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Cochrane Database of Systematic Reviews

Professionelle Interventionen für Hausärzte für das Management muskoloskelettaler Beschwerden

Información

DOI:
https://doi.org/10.1002/14651858.CD007495.pub2Copiar DOI
Base de datos:
  1. Cochrane Database of Systematic Reviews
Versión publicada:
  1. 06 mayo 2016see what's new
Tipo:
  1. Intervention
Etapa:
  1. Review
Grupo Editorial Cochrane:
  1. Grupo Cochrane de Práctica y organización sanitaria efectivas

Copyright:
  1. Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

  • Victoria Tzortziou Brown

    Correspondencia a: Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry., London, UK

    [email protected]

    Centre for Sports and Exercise Medicine, William Harvey Research Institute,, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK

  • Martin Underwood

    Warwick Clinical Trials Unit, Warwick Medical School, Coventry, UK

  • Noman Mohamed

    Croydon University Hospital, London, UK

  • Olwyn Westwood

    Warwick Medical School, The University of Warwick, Coventry, UK

  • Dylan Morrissey

    Sport and Exercise Medicine, Queen Mary University of London, London, UK

    Physiotherapy Department, Barts Health NHS Trust, London, UK

Contributions of authors

VTB, DM and MU conceived and designed the review. VTB and NM screened search results and DM and MU acted as arbitrators when disagreement arose. VTB and NM extracted data from included studies. VTB led the interpretation and write up of the results of the review, and DM, MU and OW provided detailed comments and guidance on different aspects of the review.

Sources of support

Internal sources

  • Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, UK.

    PhD supervision

  • Institute of Health Science Education, Barts and The London School of Medicine and Dentistry at Queen Mary, University of London, UK.

    PhD supervision

  • Health Sciences Research Institute, Warwick Medical School, UK.

    PhD supervision

External sources

  • National Institute for Health Research (NIHR), UK.

    Funding of the review protocol

  • Arthritis Research UK, UK.

    Funding of the work on the full review

Declarations of interest

Victoria Tzortziou Brown: None to declare

Martin Underwood: None to declare

Noman Mohamed: None to declare

Olwyn Westwood: None to declare

Dylan Morrissey: None to declare

Acknowledgements

We thank Julia Worswick,Tomas Pantoja Sasha Shepperd and Alain Mayhew for their helpful comments on various aspects of this review. We thank Michelle Fiander for her assistance in formulating and running the search strategy. We also thank Orlaith Burke (senior statistician at University of Oxford), Miland Joshi (statistician at Queen Mary, University of London), and Sean Williams (statistician, University of Bath), for their advice on statistical aspects of the review.

Version history

Published

Title

Stage

Authors

Version

2016 May 06

Professional interventions for general practitioners on the management of musculoskeletal conditions

Review

Victoria Tzortziou Brown, Martin Underwood, Noman Mohamed, Olwyn Westwood, Dylan Morrissey

https://doi.org/10.1002/14651858.CD007495.pub2

2008 Oct 08

Professional interventions for general practitioners on the management of musculoskeletal conditions

Protocol

Victoria Tzortziou, Dylan Morrissey, Martin Underwood

https://doi.org/10.1002/14651858.CD007495

Differences between protocol and review

Michelle Fiander, Trials Search Co‐ordinator (TSC) for the EPOC Group, reviewed the search strategy in 2008, and recommended changes in order to broaden the scope of the review and identify all relevant studies. These revised strategies were based on the 2008 strategy and finalised in consultation with the authors.

We revised the wording of the primary outcomes so that this is more consistent with the EPOC guidance on reporting outcomes in EPOC reviews (EPOC 2013d).

We modified some of the planned methods documented in the protocol in response to piloting and advances in the methods for systematic reviews. As noted in the main text of the review, we modified the search strategy, we changed the methods of assessment of risk of bias, and changed some of the methods of data analysis.

In the protocol we mentioned that “We will pool the results of studies in this review if at least two studies are homogeneous regarding the participants, interventions and outcomes. Because of the expected diversity of the interventions and outcomes, it may not be possible to pool the results.” We explored the possibility of grouping the studies by intervention type and pooling the results to assess their effect. However, this was not always clinically appropriate because not all intervention outcomes were applicable to all musculoskeletal conditions (for example, BMD testing was only applicable in osteoporosis). We concluded that clinically, the main source of heterogeneity amongst studies was the musculoskeletal condition studied, as this often determined the type of intervention and measured outcomes. Therefore, and in accordance with the protocol, we presented a narrative summary after grouping the studies by condition, and we included in a meta‐analysis only those studies which were sufficiently similar in terms of intervention and outcomes.

We further divided the osteoporosis studies which were sufficiently similar to allow their results to be combined, into those where the intervention targeted just physicians versus those where both physicians and patients were targeted. This allowed an assessment of the effect of adding a patient‐directed component to interventions targeting a physician in order to establish whether the combined intervention results in improved outcomes.

We used risk differences and risk ratios to express the effect sizes for dichotomous outcomes, in accordance with the protocol. For the expression of the meta‐analysis results, we decided to use risk ratios because reporting relative effect measures is, on average, more consistent, in accordance with the Cochrane Handbook (Deeks 2011). However, we also conducted a sensitivity analysis in order to investigate whether the choice of the summary statistic was critical to the conclusions of the meta‐analysis.

We planned to do a sensitivity analysis in order to re‐examine our inclusion criteria with regards to the study design, as mentioned in the protocol. However, in view of the fact that all studies in the meta‐analysis were RCTs, we could not undertake a sensitivity analysis after removing the NRCTs, as planned in the protocol where we mentioned that we would conduct further "analyses based upon study design (RCT versus other)".

We did a subgroup analysis to assess the intended direction of the intervention's effect on the targeted behavioural change (i.e. whether increasing or decreasing an existing behaviour resulted in different effects).

Two additional authors (Olwyn Westwood and Noman Mohamed) joined the review for this update.
The surname of the corresponding author is changed to "Tzortziou Brown".

Keywords

MeSH

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Prisma study flow diagram.
Figuras y tablas -
Figure 1

Prisma study flow diagram.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Risk of bias summary for ITS study design: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 3

Risk of bias summary for ITS study design: review authors' judgements about each risk of bias item for each included study.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figuras y tablas -
Figure 4

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias graph for ITS study design: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figuras y tablas -
Figure 5

Risk of bias graph for ITS study design: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Comparison 1 Meta‐analysis of osteoporosis studies evaluating physician and patient interventions versus usual care, Outcome 1 Bone Mineral Density.
Figuras y tablas -
Analysis 1.1

Comparison 1 Meta‐analysis of osteoporosis studies evaluating physician and patient interventions versus usual care, Outcome 1 Bone Mineral Density.

Comparison 1 Meta‐analysis of osteoporosis studies evaluating physician and patient interventions versus usual care, Outcome 2 Osteoporosis medication.
Figuras y tablas -
Analysis 1.2

Comparison 1 Meta‐analysis of osteoporosis studies evaluating physician and patient interventions versus usual care, Outcome 2 Osteoporosis medication.

Comparison 2 Meta‐analysis of osteoporosis studies evaluating physician‐only interventions versus usual care, Outcome 1 Bone mineral density.
Figuras y tablas -
Analysis 2.1

Comparison 2 Meta‐analysis of osteoporosis studies evaluating physician‐only interventions versus usual care, Outcome 1 Bone mineral density.

Comparison 2 Meta‐analysis of osteoporosis studies evaluating physician‐only interventions versus usual care, Outcome 2 Osteoporosis medication.
Figuras y tablas -
Analysis 2.2

Comparison 2 Meta‐analysis of osteoporosis studies evaluating physician‐only interventions versus usual care, Outcome 2 Osteoporosis medication.

Comparison 3 Meta‐analysis of osteoporosis studies evaluating physician only interventions versus physician and patient interventions, Outcome 1 Bone mineral density.
Figuras y tablas -
Analysis 3.1

Comparison 3 Meta‐analysis of osteoporosis studies evaluating physician only interventions versus physician and patient interventions, Outcome 1 Bone mineral density.

Comparison 3 Meta‐analysis of osteoporosis studies evaluating physician only interventions versus physician and patient interventions, Outcome 2 Medication.
Figuras y tablas -
Analysis 3.2

Comparison 3 Meta‐analysis of osteoporosis studies evaluating physician only interventions versus physician and patient interventions, Outcome 2 Medication.

Summary of findings for the main comparison. Primary care physician alerting system and a patient‐directed intervention (education and reminder to see their primary care physician) compared to standard care for osteoporosis management

Primary care physician alerting system and a patient‐directed intervention (education and reminder to see their primary care physician) compared to usual care for osteoporosis management

Patient or population: General practitioners/family doctors involved in the management of patients with osteoporosis
Settings: Primary care
Intervention: Primary care physician alerting system and a patient‐directed intervention (education and reminder to see their primary care physician)
Comparison: Usual care

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Usual care

A physician alerting system and a patient‐directed intervention (education and reminder to see their primary care physician)

Bone Mineral Density 1
Follow‐up: 6‐12 months

Study population

RR 4.44
(3.54 to 5.55)

3386
(3 studies)

⊕⊕⊕⊕
high3

49 per 1000

220 per 1000
(124 to 390)

Moderate

39 per 1000

176 per 1000
(99 to 311)

Osteoporosis medication 2
Follow‐up: 6‐12 months

Study population

RR 1.71
(1.50 to 1.94)

4223
(5 studies)

⊕⊕⊕⊕
high3

131 per 1000

241 per 1000 3
(193 to 301)

Moderate

106 per 1000

195 per 1000 3
(156 to 244)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Bone mineral density (BMD) testing is an important outcome for osteoporosis because it leads to the diagnosis of the condition. This is one of the GP behaviour‐related outcomes (primary outcome)

2 Osteoporosis medication prescribing is an important outcome for osteoporosis management as it is the main aspect of treatment. This is one of the GP behaviour‐related outcomes (primary outcome)

3 One of the five studies (Roux 2013) had two intervention comparison groups which were combined to create a single pair‐wise comparison as recommended in chapter 16.5.4 of the Cochrane Handbook.

Figuras y tablas -
Summary of findings for the main comparison. Primary care physician alerting system and a patient‐directed intervention (education and reminder to see their primary care physician) compared to standard care for osteoporosis management
Summary of findings 2. Primary care physician alerting system compared to usual care for osteoporosis management

Primary care physician alerting system compared to usual care for osteoporosis management

Patient or population: General practitioners/family doctors involved in the management of patients with osteoporosis
Settings: Primary care
Intervention: Primary care physician alerting system
Comparison: Usual care

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Usual care

Primary care physician alerting system

Bone mineral density1
Follow‐up: 6‐12 months

Study population

RR 4.75
(3.62 to 6.24)

3047
(2 studies)

⊕⊕⊕⊖
Moderate3

38 per 1000

302 per 1000
(64 to 1000)

Moderate

29 per 1000

231 per 1000
(49 to 1000)

Osteoporosis medication2
Follow‐up: 6‐12 months

Study population

RR 1.52
(1.26 to 1.84)

3047
(2 studies)

⊕⊕⊕⊖
Moderate3

102 per 1000

268 per 1000
(67 to 1000)

Moderate

77 per 1000

202 per 1000
(50 to 809)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Bone mineral density (BMD) testing is an important outcome for osteoporosis because it leads to the diagnosis of the condition. This is one of the GP behaviour‐related outcomes (primary outcome)

2 Osteoporosis medication prescribing is an important outcome for osteoporosis management as it is the main aspect of treatment. This is one of the GP behaviour‐related outcomes (primary outcome)

3 The quality of evidence was downgraded because only two studies were included, one of which had a small number of participants and events, and in view of the considerable statistical heterogeneity observed.

