Postupci liječnika opće prakse u liječenju mišićnokoštanih stanja
Abstract
Background
Musculoskeletal conditions require particular management skills. Identification of interventions which are effective in equipping general practitioners (GPs) with such necessary skills could translate to improved health outcomes for patients and reduced healthcare and societal costs.
Objectives
To determine the effectiveness of professional interventions for GPs that aim to improve the management of musculoskeletal conditions in primary care.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), 2010, Issue 2; MEDLINE, Ovid (1950 ‐ October 2013); EMBASE, Ovid (1980 ‐ Ocotber 2013); CINAHL, EbscoHost (1980 ‐ November 2013), and the EPOC Specialised Register. We conducted cited reference searches using ISI Web of Knowledge and Google Scholar; and handsearched selected issues of Arthritis and Rheumatism and Primary Care‐Clinics in Office Practice. The latest search was conducted in November 2013.
Selection criteria
We included randomised controlled trials (RCTs), non‐randomised controlled trials (NRCTs), controlled before‐and‐after studies (CBAs) and interrupted time series (ITS) studies of professional interventions for GPs, taking place in a community setting, aiming to improve the management (including diagnosis and treatment) of musculoskeletal conditions and reporting any objective measure of GP behaviour, patient or economic outcomes. We considered professional interventions of any length, duration, intensity and complexity compared with active or inactive controls.
Data collection and analysis
Two review authors independently abstracted all data. We calculated the risk difference (RD) and risk ratio (RR) of compliance with desired practice for dichotomous outcomes, and the mean difference (MD) and standardised mean difference (SMD) for continuous outcomes. We investigated whether the direction of the targeted behavioural change affects the effectiveness of interventions.
Main results
Thirty studies met our inclusion criteria.
From 11 studies on osteoporosis, meta‐analysis of five studies (high‐certainty evidence) showed that a combination of a GP alerting system on a patient's increased risk of osteoporosis and a patient‐directed intervention (including patient education and a reminder to see their GP) improves GP behaviour with regard to diagnostic bone mineral density (BMD) testing and osteoporosis medication prescribing (RR 4.44; (95% confidence interval (CI) 3.54 to 5.55; 3 studies; 3,386 participants)) for BMD and RR 1.71 (95% CI 1.50 to 1.94; 5 studies; 4,223 participants) for osteoporosis medication. Meta‐analysis of two studies showed that GP alerting on its own also probably improves osteoporosis guideline‐consistent GP behaviour (RR 4.75 (95% CI 3.62 to 6.24; 3,047 participants)) for BMD and RR 1.52 (95% CI 1.26 to 1.84; 3.047 participants) for osteoporosis medication) and that adding the patient‐directed component probably does not lead to a greater effect (RR 0.94 (95% CI 0.81 to 1.09; 2,995 participants)) for BMD and RR 0.93 (95% CI 0.79 to 1.10; 2,995 participants) for osteoporosis medication.
Of the 10 studies on low back pain, seven showed that guideline dissemination and educational opportunities for GPs may lead to little or no improvement with regard to guideline‐consistent GP behaviour. Two studies showed that the combination of guidelines and GP feedback on the total number of investigations requested may have an effect on GP behaviour and result in a slight reduction in the number of tests, while one of these studies showed that the combination of guidelines and GP reminders attached to radiology reports may result in a small but sustained reduction in the number of investigation requests.
Of the four studies on osteoarthritis, one study showed that using educationally influential physicians may result in improvement in guideline‐consistent GP behaviour. Another study showed slight improvements in patient outcomes (pain control) after training GPs on pain management.
Of three studies on shoulder pain, one study reported that there may be little or no improvement in patient outcomes (functional capacity) after GP education on shoulder pain and injection training.
Of two studies on other musculoskeletal conditions, one study on pain management showed that there may be worse patient outcomes (pain control) after GP training on the use of validated assessment scales.
The 12 remaining studies across all musculoskeletal conditions showed little or no improvement in GP behaviour and patient outcomes.
The direction of the targeted behaviour (i.e. increasing or decreasing a behaviour) does not seem to affect the effectiveness of an intervention. The majority of the studies did not investigate the potential adverse effects of the interventions and only three studies included a cost‐effectiveness analysis.
