Evaluating two implementation strategies for whiplash guidelines in physiotherapy: A cluster-randomised trial

Question: Are implementation strategies involving education any more effective than mere dissemination of clinical practice guidelines in changing physiotherapy practice and reducing patient disability after acute whiplash? Design: Cluster-randomised trial. Participants: Twenty-seven physiotherapists from different private physiotherapy clinics and the 103 patients (4 dropouts) who presented to them with acute whiplash. Intervention: The implementation group of physiotherapists underwent education by opinion leaders about whiplash guidelines and the dissemination group had the guidelines mailed to them. Outcome measures: The primary outcome was patient disability, measured using the Functional Rating Index, collected on admission to the trial and at 1.5, 3, 6 and 12 months. Physiotherapist knowledge about the guidelines was measured using a custom-made questionnaire. Physiotherapist practice and cost of care were measured by audit of patient notes. Results: There were no significant differences between groups for any of the patient outcomes at any time. The implementation patients had 0.6 points (95% CI -7.8 to 6.6) less disability than the dissemination patients at 12 months; 44% more physiotherapists in the implementation group reported that they prescribed two out of the five guideline-recommended treatments; and 32% more physiotherapists actually prescribed them. The cost of care for patients in the implementation group was $255 (95% CI -1505 to 996) less than for patients in the dissemination group. Conclusion: Although the active implementation program increased guideline-consistent practice, patient outcomes and cost of care were not affected.