Figuras y tablas -
Summary of findings 2. Primary care physician alerting system compared to usual care for osteoporosis management
Summary of findings 3. Primary care physician alerting system compared to primary care physician alerting system and a patient‐directed intervention (education and reminder to see their primary care physician) for osteoporosis management

Primary care physician alerting system compared to Primary care physician alerting system and a patient‐directed intervention (education and reminder to see their primary care physician) for osteoporosis management

Patient or population: General practitioners/family doctors involved in the management of patients with osteoporosis
Settings: Primary care
Intervention: Primary care physician alerting system
Comparison: Primary care physician alerting system and a patient‐directed intervention (education and reminder to see their primary care physician)

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Primary care physician alerting system and a patient‐directed intervention (education and reminder to see their primary care physician)

Primary care physician alerting system

Bone mineral density1
Follow‐up: 6‐12 months

Study population

RR 0.94

(0.81 to 1.09)

2995
(2 studies)

⊕⊕⊕⊖
moderate3

192 per 1000

194 per 1000
(123 to 261)

Moderate

254 per 1000

257 per 1000
(163 to 345)

Medication2

Follow‐up: 6‐12 months

Study population

RR 0.93
(0.79 to 1.10)

2995
(2 studies)

⊕⊕⊕⊖

moderate3

167 per 1000

176 per 1000
(115 to 264)

Moderate

182 per 1000

191 per 1000
(126 to 288)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Bone mineral density (BMD) testing is an important outcome for osteoporosis because it leads to the diagnosis of the condition. This is one of the GP behaviour‐related outcomes (primary outcome)

2 Osteoporosis medication prescribing is an important outcome for osteoporosis management as it is the main aspect of treatment. This is one of the GP behaviour‐related outcomes (primary outcome)

3 The quality of evidence was downgraded because only two studies were included, one of which had a small number of participants and events.

Figuras y tablas -
Summary of findings 3. Primary care physician alerting system compared to primary care physician alerting system and a patient‐directed intervention (education and reminder to see their primary care physician) for osteoporosis management
Summary of findings 4. Osteoporosis studies: Summary of findings

Professional interventions for GPs on the management of osteoporosis compared to usual care

Patient or population: General practitioners/family doctors involved in the management of patients with osteoporosis

Settings: Primary care

Intervention: Professional interventions (targeting physician‐only)

Comparison: Usual care

Outcomes

Impact (including effect sizes wherever available)

Number of Participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Health professional (GP) behaviour‐related outcomes

  • Bone Mineral Density (BMD) testing

  • Osteoporosis medication (appropriate prescribing)

  • BMD RR 4.75 (95% CI 3.62 to 6.24)

  • Osteoporosis medication RR 1.52 (95% CI 1.26 to 1.84)

  • BMD 3047 (2 studies)

  • Osteoporosis medication 3047 (2 studies)

  • BMD ⊕⊕⊕⊖ moderate1

  • Osteoporosis ⊕⊕⊕⊖ moderate1

Patient outcomes

  • Fragility fractures

  • Hospitalisation

None of the included studies assessed these outcomes

Economic outcomes

  • Health service costs (including prescribing costs)

  • Cost effectiveness

Majumdar 2007, assessed the cost effectiveness of the study Majumdar 2008, and concluded that the intervention led to a per patient cost saving of CAD 13 (USD 9) and a gain of 0.012 quality‐adjusted life years.

272 participants (1 study)

⊕⊕⊖⊖ low2

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence Interval; RR: Risk Ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1The quality of evidence was downgraded because only two studies were included, one of which had a small number of participants and events, and in view of the considerable statistical heterogeneity observed.

2 The quality of evidence was downgraded because only one study was included which had some risk of bias.

Figuras y tablas -
Summary of findings 4. Osteoporosis studies: Summary of findings
Summary of findings 5. Low back pain studies: Summary of findings

Professional interventions for GPs on the management of low back pain compared to usual care

Patient or population: General practitioners/family doctors involved in the management of patients with low back pain

Settings: Primary care

Intervention: Professional interventions (targeting physician‐only)

Comparison: Usual care

Outcomes

Impact (including effect sizes wherever available)

No of studies

Certainty of the evidence
(GRADE)

Comments

H ealth professional (GP) behaviour‐related outcomes

Guideline‐consistent advice during consultation

Bishop 2006 showed that the intervention may result in little or no improvements (RD < 10%) with regard to guideline‐consistent advice about exercise, return to work and education and reassurance.

Dey 2004 showed that the intervention probably results in a small reduction of sickness certification (RD 1.3).

Engers 2005 showed that the intervention may lead to no improvement of GP behaviour with regards to patient education and advice during the consultation (RD range (‐1.3 to 12.8), authors reported OR ranging between 0.4 and 2.9).

3

⊕⊕⊖⊖ low1

Guideline‐consistent prescribing of medication

Bishop 2006 showed that the intervention may lead to little improvements (RD < 10%) with regards to guideline‐consistent medication prescribing.

Dey 2004 showed that the intervention probably results in no difference on prescribing rates of opioids (RD ‐1.3).

Engers 2005 showed that the intervention may result in no improvement of GP behaviour with regard to prescribing (RD=2.8, OR=1, 95% CI (0.3 to 3), reported as not statistically significant).

3

⊕⊕⊖⊖ low1

Guideline‐consistent referrals for investigations (e.g.. x‐rays)

Schectman 2003 showed that the intervention may result in little or no change in GP behaviour with regards to the number of guideline‐consistent referrals for lumbar spine x‐rays and CT scans (RD <5%).

1

⊕⊕⊖⊖ low2

Guideline‐consistent referrals to other services

Bishop 2006 showed that the intervention may lead to little or no improvements (RD < 5%) with regards to guideline‐consistent referral to other services (such as physiotherapy).

Schectman 2003 showed that the intervention may result in little or no difference with regards to the number of guideline‐consistent specialist or physiotherapy referrals (RD <5%).

2

⊕⊕⊖⊖ low3

Number of investigations

Dey 2004 showed that the intervention probably results in a small increase in the ordering of x‐rays (RD 1.4).

French 2013 showed that the intervention may lead to little or no difference in the number of x‐ray and CT requests (RD ‐0.2% and 0.0% respectively).

Kerry 2000 showed that the intervention probably results in a cluster‐adjusted reduction of spinal x‐ray requests of 20% between the intervention and control groups (95% CI 4 to 36, P<0.05).

Schectman 2003 showed that the intervention may result in little or no change in GP behaviour with regards to referrals for lumbar spine x‐rays and CT scans (RD <5%).

4

⊕⊕⊖⊖low4

Number of referrals to other services

Dey 2004 showed that the intervention probably results in increased referrals to fast‐track physiotherapy and a back‐pain triage service (RD 12.6%).

Engers 2005 showed that the intervention may lead to little reduction of onward referrals to a therapist (RD 4.6, 23% in the intervention group versus 28% in the control group, clustered adjusted OR 0.8, 95% CI (0.5 to 1.4)).

Schectman 2003 showed that the intervention may result in little or no difference with regards to the number of specialist or physiotherapy referrals (RD <5%).

3

⊕⊕⊖⊖ low4

Patient outcomes

Functional capacity/activity scores

0

None of the included studies assessed this outcome

Pain control

0

None of the included studies assessed this outcome

Work absence

Hazard 1997 showed that the intervention may result in no improvement with respect to days of sick leave compared to the control group (RD ‐4.6%).

1

⊕⊕⊖⊖ low2

The study by Hazard 1997 was very small (just 53 participants)

Quality of life

0

None of the included studies assessed this outcome

Economic outcomes

  • Health service costs (including prescribing costs)

  • Cost effectiveness

0

None of the included studies assessed these outcomes

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
RD: Risk Difference SMD: Standardised Mean Difference CI: Confidence Interval; RR: Risk Ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 The quality of evidence was downgraded because the studies have a high risk of bias and high heterogeneity in terms of the types of interventions evaluated. Additionally the effect sizes are small.

2 The quality of evidence was downgraded because the results are based only on one study with high risk of bias.

3 The quality of evidence was downgraded because the results are based on just two studies with high risk of bias.

4 The quality of evidence was downgraded because the studies have a high risk of bias and high heterogeneity in terms of the types of interventions evaluated. Additionally there is high inconsistency in the direction of effects across the studies.

Figuras y tablas -
Summary of findings 5. Low back pain studies: Summary of findings
Summary of findings 6. Osteoarthritis studies: Summary of findings

Professional interventions for GPs on the management of osteoarthritis compared to usual care

Patient or population: General practitioners/family doctors involved in the management of patients with osteoarthritis

Settings: Primary care

Intervention: Professional interventions (targeting physician‐only)

Comparison: Usual care

Outcomes

Impact (including effect sizes wherever available)

No of studies

Certainty of the evidence
(GRADE)

Comments

Health professional (GP) behaviour‐related outcomes

Guideline‐consistent advice during consultation

Stross 1985 showed that the intervention may increase the use of intra‐articular corticosteroids (RD large at 29%).

⊕⊕⊖⊖ low1

Guideline‐consistent prescribing of medication

Rahme 2005 showed that the intervention may result in a slight improvement in osteoarthritis guideline‐consistent GP prescribing of medication (acetaminophen, NSAIDs and COX‐2 inhibitors) 5 months afterwards (RD 5% after dissemination of educational material, RD 7% after a workshop and RD 13% for the combined intervention)

Rosemann 2007 showed that prescriptions for painkillers may slightly increase following the intervention (RDs between ‐2.2% and 11.1%).

Stross 1985 showed that the intervention may reduce the use of systemic corticosteroids according to the guidelines (RD moderate at 19%).

⊕⊕⊖⊖ low1

Guideline‐consistent referrals for investigations (e.g.. x‐rays)

None of the included studies assessed this outcome

Guideline‐consistent referrals to other services

Stross 1985 showed that the intervention may increase the utilisation of physical therapy pre‐operatively (RD large at 57%).

⊕⊕⊖⊖ low1

Number of investigations

Rosemann 2007 showed that the intervention may result in some small reduction in the number of GP referrals for radiographs (SMD 0.2‐0.4).

⊕⊕⊖⊖low3

Number of referrals to other services

Rosemann 2007 showed that the intervention may result in a reduction in the number of GP referrals to orthopaedics (SMD 0.8 for the educational intervention and 0.2 for the combined intervention after adding nurse case management).

⊕⊕⊖⊖ low4

Patient outcomes

Functional capacity/activity scores

Chassany 2006 showed that the intervention may result in small improvements with regard to physical function scores (WOMAC index physical function score) (SMD 0.3, P<0.05).

⊕⊕⊖⊖ low5

Results were assessed within two weeks of the Chassany 2006 trial, so it is unclear whether the positive patient outcomes persisted.

Pain control

Chassany 2006 showed that the intervention may result in small improvements with regard to pain scores (VAS score, Pain relief (SPID), WOMAC index pain score) (SMD 0.2, P<0.05 across all outcomes).

