Adoption and use of guidelines for whiplash: an audit of insurer and health professional practice in New South Wales, Australia.

BACKGROUND: In Australia, the New South Wales (NSW) State Insurance Regulatory Authority has been continuously developing and implementing clinical practice guidelines to address the health and economic burden from whiplash associated disorders (WAD). Despite this, it is uncertain the extent to which the guidelines are followed. This study aimed to determine insurer and health professional compliance with recommendations of the 2014 NSW clinical practice guidelines for the management of acute WAD; and explore factors related to adherence. METHODS: This was an observational study involving an audit of 288 randomly-selected claimant files from 4 insurance providers in NSW, Australia between March and October 2016. Data extracted included demographic, claim and injury details, use of health services, and insurer and health professional practices related to the guidelines. Analyses involved descriptive statistics and correlation analysis. RESULTS: Median time for general practitioner medical consultation was 4 days post-injury and 25 days for physical treatment (e.g. physiotherapy). Rates of x-ray investigations were low (21.5%) and most patients (90%) were given active treatments in line with the guideline recommendations. The frequency of other practices recommended by the guidelines suggested lower guideline adherence in some areas such as; using the Quebec Task Force classification (19.9%); not using specialised imaging for WAD grades I and II (e.g. MRI, 45.8%); not using routine passive treatments (e.g. manual therapy, 94.0%); and assessing risk of non-recovery using relevant prognostic tools (e.g. Neck Disability Index, 12.8%). Over half of the claimants (59.0%) were referred to other professionals at 9-12 weeks post-injury, among which 31.2% were to psychologists and 68.8% to specialists (surgical specialists, 43.6%; WAD specialists, 20.5%). Legal representation and lodgment of full claim were associated with increased number of medical visits and imaging (ρ 0.23 to 0.3; p < 0.01). CONCLUSION: There is evidence of positive uptake of some guideline recommendations by insurers and health professionals; however, there are practices that are not compliant and might lead to poor health outcomes and greater treatment cost. Organisational, regulatory and professional implementation strategies may be considered to change practice, improve scheme performance and ultimately improve outcomes for people with WAD.

Exercise Telemonitoring and Telerehabilitation Compared with Traditional Cardiac and Pulmonary Rehabilitation: A Systematic Review and Meta-Analysis.

Background: Despite exercise capacity and quality-of-life benefits, pulmonary rehabilitation (PR) and cardiac rehabilitation (CR) programmes are not easily accessed because of several barriers. A solution may be telerehabilitation (TR), in which patients exercise in their communities while they are monitored via teletechnology. However, the benefits of TR for the purposes of PR and CR have not been systematically reviewed. Objective: To determine whether the benefits of the exercise component of PR and CR using TR are comparable to usual-care (UC) programmes. Methods: A comprehensive literature search was performed of the Medline, Embase, and CINAHL databases up to July 13, 2015. Meta-analyses were performed for peak oxygen consumption, peak workload, exercise test duration, and 6-minute walk test (6MWT) distance using the I2 statistic and forest plots displaying standardized mean difference (SMD). Results: Of 1,431 citations found, 8 CR studies met the inclusion criteria. No differences were found in exercise outcomes between UC and TR groups for CR studies, except in exercise test duration, which slightly favoured UC (SMD 0.268, 95% CI: 0.002, 0.534, p<0.05). Only 1 PR study was included, and it showed similar improvements on the 6MWT between the UC and TR groups. Conclusion: TR for patients with cardiac conditions provided benefits similar to UC with no adverse effects reported. Similar studies of TR for patients with pulmonary conditions need to be conducted.

Contexte : malgré leurs effets positifs sur la capacité d'effort et la qualité de vie, les programmes de réadaptation pulmonaire (PR) et de réadaptation cardiaque (CR) ne sont pas faciles d'accès en raison de divers obstacles. La téléréadaptation permet aux patients de faire de l'exercice dans leur communauté tout en étant suivis grâce aux télétechnologies. Or, les bienfaits de la téléréadaptation pulmonaire et cardiaque n'ont pas encore été recensés de façon systématique. Objectif : déterminer si les effets du volet exercice de la réadaptation pulmonaire et cardiaque par téléréadaptation se comparent à ceux que l'on observe chez les patients recevant des soins habituels. Méthodes : une recherche exhaustive a été effectuée sur les banques de données Medline, Embase et CINAHL en amont du 13 juillet 2015. Des méta-analyses ont été effectuées pour la consommation maximale d'oxygène, la charge de travail maximale, la durée du test d'effort et la distance marchée lors du test de 6 minutes de marche au moyen de la statistique I2 et de graphiques en forêt affichant la différence moyenne normalisée (DMN). Résultats : parmi les 1431 articles relevés, huit études en réadaptation cardiaque satisfaisaient aux critères. Aucune différence notable n'a été observée dans les effets de l'exercice entre les groupes recevant des soins traditionnels et les groupes en téléréadaptation dans les études de réadaptation cardiaque, sauf pour la durée du test d'effort, où les résultats des soins traditionnels étaient légèrement meilleurs (DMN: 0,268, intervalle de confiance de 95%, 0,002 à 0,534; p<0,05). Une seule étude sur la réadaptation pulmonaire a été retenue; les améliorations observées au test de marche de 6 minutes étaient semblables pour les groupes en soins traditionnels et en téléréadaptation. Conclusion : la téléréadaptation procure aux patients souffrant de problèmes cardiaques des bienfaits semblables aux soins traditionnels sans effets indésirables signalés. Il faudra réaliser des études similaires sur des patients atteints de problèmes pulmonaires.