistent high quality research evidence on strategies to best to manage spinal pain in the community, and which patients need to be referred for specialist services, this was not translated into clinical practice. This resulted in significant waiting periods due to sheer number of patients being referred for specialist services. Therefore, the importance of reducing waiting times in order to achieve optimal patient outcomes lead to the need to address the clinical practices of primary care providers.

While investigating these issues, it became quickly apparent that there were issues of misuse and overuse of specialist spinal services by General Practitioners (GP) who were the primary referrers of patients to the spinal outpatient services. Further investigations revealed those problems with GP referrals related to insufficient referral detail (thereby creating inefficiencies), the high frequency of referrals received for patients who are unlikely to be surgical candidates (potential for misuse and overuse of health care interventions which may not be appropriate for these patients) and the apparent mismatch between research evidence and current health care practices (evidence-practice gaps).

Therefore, to address these issues, the allied health professionals, along with their medical colleagues, turned to technology. As GPs have regular access to, and routinely utilise, computers during consultations with their patients, a comprehensive online resource was developed. The comprehensive online resource aimed at enhancing the practice of primary care clinicians in managing patients with spinal pain.

The specific aims of the content were to:

  • provide GPs with concise, clinically-relevant, evidence-based guidelines to assist with the assessment, decision making and management of patients with lumbar disorders
  • include information regarding when and how to refer to Spinal Services, with direct linking to referral templates
  • promote appropriate, early, community-based management of lumbar disorders contributing to optimal outcomes for potential surgical candidates, and
  • guide the community-based intervention and support for patients who do not require surgical opinion.

Recognising the important role of patients, patient resources were also included to promote community understanding and support the management decisions and recommendations of treating health professionals.

The development of this online resource involved consideration of what information may be helpful in assisting decision making and promoting appropriate utilisation of spinal outpatient services. Examination of Australian and international evidence-based guidelines for the management of acute low back pain was undertaken, with the final material a distillation of recommendations by the National Health and Medical Research Council Australia, Work Cover South Australia, and current New Zealand, United Kingdom, European and American clinical practice guidelines. Important input was provided from local medical and surgical specialists when discrepancies in the published guidelines were encountered. Liaison with GPs was also an important component of the project’s development from which feedback was integrated at several stages. Final implementation processes included review by the relevant service providers and approval committees at the RAH and formal endorsement by the State-wide Orthopaedic Clinical network. The content was then accepted for inclusion on the SA Health internet site and can be publicly accessed by following links from the ‘For Clinicians’ (http://www.sahealth.sa.gov.au/lumbardisorders) and ‘My Health’ (http://www.sahealth.sa.gov.au/lowbackpain) information tabs on the SA Health home page.

At completion, the resource included seven documents developed for patient access and 20 documents developed specifically for the reference of primary care providers. Information covered included such topics as diagnosis and triage, red flag screening, imaging and analgesia guidelines, differential diagnosis, physical examination, yellow flag screening and referral processes. Extensive e-promotion of the online content to stakeholder groups was undertaken in order to assist in the uptake of this evidence-based resource into clinical practice. It is anticipated that through the application of the decision-support tools developed for this resource, GPs will gain confidence in their ability to manage non-surgical cases in the primary health setting. Optimised management of the majority of individuals with spinal pain will involve confident decision making in primary care and effective community-based management, thereby reducing the number of referrals to specialist spinal services. By ensuring the right patient is referred to the spinal outpatient services at the RAH will mean appropriate and timely health care interventions can be provided to these patients. This will ultimately lead to positive impacts on the patient outcomes, efficiencies in health care service delivery and address an important evidence-practice gap.

This practical example of health services research, driven by health care professionals, provides numerous lessons for evidence-based practice more broadly and evidence implementation more specifically. It highlights the persistent nature of evidence-practice gaps in the health system and how a targeted, systematic, health care professional driven approach can address these gaps. It also highlights the timely use of technology and building on the current behaviours of heath care professionals to assist in the uptake of research evidence into practice. When I communicate with health care professionals, the overwhelming message I get is that they want to do the right thing for their patients. However, for many, due to time, resources and workload pressures, they are unsure on how best to do this within the framework of evidence-based practice. This initiative is a timely example of how health professionals can help each other in the uptake and implementation of research evidence into practice. By doing so, misuse, overuse and underuse of health care practices can be avoided resulting in improved practice and patient outcomes.

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