⊕⊕⊖⊖ low5

Results were assessed within two weeks of the Chassany 2006 trial, so it is unclear whether the positive patient outcomes persisted.

Work absence

None of the included studies assessed this outcome

Quality of life

Rosemann 2007 showed that the intervention may result in small or no improvement with regard to patient related outcomes (SMD <0.40).

⊕⊕⊖⊖ low3

Economic outcomes

  • Health service costs (including prescribing costs)

  • Cost effectiveness

None of the included studies assessed these outcomes

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
RD: Risk Difference SMD: Standardised Mean Difference CI: Confidence Interval; RR: Risk Ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 The quality of evidence was downgraded because the results are based on one study only with high risk of bias and a small number of participants (114).

2 The quality of evidence was downgraded because the studies have high heterogeneity in terms of the types of interventions and the types of medications prescribed.

3 The quality of evidence was downgraded because the results are based on just one study and the effect size was small.

4 The quality of evidence was downgraded because the results are based on just one study and the effect size varies considerably between the two intervention groups.

5 The quality of evidence was downgraded because the results are based on just one study and were assessed just 2 weeks following the intervention.

NSAIDs: Non steroidal anti‐inflammatory drugs, COX‐2 inhibitors: Cyclo‐oxygenase 2 inhibitors, WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index, VAS: Visual analogue scale, SPID: sum of pain intensity differences.

Figuras y tablas -
Summary of findings 6. Osteoarthritis studies: Summary of findings
Summary of findings 7. Shoulder pain studies: Summary of findings

Professional interventions for GPs on the management of shoulder pain compared to usual care

Patient or population: General practitioners/family doctors involved in the management of patients with shoulder pain

Settings: Primary care

Intervention: Professional interventions (targeting physician‐only)

Comparison: Usual care

Outcomes

Impact (including effect sizes wherever available)

Number of studies

Certainty of the evidence
(GRADE)

Comments

Health professional (GP) behaviour‐related outcomes

Guideline‐consistent advice during consultation

None of the included studies assessed this outcome

Guideline‐consistent prescribing of medication

None of the included studies assessed this outcome

Guideline‐consistent referrals for investigations (e.g.. x‐rays)

None of the included studies assessed this outcome

Guideline‐consistent referrals to other services

None of the included studies assessed this outcome

Number of investigations

Broadhurst 2007 showed that the intervention may result in a temporary, slight reduction in ultrasound requests, but little or no change in the x‐ray requests.

⊕⊕⊖⊖ low1

Number of referrals to other services

None of the included studies assessed this outcome

Patient outcomes

Functional capacity/activity scores

Watson 2008 showed that the intervention may result in little or no improvement in function a year later (BSDQ SMD 0.2, SF‐36 for physical component SMD 0 and SF‐36 mental component SMD 0.1)

⊕⊕⊖⊖ low2

Pain control

None of the included studies assessed this outcome

Work absence

None of the included studies assessed this outcome

Quality of life

None of the included studies assessed this outcome

Economic outcomes

  • Health service costs (including prescribing costs)

  • Cost effectiveness

McKenna 2009 assessed the cost effectiveness of providing practical training to GPs in the SAPPHIRE study by Watson 2008. It reported an incremental cost‐effectiveness ratio of GBP 2,813 per QALY gained for trained GPs.

⊕⊕⊖⊖ low2

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
RD: Risk Difference SMD: Standardised Mean Difference CI: Confidence Interval; RR: Risk Ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 The quality of evidence was downgraded because the results are based on just one study (CBA) with high risk of bias.

2 The quality of evidence was downgraded because the results are based on just one study and the effect size was small.

BSDQ: British Shoulder Disability questionnaire, SF‐36: Short‐form 36 item Health Survey, GBP: Great Britain Pound

Figuras y tablas -
Summary of findings 7. Shoulder pain studies: Summary of findings
Summary of findings 8. Studies on other musculoskeletal conditions: Summary of findings

Professional interventions for GPs on the management of shoulder pain compared to usual care

Patient or population: General practitioners/family doctors involved in the management of patients with other musculoskeletal conditions

Settings: Primary care

Intervention: Professional interventions (targeting physician‐only)

Comparison: Usual care

Outcomes

Impact (including effect sizes wherever available)

No of studies

Certainty of the evidence
(GRADE)

Comments

Health professional (GP) behaviour‐related outcomes

Guideline‐consistent advice during consultation

None of the included studies assessed this outcome

Guideline‐consistent prescribing of medication

Huas 2006 showed that the intervention may result in increased level 3 (WHO classification) analgesic prescribing (SMD 1.2, P=0.02)

⊕⊕⊖⊖ low1

Guideline‐consistent referrals for investigations (e.g.. x‐rays)

None of the included studies assessed this outcome

Guideline‐consistent referrals to other services

None of the included studies assessed this outcome

Number of investigations

Kerry 2000 showed that the intervention may result in little or no reduction in GP knee radiology requests (relative change 10%, not statistically significant).

⊕⊕⊖⊖ low2

Number of referrals to other services

None of the included studies assessed this outcome

Patient outcomes

Functional capacity/activity scores

None of the included studies assessed this outcome

Pain control

Huas 2006 showed that the intervention may result in worse patient‐related outcomes: pain relief scores (SMD 2, P=0.0004)

⊕⊕⊖⊖ low1

Work absence

None of the included studies assessed this outcome

Quality of life

None of the included studies assessed this outcome

Economic outcomes

  • Health service costs (including prescribing costs)

  • Cost effectiveness

None of the included studies assessed these outcomes

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
RD: Risk Difference SMD: Standardised Mean Difference CI: Confidence Interval; RR: Risk Ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 The quality of evidence was downgraded because the results are based on just one study with high risk of bias.

2 The quality of evidence was downgraded because the results are based on just one study and the effect size was small.

Figuras y tablas -
Summary of findings 8. Studies on other musculoskeletal conditions: Summary of findings
Table 1. Classification of relevant interventions from EPOC taxonomy

Table 1: Classification of relevant interventions from EPOC taxonomy

Intervention

Description

Distribution of educational materials

Distribution of published or printed recommendations for clinical care, including clinical practice guidelines, audio‐visual materials and electronic publications.  The materials may have been delivered personally or through mass mailings.

Educational meetings 

Healthcare providers who have participated in conferences, lectures, workshops or traineeships

Local consensus processes

Inclusion of participating providers in discussion to ensure that they agreed that the chosen clinical problem was important and the approach to managing the problem was appropriate

Educational outreach visits 

Use of a trained person who met with providers in their practice settings to give information with the intent of changing the provider’s practice.  The information given may have included feedback on the performance of the provider(s)

Local opinion leaders

Use of providers nominated by their colleagues as ‘educationally influential’.  The investigators must have explicitly stated that their colleagues identified the opinion leaders

Patient‐mediated

New clinical information (not previously available) collected directly from patients and given to the provider e.g. depression scores from an instrument

Audit and feedback 

Any summary of clinical performance of health care over a specified period of time. The summary may also have included recommendations for clinical action. The information may have been obtained from medical records, computerised databases, or observations from patients

Reminders 

Patient or encounter specific information, provided verbally, on paper or on a computer screen, which is designed or intended to prompt a health professional to recall information.  This would usually be encountered through their general education; in the medical records or through interactions with peers, and so remind them to perform or avoid some action to aid individual patient care.  Computer aided decision support and drugs dosage are included.

Marketing

Use of personal interviewing, group discussion (‘focus groups’), or a survey of targeted providers to identify barriers to change and subsequent design of an intervention that addresses identified barriers

Mass media

(i) Varied use of communication that reached great numbers of people including television, radio, newspapers, posters, leaflets, and booklets, alone or in conjunction with other interventions;  (ii) Targeted at the population level

Other

Patient‐directed (education and reminders to see their primary care physician)

Figuras y tablas -
Table 1. Classification of relevant interventions from EPOC taxonomy
Table 2. Intervention types used in each study (N.B. All interventions evaluated were professional)

Table 2. Intervention types used in each study (N.B. All interventions evaluated were professional)

Intervention methods 1,2 

No. of Studies 

Studies 3

Distribution of educational materials

27

Becker 2008; Bessette 2011; Bishop 2006; Boyd 2002; Broadhurst 2007; Chassany 2006; Ciaschini 2010; Cranney 2008; Dey 2004; Eccles 2001; Engers 2005; Feldstein 2006; French 2013; Hazard 1997; Hollingworth 2002; Kerry 2000; Leslie 2012; Majumdar 2008; Rahme 2005; Robling 2002; Rosemann 2007; Roux 2013; Rozental 2008; Schectman 2003; Solomon 2007a; Stross 1985; Watson 2008

Educational meetings 

10

Becker 2008; Chassany 2006; Engers 2005; French 2013; Gormley 2003; Huas 2006; Rahme 2005; Rosemann 2007; Schectman 2003, Watson 2008

Local consensus processes

0

Educational outreach visits 

6

Becker 2008; Broadhurst 2007; Dey 2004; Robling 2002; Schectman 2003; Solomon 2007a

Local opinion leaders

3

Majumdar 2008; Stross 1985; Schectman 2003

Patient‐mediated

6

Boyd 2002; Ciaschini 2010; Cranney 2008; Huas 2006; Roux 2013; Rozental 2008

Audit and feedback 

4

Eccles 2001; Kerry 2000; Robling 2002; Schectman 2003

Reminders 

11

Bishop 2006; Ciaschini 2010; Cranney 2008; Eccles 2001; Feldstein 2006; Hazard 1997; Lafata 2007; Leslie 2012; Majumdar 2008; Roux 2013; Rozental 2008

Marketing

0

Mass media

0

Patient‐directed4

12

Becker 2008; Bessette 2011; Bishop 2006; Leslie 2012; Ciaschini 2010; Cranney 2008; Feldstein 2006; Lafata 2007; Majumdar 2008; Rosemann 2007; Roux 2013; Solomon 2007a

1. Category of intervention as classified by the EPOC taxonomy EPOC 2007 [9]

2. See Table 1 for definition of each intervention

3. Some studies used more than one intervention type and these are listed against their corresponding category

4. Patient‐directed interventions targeted patients and included patient education and reminders to see their primary‐care physician. These were included in the review only if they were a component of a professional intervention targeting primary‐care physicians

Figuras y tablas -
Table 2. Intervention types used in each study (N.B. All interventions evaluated were professional)
Table 3. Intervention combinations compared to a no‐intervention control group

Table 3. Intervention combinations compared to a no‐intervention control group

Intervention combinations 

No. of comparisons

Study ID

Single component interventions:

Distribution of educational materials

1

Rahme 2005

Patient‐directed

3

Lafata 2007; Leslie 2012; Solomon 2007a

Educational meetings, workshops  

1

Rahme 2005

Multifaceted interventions: Two intervention components

Distribution of educational material + reminders

4

Bishop 2006; Feldstein 2006; Hazard 1997; Leslie 2012

Distribution of educational material + educational outreach visits

4

Broadhurst 2007; Chassany 2006; Dey 2004; Solomon 2007a

Distribution of educational material + educational meeting/workshop

6

Chassany 2006; Engers 2005; French 2013; Rahme 2005; Rosemann 2007; Watson 2008

Distribution of educational material + local opinion leaders

1

Stross 1985

Distribution of educational material + audit/feedback

1

Kerry 2000

Patient‐mediated + educational meeting/workshop

1

Huas 2006

Patient‐directed +reminder

1

Lafata 2007

Patient‐directed + educational material

1

Bessette 2011

Multifaceted interventions: Three intervention components

Patient‐directed + educational material + reminder

3

Bishop 2006; Feldstein 2006, Leslie 2012

Patient‐directed + educational material + educational meeting/workshop

1

Rosemann 2007

Patient‐directed + educational material + educational outreach visit

1

Solomon 2007a

Multifaceted interventions: Four intervention components

Patient‐directed + distribution of educational material + reminder + local opinion leaders

