Table 2 Process of care in IHC trials

Maiers, Westom, Bronfort et al. [39, 41, 44, 89]

Patient completes a baseline evaluation profile comprising self-report back pain symptoms, disability, general health status, fear avoidance, self-efficacy measures and patient perspectives (previous experiences with LBP treatments, preferences for care and expectations of study treatment) as well as physical exam and objective test findings.

One or more treatment plans are developed for the patient at a weekly meeting. Each treatment plan consists of one or more modality and consensus must be reached for the plan to be presented to the patient. Typically there are three care plan options consisting of two to three modalities.

Clinicians attended one full day training prior to commencing study. Training included:

Cost effectiveness analysis between intervention groups using ICER and a cost utility analysis based on the EuroQoL5D from a societal perspective.

Before randomisation, the profile is reviewed by multidisciplinary team during weekly case review meetings to determine eligibility. A second baseline evaluation visit where patients are enrolled and complete baseline measures. Once randomized, patients are discussed at weekly meetings.

Care consultation with patient conducted by non-clinician case managers where treatment plans were presented and patient exerts preference for a plan.

information on each healthcare discipline;

At weekly meetings, clinicians review patient progress using the PSAF, self-rated symptoms and activity against benchmarks of expected improvement. If progress not satisfactory, a patient’s profile may return to team meeting for consideration of changing the treatment plan. Facilitated by specifically trained non-clinician case managers.

review of the available clinical evidence on the effectiveness of each modality when used to treat LBP;

applying an evidence informed practice model;

methods for reaching consensus in a team.

Ongoing training as needed throughout the study.

Site visits by consultant to observe team dynamics and provide feedback.

Weekly meetings facilitated by non-clinician.

Shared access to treatment notes.

Eisenberg et al. [38]

Allopathic doctor and CM clinician evaluate the patient together.

The two evaluators meet to develop an individualized treatment plan. Treatment plan initiated by appropriate clinicians.

Team trained one full day per wk for 14 weeks prior to study. Co-led by a professional facilitator, a medical anthropologist included:

Maximum outcomes with minimum treatment. Number and frequency of visits recorded but no cost effectiveness component included in the study.

At team meetings, cases are presented and discussed for input from all members and treatment plan modified by team’s recommendations. This process was ongoing.

Presentations by each member

Experiential education including hands on diagnosis and treatment by each member on other team members

Diagnosis and treatment of volunteer subjects with chronic LBP

The development of a shared treatment protocol for the implementation of the pilot RCT.

Sundberg, Andersson et al. [36, 46]

Allopathic doctor served as gatekeeper with responsibility for overall management of the patient – only licensed medical doctors are permitted to fully utilise the complete range of medical services. The allopathic doctor had clinical knowledge and experience of CM.

Consensus case conference with CM providers to identify appropriate treatment strategies tailored to the patients’ needs.

Regular team meetings in the lead up to and during the project Training to work collaboratively, utilise a consensus case conference model within primary care, meeting included:

Patients charged a low fee per treatment and low maximum treatment cost to obtain all treatments. No adverse events. The IM model, on average integrating 7 CT sessions with conventional primary care over 10 weeks, resulted in increased QALYs, somewhat higher cost of healthcare provision but a reduced cost of using healthcare resources, including less use of analgesics compared to conventional primary care. The costs/QALY ranged between euro 24 000 and 41 00There was a conservative likelihood of the IC model being cost-effective at a threshold of EUR 50,000 per quality-adjusted life year gained.

Initial conference followed by regular consensus case conferences combining conventional and CM clinical reasoning to verify and improve clinical management of patient.

Professional presentations

Aimed for non-hierarchical decision making.

Educational items on different medical models

Patients did not participate in the consensus case conference but via personal interaction with IM provider.

Case management strategies (approaches to diagnosis, treatment, prevention and documentation)

Used a medical record developed specifically for the trial

Goertz et al. [37]

Doctor of Chiropractic gathers history, conducts eligibility examination including mobility assessment, fracture risk, reviews scores for depression, anxiety and substance abuse, and requests any additional information such as x-rays. All data recorded on web based form and reviewed by other physicians and patient attends second eligibility exam with Doctor of Osteopathy or medical doctor. Case review sessions held twice weekly with DoC and study coordinators present to agree on inclusion. Patient is then randomized.

Team of clinicians assigned to case to follow during 12 weeks.

To prepare for “Shared Care” clinicians completed a 6-month interprofessional educational program comprised of advanced training in LBP both medical and chiropractic, imaging studies and LBP in older adults. Interdisciplinary discussions on simple and complex cases for LBP suitable for co-management

No.

Interprofessional telephone consultation to discuss patient and establish treatment plan.

To foster interdisciplinary practice during the study:

Treatment plan communicated to patient by next treating practitioner

research record sharing via a secure electronic Doctor Communications module specifically constructed and maintained for the study within a web-based tracking and reporting system;

Team based case management:

interprofessional telephone consultations;

Additional telephone call consultations or research record exchanges may be initiated to change treatment plan, refer as warranted

patient centred treatment planning and evaluation

half day site visit at partner clinic to shadow one or more practitioners involved in trial

quarterly interprofessional education sessions

Richardson et al. [40]

A pilot service run by a consultant physician and managed by a service manager, coordinated on a daily basis by a senior staff nurse who was also qualified in massage. Patients referred to the service by local GP and hospitals. The GPs act as gatekeeper and refers to the service. Referral guidelines were developed through consensus conference of 27 health professionals. The referral table lists over 20 conditions suited to one of the three therapies available and contraindications. GPs were the gatekeeper for referral to treatment, and used the referral table for guidance. Patient preference unclear.

Unclear. Staff meetings regularly held and audits conducted but not clear if these discussions altered the patient treatment plan.

The initial Delphi process involved a half day discussion of conditions, therapies and the indications of each for 26 health professionals.

No

Shared bespoke computer system for patient demographic and clinical information.

Practitioners discussed cases in staff meetings which were attended by the medical director, clinic nurse and other practitioners. Local GPs were involved in case presentations where possible.