Overall, there were important methodological limitations in the body of evidence, with just a third of the studies reporting adequate allocation concealment and blinded outcome assessments. While our confidence in the pooled effect estimate of interventions for improving diagnostic testing and medication prescribing in osteoporosis is high, our confidence in the reported effect estimates in the remaining studies is low.
Authors' conclusions
There is good‐quality evidence that a GP alerting system with or without patient‐directed education on osteoporosis improves guideline‐consistent GP behaviour, resulting in better diagnosis and treatment rates.
Interventions such as GP reminder messages and GP feedback on performance combined with guideline dissemination may lead to small improvements in guideline‐consistent GP behaviour with regard to low back pain, while GP education on osteoarthritis pain and the use of educationally influential physicians may lead to slight improvement in patient outcomes and guideline‐consistent behaviour respectively. However, further studies are needed to ascertain the effectiveness of such interventions in improving GP behaviour and patient outcomes.
PICO
Plain language summary
Kako potaknuti liječnike opće prakse na bolje liječenje mišićno‐koštanih poremećaja
U ovom Cochrane sustavnom pregledu literature kriterije uključenja je zadovoljilo 30 studija.
U 11 studija istraživani su postupci kojima je cilj poboljšati način na koji liječnici opće prakse liječe osteoporozu. Podatci iz pet studija zajedno su analizirani jer su te studije bile dovoljno slične. Dokazi pokazuju da sustavi pozoravanja liječnika opće prakse da pacijent ima rizik od osteoporoze i edukacija pacijenata, pri čemu ih se podsjeća da posjete liječnike, vodi k boljem ponašanju liječnika opće prakse (dijagnostičke pretrage i propisivanje lijekova). To su pouzdani rezultati budući da su dokazi visoke kvalitete. Sustavi upozoravanja liječnika opće prakse su vjerojatno već dovoljno učinkoviti sami za sebe (temeljem dviju studija) pa izobrazba bolesnika kao dodatni postupak vjerojatno ne doprinosi većem učinku.
Od deset istraživanja na temu križobolje, sedam je pokazalo da edukacija liječnika opće prakse i dijeljenje smjernica mogu dovesti do malog ili nikakvog poboljšanja kliničkog rada liječnika. Dvije studije su pokazale da davanje smjernica liječnicima i informacija o ukupnom broju pretraga koje su naručili može promijeniti postupke liječnika opće prakse (i dovesti do malog smanjenja traženih pretraga). Istovremeno davanje smjernica i podsjetnika zakačenih na nalaze može dovesti do malog, ali održivog smanjenja broja pretraga.
Pokazalo se da uključivanje uglednih liječnika opće prakse u edukaciju liječnika ima učinka na njihovo ponašanje u jednoj od 4 studije o osteoartrozi. Edukacija liječnika opće prakse o liječenju boli može malo poboljšati smanjenje boli u bolesnika na temelju jedne druge studije.
U tri studije o bolovima u ramenu, jedna je pokazala da postoji nikakvo ili malo poboljšanje ishoda u bolesnika nakon edukacije liječnika opće prakse o bolovima u ramenu i davanju injekcija.
Dvije studije o drugim mišićno‐koštanim stanjima su pokazale da je ishod liječenja boli lošiji nakon edukacije liječnika opće prakse o ljestvicama za mjerenje boli (rezultat jedne studije).
U 12 preostalih studija o mišićnokoštanim stanjima je nađeno malo ili nikakvo poboljšanje postupaka liječnika opće prakse i pokazatelja zdravlja pacijenata. U većini studija nisu istraživanje nuspojave postupaka, a u samo 3 je uključena ekonomska analiza.
Promjene količine tih postupaka (njihovo smanjenje ili povećanje) izgleda da nemaju ishod na učinak postupaka.
Pouzdanost dokaza je bila visoka u studijama učinkovitosti postupaka za bolje liječenje osteoporoze kod liječnika opće prakse. Nađena su ozbiljna ograničenja u provedbi studija ili prikazu rezultata, te su dokazi o postupcima usmjerenima na liječnike opće prakse, a kojima je cilj poboljšanje liječenja mišićno‐koštanih stanja nepouzdani.