1

Majumdar 2008

Patient‐mediated + distribution of educational material + reminders + patient‐directed (education and reminders)

3

Ciaschini 2010; Cranney 2008; Roux 2013

Multifaceted interventions: Five intervention components

Distribution of educational material + educational meetings/workshops + audit + educational outreach visit + local opinion leaders

1

Schectman 2003

Figuras y tablas -
Table 3. Intervention combinations compared to a no‐intervention control group
Table 4. Intervention combinations compared to a different intervention

Table 4. Intervention combinations compared to a different intervention

Intervention combinations 

No. of comparisons

Study ID

Single component interventions:

Educational meetings/workshops vs distribution of educational material

1

Rahme 2005

Educational meetings/workshops vs a different educational meeting/workshop

1

Gormley 2003

Multifaceted interventions: Two intervention components

Distribution of educational material + patient‐mediated vs the same intervention but less intensive

1

Boyd 2002

Distribution of educational material + educational outreach visit vs distribution of educational material

1

Robling 2002

Distribution of educational material + audit vs distribution of educational material

2

Robling 2002; Eccles 2001

Distribution of educational material + audit vs distribution of educational material + reminder

1

Eccles 2001

Distribution of educational material + outreach vs distribution of educational material + audit

1

Robling 2002

Distribution of educational material + educational outreach visit vs patient‐directed

1

Solomon 2007a

Distribution of educational material + patient‐directed vs the same (more intensive)

1

Bessette 2011

Patient‐directed + reminder vs patient‐directed

1

Lafata 2007

Distribution of educational material + reminder vs distribution of educational material

1

Eccles 2001

Distribution of educational material + reminder vs patient‐mediated

1

Rozental 2008

Distribution of educational material + educational meeting/workshop vs educational meeting/workshop

1

Rahme 2005

Distribution of educational material + educational meeting/workshop vs distribution of educational material

1

Rahme 2005

Multifaceted interventions: Three intervention components

Distribution of educational material + reminders + patient‐directed vs distribution of educational material + reminders

2

Bishop 2006; Feldstein 2006

Distribution of educational material + reminder + patient‐directed vs patient‐directed

1

Leslie 2012

Distribution of educational material + audit + reminders vs distribution of educational material

1

Eccles 2001

Distribution of educational material + audit + reminders vs distribution of educational material + audit

1

Eccles 2001

Distribution of educational material + audit + reminders vs distribution of educational material + reminders

Eccles 2001

Distribution of educational material + audit + outreach vs distribution of educational material + outreach

1

Robling 2002

Distribution of educational material + audit + outreach vs distribution of educational material + audit

1

Robling 2002

Distribution of educational material + audit + outreach vs distribution of educational material

1

Robling 2002

Distribution of educational material + educational meetings/workshops + educational outreach visits vs distribution of educational material

1

Becker 2008

Distribution of educational material + educational outreach visit + patient‐directed vs patient‐directed

1

Solomon 2007a

Distribution of educational material + educational outreach visit + patient‐directed vs distribution of educational material + educational outreach visit

1

Solomon 2007a

Distribution of educational material + educational meeting/workshop + patient‐directed vs distribution of educational material + educational meeting/workshop

1

Rosemann 2007

Multifaceted interventions: Four intervention components

Distribution of educational material + educational meetings/workshops + educational outreach visits + patient‐directed vs distribution of educational material

1

Becker 2008

Distribution of educational material + educational meetings/workshops +educational outreach visits + patient directed vs distribution of educational material + educational meetings/workshops + educational outreach visits

1

Becker 2008

Patient‐mediated + distribution of education material + reminders + patient‐directed (education and reminders) vs patient‐mediated + distribution of education material + reminders + patient‐directed (education and reminders)

1

Roux 2013

Figuras y tablas -
Table 4. Intervention combinations compared to a different intervention
Table 5. Osteoporosis studies: intervention versus no intervention (control), outcome: BMD, dichotomous data

(Study)

Intervention

Int pre (%) 1

C pre (%)2

Int post (%)3

C post (%)4

ARD 5

Risk difference 6

(P value if reported by authors)

Relative % change post 7

Risk ratio 8

(Bessette 2011)*

Patient education and reminder to see their physician (patient directed), education of physician via the patient (distribution of educational material)

14.72%

11.96%

2.8%

23%

1.2

(Bessette 2011)*

Patient education (including video on osteoporosis) and reminder to see their physician, education of physician via the patient (distribution of educational material)

15.81%

11.96%

3.9%

32%

1.3

(Cranney 2008)**

Patient‐specific mailed letter to primary are physician (including guidelines) and patient education and reminder

64/125 (51%)

36/145 (25%)

26.4%

(P< 0.0001)

106%

2.1

(Feldstein 2006)

Patient‐specific Electronic Medical Record (EMR) reminders to primary‐care provider informing them of patient increased risk and guidelines. Sent twice.

40/101 (39.6%)

2/103 (1.9%)

37.7%

(P< 0.01)

1940%

20.4

(Feldstein 2006)

EMR reminder plus patient‐directed intervention: education and reminder

36/110 (32.7%)

2/103 (1.9%)

30.8%

(P< 0.01)

1585%

16.9

(Lafata 2007)**

Patient‐directed: 2 mailings (educational and reminders)

720/3367 (21.4%)

313/2901 (10.8%)

10.6%

(P< 0.001)

98%

2

(Lafata 2007)**

Physician prompt: Electronic Medical Record (EMR) reminder to physician and biweekly mailing plus patient‐directed: 2 mailings (educational and reminders)

1181/4086 (28.9%)

313/2901 (10.8%)

18.1%

(P< 0.001)

168%

2.7

(Leslie 2012)

Physician reminder plus educational material

224/1363 (16.4%)

58/1480 (3.9%)

12.5%

319%

4.2

(Leslie 2012)

Physician reminder plus educational material plus patient‐directed intervention (reminder to see their physician)

258/1421 (18.2%)

58/1480 (3.9%)

14.2%

363%

4.6

(Majumdar 2008)

Patient education, physician patient‐specific reminders by mail/fax, physician guidelines endorsed by opinion leaders

71/137 (51.8%)

24/135 (17.8%)

34%

(P< 0.001)

192%

2.9

(Solomon 2007a)**

Patient directed (3 mailed letters educational)

249/3274 (7.6%)

224/3268 (6.9%)

0.8%

(NS)

11%

1.1

(Solomon 2007a)**

Physician education following an academic‐detailing approach

183/3574 (5.1%)

224/3268 (6.9%)

‐1.7%

(NS)

‐25%

0.7

(Solomon 2007b)**

Combination of both physician and patient education

223/3339 (6.7%)

224/3268 (6.9%)

‐0.2%

(NS)

‐3%

1

1. Intervention group pre‐intervention proportion

2. Control group pre‐intervention proportion

3. Intervention group post‐intervention proportion

4. Control group post‐intervention proportion

5. ARD = [Int post (%) minus C post (%)] minus [Int pre (%) minus C pre (%)]. The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome, according to Grimshaw 2004.

6. Risk Difference (RD) is the absolute % change post‐intervention = Int post (%) minus C post (%). This is considered to be "small" if ≤ 5%, "modest" if > 5% and ≤10%,"moderate" if > 10% but ≤ 20%, and "large" if > 20%.The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome, according to Grimshaw 2004.

7. Relative % change post = absolute % change post divided by C post (%). The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome, according to Grimshaw 2004.

8. Risk ratio (RR) = Int post (%) divided by C post (%)

BMD: bone mineral density; C: control group; Int: intervention group; ARD: adjusted risk difference; NS: not significant

* In the study by Bessette 2011, the outcomes reported above include the participants with a diagnosis following the intervention. The women were considered "diagnosed" if they received a BMD test, if they were informed by their physician that they were suffering from osteoporosis and/or if they were initiated on osteoporosis medication. Therefore, the above percentages do not necessarily mean that the women received a BMD test.

** The data reported above for the studies by Cranney 2008, Lafata 2007 and Solomon 2007b does not account for clustering. We did not have access to sufficient information to adjust the data for clustering.

Figuras y tablas -
Table 5. Osteoporosis studies: intervention versus no intervention (control), outcome: BMD, dichotomous data
Table 6. Osteoporosis studies, intervention versus no intervention (control), outcome:osteoporosis medication, dichotomous data

(Study)

Intervention

Int pre (%) 1

C pre (%)2

Int post (%)3

C post (%)4

ARD 5

Risk difference 6

(P value if reported by authors)

Relative % change post 7

Risk ratio 8

(Bessette 2011)

Patient education (patient directed), education of physician via the patient (for group of patients without diagnosis or treatment at randomisation)

11.79%

7.78%

4%

52%

1.5

(Bessette 2011)

Patient education (including video on osteoporosis), education of physician via the patient (for group of patients without diagnosis or treatment at randomisation)

10.64%

7.78%

2.9%

37%

1.4

(Bessette 2011)

Patient education (patient directed), education of physician via the patient (for group of patients without treatment at randomisation)

13.49%

10.31%

3.2%

31%

1.3

(Bessette 2011)

Patient education (including video on osteoporosis), education of physician via the patient (for group of patients without treatment at randomisation)

12.71%

10.31%

2.4%

23%

1.2

(Bessette 2011)

Patient education, education of physician via the patient where the patient did pass the information on to the physician (for group of patients without treatment at randomisation)

15%

10%

5%

50%

1.5

(Ciaschini 2010)

Patient‐specific evidence‐based recommendations targeted to improve osteoporosis treatment to both the patients and their primary‐care providers

29/52 (55.8%)

16/60 (26.7%)

29.1%

109%

2.1

(Cranney 2008)*

Patient‐specific mailed letter to primary are physician (including guidelines) and patient education and reminder

35/125 (28%)

15/145 (10.3%)

17.7%

(P=0.0002)

171%

2.7

(Feldstein 2006)

Patient‐specific Electronic Medical Record (EMR) reminders to primary‐care provider informing them of patient increased risk and guidelines. Sent twice.

