Purpose and Background: The introduction of clinical governance made NHS organisations accountable for the monitoring and continuous improvement of the quality of patient care at all levels, across all services. Implementation of evidence-based practice and provision of an adequate infrastructure to support it is a major component and at local level, clinicians in all NHS organisations are required to participate fully in audit. The following describes the second phase* of a study investigating the dissemination and utilisation of an audit toolkit for the UK acute low back pain guideline through clinical governance routes.

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Phase I Results Were Previously Reported At SBPR

Methods: structured telephone interviews were conducted with 50 clinical governance leads and 22 clinical audit leads in 72 primary care trusts (pcts). the qualitative data were analysed using a framework approach involving identification of issues, concepts and themes and the construction of a theoretical perspective for the main categories. these were cross-validated by the original interviewer checking for dissonance.

Results: Six categories were identified: priorities; capacity and resources; loss of quality support groups; organisational issues; local environment and lack of audit strategies. the results suggest that low back pain is still a considerable problem but has lost its priority status at both government and local levels, largely due to the introduction of national service frameworks (nsfs) and to inadequate resourcing. primary care has a huge agenda that is seen as being grossly under-resourced with respondents reporting difficulty in meeting nsf requirements. many localities had not generated or finalised audit strategies while gp autonomy and poor communication between the gps and pcts were identified as barriers to the implementation of audit processes in primary care.

Conclusion: Presently, implementation of evidence-based healthcare for non-priority areas seems not to be feasible through clinical governance routes. without nsf status, the likelihood of seeing clinical audit used to assure evidence-based primary care for low back pain seems remote.

Background: Back pain is often characterised by recurrent episodes and low patient satisfaction with care and there is little evidence about what constitutes improvement as perceived by the sufferer. Care by chiropractors has been associated with high patient satisfaction, often apparently out of proportion to other outcomes (1), but little is known about what actually contributes to this.

Methods and results: Baseline questionnaires were completed by 965 patients with low back pain of all durations at the start of chiropractic treatment, with blinded follow-up at 6 weeks. Patients were asked about the commonly used functional and affective outcomes of: pain intensity, normal activity, work, affect on lifestyle, ability to control pain, anxiety and perceived depression. The contribution of change in these scores to overall improvement and satisfaction with care was evaluated by stepwise multiple regression. Pain intensity, work and ability to control pain predicted 27% of the variance in overall improvement, leaving 73% unexplained by any of the variables. Overall improvement predicted 57% of satisfaction leaving 43% unexplained. A 2-stage block regression to find out what factors other than overall improvement predicted satisfaction revealed that ability to carry out normal activities alone predicted only an additional 0.5% of this. (All relationships were significant at the 5% level or below.)

Conclusions: Some of the overall improvement following chiropractic treatment for back pain was significantly predicted by functional outcomes alone. Very few items other than overall improvement predicted satisfaction. There is a need to consider what other factors constitute improvement and lead to satisfaction with care for low back pain.