28/101 (27.7%)

5/103 (5%)

22.9%

(P< 0.01)

471%

5.7

(Feldstein 2006)

EMR reminder plus patient‐directed intervention: education and reminder

22/110 (20.2%)

5/103 (5%)

15.1%

(P< 0.01)

312%

4.1

(Lafata 2007)*

Patient‐directed: x2 mailings (educational and reminders)

11/128 (8.6%)

3/51 (5.9%)

2.7%

46%

1.5

(Lafata 2007)*

Physician prompt: Electronic Medical Record (EMR) reminder to physician and biweekly mailing plus Patient‐directed: 2 mailings (educational and reminders)

15/162 (9.3%)

3/51 (5.9%)

3.4%

57%

1.6

(Leslie 2012)

Physician reminder plus educational material

200/1363 (14.7%)

157/1480 (10.6%)

4.1%

38%

1.4

(Leslie 2012)

Physician reminder plus educational material plus patient‐directed intervention (reminder to see their physician)

234/1421 (16.5%)

157/1480 (10.6%)

5.9%

55%

1.6

(Majumdar 2008)

Patient education, physician patient‐specific reminders by mail/fax, physician guidelines endorsed by opinion leaders

30/137 (21.9%)

10/135 (7.4%)

14.5%

(P<0.001)

196%

3

(Roux 2013)

Verbal and written information on osteoporosis to patient and letter with specific management plan sent to their treating physician. Patient reminders at 6 and 12 months. Reminder to physician if patient untreated at 6 months

82/275 (29.8%)

45/199 (22.6%)

151/275 (54.9%)

71/199 (35.7%)

12%

19.2%

(P< 0.005)

54%

1.5

(Roux 2013)

Verbal and written information on osteoporosis to patient and letter with specific management plan sent to their treating physician. Blood tests and BMD test ordered for patient and results sent to the physician. Patient reminders at 4,8 and 12 months and physician reminders at 4 and 8 months if patient remained untreated

65/251 (25.9%)

45/199 (22.6%)

156/251

(62.2%)

71/199 (35.7%)

23.2%

26.5%

(P< 0.005)

74%

1.7

(Solomon 2007a)*

Patient directed (x3 mailed letters educational)

208/3274 (6.4%)

231/3268 (7.1%)

‐0.7%

‐10%

0.9

(Solomon 2007a)*

Physician education following an academic detailing approach

197/3574 (5.5%)

231/3268 (7.1%)

‐1.6%

‐22%

0.8

(Solomon 2007a)*

Combination of both physician and patient education

236/3339 (7.1%)

231/3268 (7.1%)

0

0

1

1. Intervention group pre‐intervention proportion

2. Control group pre‐intervention proportion

3. Intervention group post‐intervention proportion

4. Control group post‐intervention proportion

5. ARD = [Int post (%) minus C post (%)] minus [Int pre (%) minus C pre (%)]. The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome, according to Grimshaw 2004.

6. Risk Difference (RD) is the absolute % change post‐intervention = Int post (%) minus C post (%). This is considered to be "small" if ≤ 5%, "modest" if > 5% and ≤10%,"moderate" if > 10% but ≤ 20%, and "large" if > 20%.The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome, according to Grimshaw 2004.

7. Relative % change post = absolute % change post divided by C post (%). The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome, according to Grimshaw 2004.

8. Risk ratio (RR) = Int post (%) divided by C post (%)

BMD: bone mineral density; C: control group; Int: intervention group; ARD: adjusted risk difference; NS: not significant

* The data reported above for the studies by Cranney 2008, Lafata 2007 and Solomon 2007b does not account for clustering. We did not have access to sufficient information to adjust the data for clustering.

Figuras y tablas -
Table 6. Osteoporosis studies, intervention versus no intervention (control), outcome:osteoporosis medication, dichotomous data
Table 7. Osteoporosis studies intervention versus another intervention, outcome: BMD, dichotomous data

(Study)

Interventions

Int 1 pre (%) 1

Int 2 pre (%)2

Int 1 post (%)3

Int 2 post (%)4

ARD 5

Risk difference6

(P value if reported by authors)

Relative % change post 7

Risk ratio 8

(Bessette 2011)*

Patient education, education of physician via the patient, reminder to family physician versus Patient education (including video on osteoporosis), education of physician via the patient, reminder to family physician

14.72%

15.81%

‐1.1%

‐7%

0.9

(Boyd 2002)

Patient‐specific letter to primary care physician containing information on results and recommendations: standard versus extended letter

25/83 (30.1%)

29/78 (37.2%)

‐7.1%

‐19%

0.8

(Feldstein 2007)

Patient‐specific Electronic Medical Record (EMR) reminders to primary‐care provider informing them of patient increased risk and guidelines (sent twice) versus EMR plus patient‐directed intervention (education and reminder)

40/101 (39.6%)

36/110

(32.7%)

6.9%

21%

1.2

(Lafata 2007)**

Patient‐directed: 2 mailings (educational and reminders) versus physician prompt: Electronic Medical Record (EMR) reminder to physician and biweekly mailing plus patient‐directed: 2 mailings (educational and reminders)

720/3367 (21.4%)

1181/4086 (28.9%)

‐7.5%

‐26%

0.7

(Leslie 2012)

Physician reminder plus educational material versus physician reminder plus educational material plus patient‐directed intervention (reminder to see their physician)

224/1363 (16.4%)

258/1421 (18.2%)

‐1.7%

(NS)

‐9%

0.9

(Rozental 2008)

Patient‐specific letter to primary‐care physician outlining guidelines versus orthopaedic surgeon ordering BMD and forwarding results to primary‐care physician

7/23 (30.4%)

25/27(92.6%)

‐62.2%

‐67%

0.3

(Solomon 2007a)**

Patient‐directed (3 mailed letters educational) versus physician education following an academic‐detailing approach

249/3274 (7.6%)

183/3574 (5.1%)

2.5%

49%

1.5

(Solomon 2007a)**

Patient‐directed (3 mailed letters educational) versus combination of both physician and patient education

249/3274 (7.6%)

223/3339 (6.7%)

0.9%

14%

1.1

(Solomon 2007a)**

Physician education following an academic‐detailing approach versus combination of both physician and patient education

183/3574 (5.1%)

223/3339 (6.7%)

‐1.6%

‐23%

0.8

1. Intervention 1 group pre‐intervention proportion

2. Intervention 2 group pre‐intervention proportion

3. Intervention 1 group post‐intervention proportion

4. Intervention 2 group post‐intervention proportion

5. ARD = [Int 1 post (%) minus Int 2 post (%)] minus [Int 1 pre (%) minus Int 2 pre (%)]. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

6. Risk Difference (RD) is the absolute % change post‐intervention = Int 1 post (%) minus Int 2 post (%). This is considered to be "small" if ≤ 5%, "modest" if > 5% and ≤10%,"moderate" if > 10% but ≤ 20%, and "large" if > 20%.The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome.

7. Relative % change post = absolute % change post divided by Int 2 post (%). The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

8. Risk ratio (RR) = Int 1 post (%) divided by Int 2 post (%)

BMD: bone mineral density; Int 1: intervention 1 group; Int 2: Intervention 2 group; ARD: adjusted risk difference; NS: not significant

* In the study by Bessette 2011, the outcomes reported above include the participants with a diagnosis following the intervention. The women were considered "diagnosed" if they received a BMD test, if they were informed by their physician that they were suffering from osteoporosis and/or if they were initiated on osteoporosis medication. Therefore, the above percentages do not necessarily mean that the women received a BMD test.

**The data reported above for the studies by Lafata 2007 and Solomon 2007b does not account for clustering. We did not have access to sufficient information to adjust the data for clustering.

Figuras y tablas -
Table 7. Osteoporosis studies intervention versus another intervention, outcome: BMD, dichotomous data
Table 8. Osteoporosis studies, intervention versus another intervention, outcome: osteoporosis medication, dichotomous data

(Study)

Interventions

Int 1 pre (%) 1

Int 2 pre (%)2

Int 1 post (%)3

Int 2 post (%)4

ARD 5

Risk difference 6

(P value if reported by authors)

Relative % change post 7

Risk ratio 8

(Bessette 2011)

Patient education, education of physician via the patient, reminder to family physician (for group of patients without diagnosis or treatment at randomisation) versus Patient education (including video on osteoporosis), education of physician via the patient, reminder to family physician (for group of patients without diagnosis and treatment at randomisation)

11.79%

10.64%

1.2%

11%

1.1

(Bessette 2011)

Patient education, education of physician via the patient, reminder to family physician (for group of patients without diagnosis or treatment at randomisation) versus Patient education (including video on osteoporosis), education of physician via the patient, reminder to family physician (for group of patients without treatment at randomisation)

13.49%

12.71%

0.8%

6%

1.1

(Boyd 2002)

Patient‐specific letter to primary care physician containing information on results and recommendations: standard versus extended letter

11/104 (10.6%)

14/93 (15.1%)

‐4.5%

‐30%

0.7

(Feldstein 2007)

Patient specific Electronic Medical Record (EMR) reminders to primary care provider informing them of patient increased risk and guidelines (sent twice) versus EMR plus patient‐directed intervention (education and reminder).

28/101 (27.7%)

22/110 (20%)

7.7%

39%

1.4

(Lafata 2007)*

Patient‐directed: 2 mailings (educational and reminders) versus physician prompt: Electronic Medical Record (EMR) reminder to physician and biweekly mailing plus patient‐directed: 2 mailings (educational and reminders)

11/128 (8.6%)

15/162 (9.3%)

‐0.7%

‐7%

0.9

(Leslie 2012)

Physician reminder plus educational material versus physician reminder plus educational material plus patient‐directed intervention (reminder to see their physician)

200/1363 (14.7%)

234/1421 (16.5%)

‐1.8%

(NS)

‐11%

0.9

(Roux 2013)

Verbal and written information on osteoporosis to patient and letter with specific management plan sent to their treating physician. Patient reminders at 6 and 12 months. Reminder to physician if patient untreated at 6 months versus verbal and written information on osteoporosis to patient and letter with specific management plan sent to their treating physician. Blood tests and BMD test ordered for patient and results sent to the physician. Patient reminders at 4,8 and 12 months and physician reminders at 4 and 8 months if patient remained untreated

82/275 (29.8%)

65/251 (25.9%)

151/275 (54.9%)

156/251

(62.2%)

‐11.2%

‐7.2%

(P<0.001)

‐12%

0.9

(Rozental 2008)

Patient specific letter to primary care physician outlining guidelines versus orthopaedic surgeon ordering BMD and forwarding results to primary‐care physician

6/23 (26.1%)

20/27(74.1%)

‐48%

‐65%

0.4

(Solomon 2007a)*

Patient directed (x3 mailed letters educational) versus physician education following an academic detailing approach

208/3274 (6.4%)

197/3574 (5.5%)

0.8%

15%

1.2

(Solomon 2007a)*

Patient directed (x3 mailed letters educational) versus combination of both physician and patient education

208/3274 (6.4%)

236/3339 (7.1%)

‐0.7%

‐10%

0.9

(Solomon 2007a)*

Physician education following an academic detailing approach versus combination of both physician and patient education

197/3574 (5.5%)

236/3339 (7.1%)

‐1.6%

‐22%

0.8

1. Intervention 1 group pre‐intervention proportion

2. Intervention 2 group pre‐intervention proportion

3. Intervention 1 group post‐intervention proportion

4. Intervention 2 group post‐intervention proportion

5. ARD = [Int 1 post (%) minus Int 2 post (%)] minus [Int 1 pre (%) minus Int 2 pre (%)]. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

6. Risk Difference (RD) is the absolute % change post‐intervention = Int 1 post (%) minus Int 2 post (%). This is considered to be "small" if ≤ 5%, "modest" if > 5% and ≤10%,"moderate" if > 10% but ≤ 20%, and "large" if > 20%.The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome.

7. Relative % change post = absolute % change post divided by Int 2 post (%). The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

8. Risk ratio (RR) = Int 1 post (%) divided by Int 2 post (%)

BMD: bone mineral density; Int 1: intervention 1 group; Int 2: Intervention 2 group; ARD: Adjusted risk difference; NS: not significant

* The data reported above for the studies by Lafata 2007 and Solomon 2007b does not account for clustering. We did not have access to sufficient information to adjust the data for clustering.

Figuras y tablas -
Table 8. Osteoporosis studies, intervention versus another intervention, outcome: osteoporosis medication, dichotomous data
Table 9. Low back pain studies, intervention versus control, dichotomous data

(Study)

Intervention

Outcome

Int pre (%) 1

C pre (%)2

Int post (%)3

C post (%)4

ARD 5

Risk difference 6

(P value if reported by authors)

Relative % change post 7

Risk ratio 8

(Bishop 2006)

Physician education (guidelines) and 3 patient‐specific reminder letters

Education and reassurance according to guideline 0 ‐ 4 weeks post‐onset

10% (16/162)

7% (10/149)

3.2%

47%

1.5

Exercise according to guideline 0 ‐ 4 weeks post‐onset

38% (62/162)

43% (64/149)

‐4.7%

‐11%

0.9

Appropriate medication according to guideline 0 ‐ 4 weeks post‐onset

85% (138/162)

77% (115/149)

8%

(P=0.14)

10%

1.1

Spinal manipulation according to guideline 0 ‐ 4 weeks post‐onset

2.5% (4/162)

6% (9/149)

‐3.6%

‐59%

0.4

Guideline‐discordant physician recommended treatment 0 ‐ 4 weeks post‐onset

10% (16/162)

17% (25/149)

6.9%

(P=0.05)

41%

0.6

Supervised exercise programme (recommended treatment 5 ‐ 12 weeks post‐onset)

19% (29/154)

14% (21/149)

4.7%

(P=0.11)

34%

1.3

Return to work (recommended treatment 5 ‐ 12 weeks post‐onset)

24% (37/154)

17% (25/149)

7.2%

(P=0.18)

43%

1.4

Refer to interdisciplinary programme (recommended treatment 5 ‐ 12 weeks post‐onset)

4% (6/154)

2% (3/149)

1.9%

94%

1.9

Physiotherapy > 4 weeks (guideline‐discordant)

41% (63/154)

43% (64/149)

2%

5%

1

Continued use of spinal manipulation therapy (guideline‐discordant)

‐(no data available)

33% (49/149)

(P=0.04)

(Bishop 2006)

Physician education, reminders and also patient education and 3 reminders

Education and reassurance according to guideline 0 ‐ 4 weeks post‐onset

6% (9/151)

7% (10/149)

‐0.8%

‐11%

0.9

Exercise according to guideline 0 ‐ 4 weeks post‐onset

53% (80/151)

43% (64/149)

10%

(P=0.05)

23%

1.2

Appropriate medication according to guideline 0 ‐ 4 weeks post‐onset

81% (122/151)

77% (115/149)

3.6%

(P=0.08)

5%

1

Spinal manipulation according to guideline 0 ‐ 4 weeks post‐onset

5% (8/151)

6% (9/149)

‐0.7%

‐12%

0.9

Guideline‐discordant physician recommended treatment 0 ‐ 4 weeks post‐onset

18% (27/151)

17% (25/149)

‐1.1%

‐7%

1.1

Supervised exercise programme (recommended treatment 5 ‐ 12 weeks post‐onset)

18% (26/145)

14% (21/149)

3.8%

(P=0.07)

27%

1.3

Return to work (recommended treatment 5 ‐ 12 weeks post‐onset)

23% (33/145)

17% (25/149)

6%

(P=0.14)

36%

1.4

Refer to interdisciplinary programme (recommended treatment 5 ‐ 12 weeks post‐onset)

0

2% (3/149)

‐2%

‐100%

0

Physiotherapy > 4 weeks (guideline‐discordant)

42% (61/145)

43% (64/149)

0.9%

2%

1

Continued use of spinal manipulation therapy (guideline‐discordant)

3% (4/145)

33% (49/149)

30.1%

(P=0.05)

92%

0.1

(Dey 2004)*

Intervention (aimed at general practitioners): guidelines discussion (educational component), patient information leaflets, access to fast‐track physiotherapy and triage services for patients with persistent symptoms (organisational component) versus usual care (control)*

X‐ray referrals

15.1% (43/284)

13.7% (42/308)

‐1.4%

(P=0.62)

‐10%

1.1

Sickness certificates

17.9 % (34/190)

19.2% (40/206)

1.3%

(P=0.74)

7%

0.9

Prescriptions for opioids or muscle relaxants

18.6% (84/452)

18.7% (92/491)

0.1

(P=0.99)

1

1

Referrals to secondary care

3.4% (33/962)

2.3% (24/1044)

‐1.1%

(P=0.12)

‐49%

1.5

Referrals to physiotherapy or educational programme

26.3% (44/167)

13.8% (25/181)

‐12.6%

(P=0.01)

‐91%

1.9

(Engers 2005)**

Intervention (aimed at general practitioners): guidelines on low back pain, 2‐hour workshop, 2 scientific articles, guidelines on low back pain for occupational physicians, tool for patient education and management‐decision tool. Control group: usual care

Referral to a therapist

22.9% (75/328)

27.4% (79/288)

4.6%

17%

0.8

Prescription of pain medication on a time‐contingent basis

70% (139/328)

69% (130/288)

2.8%

6%

0.9

Handed patient information leaflet

36.9% (121/328)

38.2% (110/288)

‐1.3%

‐3%

1

Advised patient to stay active

95.1% (312/328)

89.2% (257/288)

5.9%

7%

1.1

Advised patient to gradually increase activity

78% (256/328)

65.3% (188/288)

12.8%

20%

1.2

Advised patient which activities to increase at what moment

18% (58/328)

9% (26/288)

8.7%

96%

2

(French 2013)***

Intervention (aimed at general practitioners): Interactive, educational workshops plus educational material disseminated (via DVDs); Control group: usual care**

Number of x‐ray requests out of total number of patients seen

0.83% (67/8,085)

1.02% (80/7,826)

0.2%

(P=0.2)

19%

0.8

Number of CT requests out of total number of patients seen

0.61% (64/10,419)

0.66% (66/10,085)

0.0%

(P=0.6)

7%

0.9

(Hazard 1997)

Intervention (aimed at physicians): notification that patient was at a high risk of disability and guidelines on management. Control group: usual care

3‐month work absence rates

28.6% (8/28)

24% (6/25)

‐4.6%

(NS)

‐19%

1.2

(Schectman 2003)

Intervention (aimed at physicians): guideline on low back pain, 90‐minute educational session on guideline implementation delivered by local opinion leaders and audit report summarising performance against the guideline plus outreach visit. Control group: usual care plus/minus patient education (pamphlet and video)

Lumbosacral X‐ray total utilisation (% of patients based on episode of care)

31%

21%

19%

18%

9%

‐1%

‐6%

1.1

Lumbosacral X‐ray not consistent with guideline

14.5%

8.2%

8.1%

8.6%

6.8%

0.5%

6%

0.9

Lumbosacral CT/MRI total utilisation (% of patients based on episode of care)

7.6%

5.6%

5.6%

7.1%

3.5%

1.5%

21%

0.8

Lumbosacral CT/MRI not consistent with guideline

5.7%

3.5%

3.5%

5.4%

4.1%

1.9%

35%

0.6

Physical therapy referral total utilisation (% of patients based on episode of care)

12%

13%

10%

13%

2%

3%

23%

0.8

Physical therapy referral not consistent with guideline

10%

10.9%

9.2%

12%

1.9%

2.8%

23%

0.8

Specialty referral total utilisation (% of patients based on episode of care)

12%

5.9%

8.6%

7.1%

4.6%

‐1.5%

‐21%

1.2

Specialty referral not consistent with guideline

9.5%

4%

7.1%

5.6%

4%

‐1.5%

‐27%

1.3

1. Intervention group pre‐intervention proportion

2. Control group pre‐intervention proportion

3. Intervention group post‐intervention proportion

4. Control group post‐intervention proportion

5. ARD = [Int post (%) minus C post (%)] minus [Int pre (%) minus C pre (%)]. The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome, according to Grimshaw 2004.

6. Risk Difference (RD) is the absolute % change post‐intervention = Int post (%) minus C post (%). This is considered to be "small" if ≤ 5%, "modest" if > 5% and ≤10%,"moderate" if > 10% but ≤ 20%, and "large" if > 20%.The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome, according to Grimshaw 2004.

7. Relative % change post = absolute % change post divided by C post (%). The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome, according to Grimshaw 2004.

8. Risk ratio (RR) = Int post (%) divided by C post (%)

C: control group; Int: intervention group; ARD: adjusted risk difference; NS: not significant

CT/MRI: computed tomography/magnetic resonance imaging

* Dey 2004 reported the Intercluster Correlation (ICC) for the results (mean cluster size=95.1) and this was used to calculate the above effective sample sizes according to chapter 16.3.4 of the Cochrane Handbook, Higgins 2011a.

** The data reported above for the study by Engers 2005 does not account for clustering. We did not have access to sufficient information to adjust the data for clustering.

***French 2013 reported Intercluster Correlation (ICC for x‐rays 0.004 and for CTs 0.003, mean cluster size=2,154) and this was used to calculate the above effective sample sizes according to chapter 16.3.4 of the Cochrane Handbook, Higgins 2011a

Figuras y tablas -
Table 9. Low back pain studies, intervention versus control, dichotomous data
Table 10. Low back pain studies, intervention 1 versus intervention 2, dichotomous data

(Study)

Intervention 1 versus intervention 2

Outcome

Int 1 pre (%) 1

Int 2 pre (%)2

Int 1 post (%)3

Int 2 post (%)4

ARD 5

Risk difference 6

(P value if reported by authors)

Relative % change post 7

Risk ratio 8

(Bishop 2006)

Physician education (guidelines) and 3 patient‐specific reminder letters versus physician education, reminders and also patient education and 3 reminders

Education and reassurance according to guideline 0 ‐ 4 weeks post‐onset

10% (16/162)

6% (9/151)

3.9%

(NS)

66%

1.7

Exercise according to guideline 0 ‐ 4 weeks post‐onset

38% (62/162)

53% (80/151)

‐14.7%

(P=0.0083)

‐28%

0.7

Appropriate medication according to guideline 0 ‐ 4 weeks post‐onset

85% (138/162)

81% (122/151)

4.4%

(NS)

5%

1.1

Spinal manipulation according to guideline 0 ‐ 4 weeks post‐onset

2.5% (4/162)

5% (13/151)

‐6.1%

(P=0.018)

‐71%

0.3

Guideline‐discordant physician‐recommended treatment 0 ‐ 4 weeks post‐onset

10% (16/162)

18% (27/151)

8%

(P=0.04)

45%

0.6

Supervised exercise programme (recommended treatment 5 ‐ 12 weeks post‐onset)

19% (29/154)

18% (26/145)

0.9%

(NS)

5%

1.1

Return to work (recommended treatment 5 ‐ 12 weeks post‐onset)

24% (37/154)

23% (33/145)

1.3%

(NS)

6%

1.1

Refer to interdisciplinary programme (recommended treatment 5 ‐ 12 weeks post‐onset)

4% (6/154)

0

3.9%

(P=0.02)

Physiotherapy > 4 weeks (guideline‐discordant)

41% (63/154)

42% (61/145)

1.2%

(NS)

3%

1

Continued use of spinal manipulation therapy (guideline‐discordant)

‐ (no data available)

3% (4/145)

(Eccles 2001)*

Feedback on number of spinal radiographs 6 months before and 6 months after the intervention plus guideline dissemination versus guideline dissemination

Lumbar spine radiographs concordant with guidelines

35.4% (64/181)

43.6% (120/275)

‐8.3%

‐19%

0.8

(Eccles 2001)*

Reminder messages on radiograph reports plus guideline dissemination versus guideline dissemination

Lumbar spine radiographs concordant with guidelines

41.2% (35/85)

43.6% (120/275)

‐2.5%

‐6%

0.9

(Eccles 2001)*

Feedback on number of spinal radiographs 6 months before and 6 months after the intervention plus guideline dissemination plus reminder messages on radiograph reports versus guideline dissemination

Lumbar spine radiographs concordant with guidelines

36% (89/247)

43.6% (120/275)

‐7.6%

‐17%

0.8

(Eccles 2001)*

Feedback on number of spinal radiographs 6 months before and 6 months after the intervention plus guideline dissemination versus reminder messages on radiograph reports plus guideline dissemination

Lumbar spine radiographs concordant with guidelines

35.4% (64/181)

41.2% (35/85)

‐5.8%

‐14%

0.9

1. Intervention 1 group pre‐intervention proportion

2. Intervention 2 group pre‐intervention proportion

3. Intervention 1 group post‐intervention proportion

4. Intervention 2 group post‐intervention proportion

5. ARD = [Int 1 post (%) minus Int 2 post (%)] minus [Int 1 pre (%) minus Int 2 pre (%)]. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

6. Risk Difference (RD) is the absolute % change post‐intervention = Int 1 post (%) minus Int 2 post (%). This is considered to be "small" if ≤ 5%, "modest" if > 5% and ≤10%,"moderate" if > 10% but ≤ 20%, and "large" if > 20%.The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome.

7. Relative % change post = absolute % change post divided by Int 2 post (%). The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

8. Risk ratio (RR) = Int 1 post (%) divided by Int 2 post (%)

Int 1: intervention 1 group; Int 2: Intervention 2 group; ARD: Adjusted risk difference; NS: not significant

*The data reported above for the study by Eccles 2001 does not account for clustering. We did not have access to sufficient information to adjust the data for clustering.

Figuras y tablas -
Table 10. Low back pain studies, intervention 1 versus intervention 2, dichotomous data
Table 11. Low back pain studies intervention 1 versus intervention 2, continuous data

(Study)

Intervention 1 versus Intervention 2

Outcome

Int 1 pre mean (SD)1

Int 2 pre mean (SD)2

Int 1 post mean (SD)3

Int 2 post mean (SD)4

MD 5

Relative % change 6

Adjusted relative % change7

SMD8

(P value)9

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing versus guideline dissemination

Functional capacity measured by Hannover Functional Ability Questionnaire at 6 months

72.9

70.3

2.7

4%

0.1

(P=0.12)

(Becker 2008*)

Physician education (as above) plus practice nurse training in motivational counselling versus guideline dissemination

Functional capacity measured by Hannover Functional Ability Questionnaire at 6 months

73.9

70.3

3.6

5%

0.2

(P=0.032)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing versus guideline dissemination

Days in pain at 6 months

63.3

80.8

17.4

22%

0.2

(P=0.002)

(Becker 2008*)

Physician education (as above) plus practice nurse training in motivational counselling versus guideline dissemination

Days in pain at 6 months

62.9

80.8

17.9

22%

0.2

(P=0.001)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing versus guideline dissemination

Overall activity at 6 months

36.5

33.5

3

9%

0.1

(P=0.203)

(Becker 2008*)

Physician education (as above) plus practice nurse training in motivational counselling versus guideline dissemination

Overall activity at 6 months

36.3

33.5

2.8

8%

0.1

(P=0.230)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing versus guideline dissemination

Days of sick leave at 6 months

13

14.3

1.3

9%

0

(P=0.569)

(Becker 2008*)

Physician education (as above) plus practice nurse training in motivational counselling versus guideline dissemination

Days of sick leave at 6 months

13

14.3

1.3

9%

0

(P=0.584)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing versus guideline dissemination

Quality of life at 6 months

66.6

66.8

‐0.3

0%

0

(P=0.847)

(Becker 2008*)

Physician education (as above) plus practice nurse training in motivational counselling versus guideline dissemination

Quality of life at 6 months

67.5

66.8

0.7

1%

‐‐

0

(P=0.602)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing versus guideline dissemination

Functional capacity measured by Hannover Functional Ability Questionnaire at 12 months

73

71.6

1.4

2%

0.1

(P=0.446)

(Becker 2008*)

Physician education (as above) plus practice nurse training in motivational counselling versus guideline dissemination

Functional capacity measured by Hannover Functional Ability Questionnaire at 12 months

74.6

71.6

3.1

4%

0.1

(P=0.088)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing versus guideline dissemination

Days in pain at 12 months

58.5

71.3

12.8

18%

0.2

(P=0.018)

(Becker 2008*)

Physician education (as above) plus practice nurse training in motivational counselling versus guideline dissemination

Days in pain at 12 months

61.6

71.3

9.8

14%

0.1

(P=0.067)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing versus guideline dissemination

Overall activity at 12 months

46.4

42.9

3.5

8%

0.1

(P=0.202)

(Becker 2008*)

Physician education (as above) plus practice nurse training in motivational counselling versus guideline dissemination

Overall activity at 12 months

45.4

42.9

2.5

6%

0.1

(P=0.396)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing versus guideline dissemination

Days of sick leave at 12 months

6.2

9.3

3.1

34%

0.1

(P=0.256)

(Becker 2008*)

Physician education (as above) plus practice nurse training in motivational counselling versus guideline dissemination

Days of sick leave at 12 months

6.5

9.3

2.8

30%

0.1

(P=0.320)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing versus guideline dissemination

Quality of life at 12 months

68.5

67.7

0.8

1%

0

(P=0.535)

(Becker 2008*)

Physician education (as above) plus practice nurse training in motivational counselling versus guideline dissemination

Quality of life at 12 months

70.4

67.7

2.7

4%

0.1

(P=0.036)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing vs physician education plus practice nurse training in motivational counselling

Functional capacity measured by Hannover Functional Ability Questionnaire at 6 months

72.9

73.9

‐1

‐1%

0

(NR)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing vs physician education plus practice nurse training in motivational counselling

Days in pain at 6 months

63.3

62.9

‐0.4

‐1%

0

(NR)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing vs physician education plus practice nurse training in motivational counselling

Overall activity at 6 months

36.5

36.3

0.2

0%

0

(NR)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing vs Physician education plus practice nurse training in motivational counselling

Days of sick leave at 6 months

13

13.1

0.1

0%

0

(NR)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing vs Physician education plus practice nurse training in motivational counselling

Quality of life at 6 months

66.6

67.5

‐0.9

‐1%

0

(NR)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing vs Physician education plus practice nurse training in motivational counselling

Functional capacity measured by Hannover Functional Ability Questionnaire at 12 months

73

74.6

‐1.7

‐2%

‐0.1

(NR)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing vs Physician education plus practice nurse training in motivational counselling

Days in pain at 12 months

58.5

61.6

3.1

5%

0

(NR)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing vs Physician education plus practice nurse training in motivational counselling

Overall activity at 12 months

46.4

45.4

1

2%

0

(NR)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing vs Physician education plus practice nurse training in motivational counselling

Days of sick leave at 12 months

6.2

6.458

0.3

5%

0

(NR)

(Becker 2008*)

Physician education: Guideline (in 4 versions including patient leaflet), 3 seminars and academic detailing vs Physician education plus practice nurse training in motivational counselling

Quality of life at 12 months

68.5

70.4

‐1.9

‐3%

‐0.1

(NR)

(Eccles 2001)*

Feedback on number of spinal radiographs 6 months before and 6 months after the intervention plus guideline dissemination versus guideline dissemination

Number of lumbar spine radiographs per 1000 patients

7.24 (4.8)

7.53 (4.1)

5.97 (4.2)

6.80 (4.3)

0.83

12%

8%

0.2

(NR)

(Eccles 2001)*

Reminder messages on radiograph reports plus guideline dissemination versus guideline dissemination

Number of lumbar spine radiographs per 1000 patients

7.31 (5.2)

7.53 (4.1)

5.14 (3.7)

6.80 (4.3)

1.66

24%

21%

0.4

(P=0.05)

(Eccles 2001)*

Feedback on number of spinal radiographs 6 months before and 6 months after the intervention plus guideline dissemination plus reminder messages on radiograph reports versus guideline dissemination

Number of lumbar spine radiographs per 1000 patients

8.30 (5.1)

7.53 (4.1)

5.23 (3.7)

6.80 (4.3)

1.57

23%

34%

0.4

(NR)

(Eccles 2001)*

Feedback on number of spinal radiographs 6 months before and 6 months after the intervention plus guideline dissemination versus reminder messages on radiograph reports plus guideline dissemination

Number of lumbar spine radiographs per 1000 patients

7.24 (4.8)

7.31 (5.2)

5.97 (4.2)

5.14 (3.7)

‐0.83

‐16%

‐18%

‐0.2

(NR)

1. Intervention 1 group pre‐intervention mean (standard deviation)

2. Intervention 2 group pre‐intervention mean (standard deviation)

3. Intervention 1 group post‐intervention mean (standard deviation)

4. Intervention 2 group postintervention mean (standard deviation)

5. Mean Difference (MD)=Difference between post‐intervention means. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

6. Relative percentage change post‐intervention = (Int1 post mean ‐ Int2 post mean)/Int2 post mean. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

7. Adjusted relative percentage change= (Int1 post mean‐Int2 post mean)‐(Int1 pre mean ‐ Int2 pre mean)/Int2 post mean. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome.

8. SMD=Standardised Mean Difference=(Int1 post mean‐Int2 post mean)/SD pooled. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

9. P value reported by study authors

Int 1: intervention 1 group; Int 2: Intervention 2 group; NR: not reported; SD: standard deviation

*The data reported above for Becker 2008 and Eccles 2001 was adjusted for clustering by the authors

Figuras y tablas -
Table 11. Low back pain studies intervention 1 versus intervention 2, continuous data
Table 12. Low back pain, interrupted time series studies, imaging outcomes

Study

Intervention

Outcome

Mean pre (SD)

Mean post (SD)

Mean post minus mean pre

Relative % change pre to post

SMD pre to post

Mean change in level (p value)

Mean change in slope (p value)

Hollingworth 2002

Educational material

Back x‐rays ordered

1133 (50)

1208.7 (111.5)

‐75.7

‐6.7

‐1.51

‐121.5 (P = 0.167)

6.8 (P = 0.776)

Figuras y tablas -
Table 12. Low back pain, interrupted time series studies, imaging outcomes
Table 13. Osteoarthritis studies: Intervention versus control (continuous data)

(Study)

Intervention

Outcome

Int pre mean (SD)1

C pre mean (SD)2

Int post mean (SD)3

C post mean (SD)4

MD 5

Relative % change 6

Adjusted relative % change7

SMD8

(P value)9

(Chassany 2006)*

GP training on relationships and communication, pain evaluation, prescription and negotiation of a patient contract delivered in a 4‐hour interactive session plus 8 reminders on recommendations

Pain relief (SPID)

315.6 (289.5)

264.7 (242.9)

50.9

19%

19%

0.2

(P< 0.0001)

Intensity of pain in motion on VAS

63.7 (13.8)

62.8 (13.5)

‐29 (23.1)

‐24.8 (21.1)

4.2

17%

‐21%

0.2

(P=0.01)

Lequesne Index

9.2 (2.9)

9.8 (3.2)

‐2.5 (2.5)

‐2.0 (2.4)

0.5

25%

5%

0.2

(P< 0.0001)

WOMAC index pain

9.3 (3.0)

9.6 (2.8)

‐2.9 (3.4)

‐2.2 (2.9)

0.7

32%

‐18%

0.2

(P< 0.0001)

WOMAC index stiffness

4.1 (1.4)

4.0 (1.4)

‐1.2 (1.6)

‐0.8 (1.4)

0.4

50%

‐62%

0.3

(P=0.0004)

WOMAC index physical function

31.2 (10.9)

32.8 (9.5)

‐8.7 (10.7)

‐6.1 (8.8)

2.6

43%

‐16%

0.3

(P< 0.0001)

WOMAC index global score

44.6 (14.4)

46.4 (12.5)

‐12.9 (14.8)

‐9.2 (12.2)

3.7

40%

‐21%

0.3

(P< 0.0001)

Acetaminophen consumption

3400 (800)

2900 (900)

‐500

‐17%

‐17%

‐0.6

(P< 0.0001)

(Rosemann 2007)*

Intervention (aimed at GPs): 2 interactive 8‐hour meetings focusing on arthritis self management, guideline dissemination and patient information material versus control (usual care)

Quality of life (AIMS2‐SF scores) Lower body

2.67 (1.88)

2.65 (1.85)

2.48

2.62

‐0.14

‐5%

‐6%

‐0.1

(P=0.349)

Quality of life (AIMS2‐SF scores) Upper body

1.47 (2.25)

1.33 (2.09)

1.43

1.34

0.09

7%

‐4%

0.1

P=0.694)

Quality of life (AIMS2‐SF scores) Symptom

4.87 (2.13)

4.81 (2.18)

4.51

4.72

‐0.21

‐4%

‐6%

‐0.2

(P=0.119)

Quality of life (AIMS2‐SF scores) Affect

2.89 (1.35)

2.88 (1.33)

2.92

2.83

0.09

3%

3%

0.1

(P=0.610)

Quality of life (AIMS2‐SF scores) Social

4.52 (1.88)

4.69 (1.80)

4.43

4.62

‐0.19

‐4%

0%

‐0.3

P=0.776

GP contacts

4.56 (6.13)

4.82 (6.00)

4.44

4.6

0.16

3%

‐2%

0.1

(P=0.339)

Referrals to orthopaedics

1.58 (3.43)

1.76 (3.52)

1.49

1.75

0.26

15%

5%

0.8

(P=0.153)

Radiographs

0.82 (3.12)

0.79 (2.78)

0.75

0.85

0.1

12%

15%

0.2

(P=0.05)

Non‐medical practitioners

0.11 (3.01)

0.36 (3.28)

0.09

0.32

0.23

72%

‐6%

0.6

(P=0.687)

Physiotherapy

4.70 (9.10)

5.81 (11.10)

4.63

5.77

1.14

20%

1%

2

(P=0.242)

Acupuncture

0.83 (3.45)

0.97 (3.80)

0.8

0.97

0.17

18%

3%

0.2

(P=0.821)

(Rosemann 2007)*

Intervention (aimed at GPs) as above plus patient case management via telephone by practice nurses versus control (usual care)

Quality of life (AIMS2‐SF scores) Lower body

3.01 (2.11)

2.65 (1.85)

2.61

2.62

‐0.01

0%

‐14%

0

(P=0.049)

Quality of life (AIMS2‐SF scores) Upper body

1.68 (2.44)

1.33 (2.09)

1.62

1.34

0.28

21%

‐5%

0.2

(P=0.621)

Quality of life (AIMS2‐SF scores) Symptom

5.02 (2.29)

4.81 (2.18)

4.42

4.72

‐0.3

‐6%

‐11%

‐0.2

(P=0.048)

Quality of life (AIMS2‐SF scores) Affect

3.04 (1.39)

2.88 (1.33)

2.98

2.83

0.15

5%

0%

0.2

(P=0.691)

Quality of life (AIMS2‐SF scores) Social

4.79 (1.80)

4.69 (1.80)

4.736

4.62

0.116

3%

0%

0.1

(P< 0.001)

GP contacts

5.01 (5.78)

4.82 (6.00)

4.9

4.6

‐0.3

‐7%

‐2%

‐0.2

(P=0.823)

Referrals to orthopaedics

1.76 (3.52)

1.76 (3.52)

1.52

1.75

0.23

13%

13%

0.2

(P=0.044)

Radiographs

0.80 (3.01)

0.79 (2.78)

0.71

0.85

0.14

16%

18%

0.4

(P=0.031)

Non‐medical practitioners

0.50 (4.20)

0.36 (3.28)

0.47

0.32

‐0.15

‐47%

‐3%

‐0.4

(P=0.225)

Physiotherapy

5.22 (10.03)

5.81 (11.10)

5.08

5.77

0.69

12%

2%

1.3

(P=0.129)

Acupuncture

0.77 (3.99)

0.97 (3.80)

0.72

1.09

0.37

34%

16%

0.4

(P=0.769)

(Stross 1985)**

Intervention: Educationally‐influential physicians (EIs) led education of primary‐care physicians: self‐study programme including textbook, audiovisual materials and recent articles on osteoarthritis versus control (usual care)

Length of stay for OA patients

8.8

8.4

8.4

8.6

0.2

2%

7%

NR

Length of stay for total hip arthroplasty (THA) patients

17.2

16.6

15.2

16.0

0.8

5%

9%

NR

1. Intervention group pre‐intervention mean (standard deviation)

2. Control group pre‐intervention mean (standard deviation)

3. Intervention group post‐intervention mean (standard deviation)

4. Control group pos‐tintervention mean (standard deviation)

5. Mean Difference (MD)=Difference between post‐intervention means. The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome, according to Grimshaw 2004.

6. Relative percentage change post‐intervention = (Int post mean ‐ Control post mean)/Control post mean

7. Adjusted relative percentage change= (Int post mean‐Control post mean)‐(Int pre mean ‐ Control pre mean)/Control post mean. The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome.

8. SMD=Standardised Mean Difference=(Int post mean‐Control post mean)/SD pooled. The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome, according to Grimshaw 2004.

9. P value reported by study authors

AIMS2‐SF: Arthritis Impact Measurement Scales Short Form
WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index

* There are potential unit of analysis errors in the reported results as the study did not account for clustering and did not provide sufficient data to allow an approximate analysis according to chapter 16.3.4 of the Cochrane Handbook, Higgins 2011a.

**The study did not report standard deviations and therefore we were unable to calculate the SMD. There are potential unit of analysis errors in the reported results as the study did not account for clustering and did not provide sufficient data to allow an approximate analysis according to chapter 16.3.4 of the Cochrane Handbook, Higgins 2011a.

Figuras y tablas -
Table 13. Osteoarthritis studies: Intervention versus control (continuous data)
Table 14. Osteoarthritis studies: intervention versus control (dichotomous data)

(Study)

Intervention

Outcome

Int pre (%) 1

C pre (%)2

Int post (%)3

C post (%)4

ARD 5

Risk difference 6

(P Value if reported by authors)

Relative % change post 7

Risk ratio 8

(Rahme 2005)*

Intervention (aimed at GPs): 90‐minute workshop on management of osteoarthritis versus control group (usual care)

Number of adequate prescription, according to the guidelines

51% (273/536)

47% (675/1437)

56% (251/450)

49% (593/1209)

3%

7%

14%

1.1

(Rahme 2005)*

Intervention (aimed at GPs): decision tree on treatment choices for osteoarthritis patients versus control (usual care)

Number of adequate prescription, according to the guidelines

51% (799/1569)

47% (675/1437)

54% (712/1317)

49% (593/1209)

1%

5%

10%

1.1

(Rahme 2005)*

Intervention (aimed at GPs): 90‐minute workshop and decision tree as above versus control (usual care)

Number of adequate prescription, according to the guidelines

58% (1022/1776)

47% (675/1437)

62% (1008/1634)

49% (593/1209)

2%

13%

26%

1.3

(Rosemann 2007)*

Intervention (aimed at GPs): 2 interactive 8‐hour meetings focusing on arthritis self management, guideline dissemination and patient information material versus control (usual care)

Paracetamol prescriptions

8.9% (31/345)

6.6% (22/332)

16.4%

5.3%

8.7%

11.1%

(<0.001)

209%

3.1

Opioids

5.8% (20/345)

6.9% (23/332)

10.1%

7.9%

3.4%

2.2%

(NS)

28%

1.3

NSAID

40% (138/345)

41.9% (139/332)

44.3%

44.2%

2.0%

0.1%

(NS)

23%

1.0

Homeopathics

6.1% (21/345)

8.1% (27/332)

7.7%

9.8%

‐0.1%

‐2.2%

(NS)

‐22%

0.8

(Rosemann 2007)*

Intervention (aimed at GPs) as above plus patient case management via telephone by practice nurses versus control (usual care)

Paracetamol prescriptions

7.3% (25/345)

6.6% (22/332)

14.1%

5.3%

8.2%

8.8%

(<0.01)

166%

2.7

Opioids

7.3% (25/345)

6.9% (23/332)

16.0%

7.9%

7.8%

8.1%

(< 0.01)

102%

2.0

NSAID

43.3% (149/345)

41.9% (139/332)

49.7%

44.2%

4.3%

5.6%

(0.019)

13%

1.1

Homeopathics

6.7% (23/345)

8.1% (27/332)

9.6%

9.8%

1.2%

‐0.2%

(NS)

‐2%

1.0

(Stross 1985)*

Intervention: Educationally‐influential physicians (EIs) led education of primary‐care physicians: self‐study programme including textbook, audiovisual materials and recent articles on osteoarthritis versus control (usual care)

Management of OA patients with aspirin

39% (9/23)

50% (9/18)

20% (6/30)

28% (5/18)

3%

‐8%

‐28%

0.7

Management of OA patients with NSAIDs

83% (19/23)

78% (14/18)

87% (26/30)

94% (17/18)

‐13%

‐8%

‐8%

0.9

Management of OA patients with systemic corticosteroids

13% (3/23)

17% (3/18)

3% (1/30)

22% (4/18)

15%

19%

(< 0.05)

85%

0.2

Management of OA patients with intra‐articular corticosteroids

17% (4/23)

11% (2/18)

40% (12/30)

11% (2/18)

23%

29%

(<0.05)

260%

3.6

Management of OA patients with physical therapy

87% (20/23)

83% (15/18)

93% (28/30)

83% (15/18)

6%

10%

12%

1.1

Referral of OA patients

39% (9/23)

39% (7/18)

30% (9/30)

33% (6/18)

‐4%

3%

10%

0.9

Pre‐op physical therapy of THA patients

56% (10/18)

46% (12/26)

97% (35/36)

40% (12/30)

48%

57%

(< 0.05)

143%

2.4

Post‐op narcotics of THA patients

72% (13/18)

77% (20/26)

89% (32/36)

93% (28/30)

0%

4%

5%

1.0

Post‐op physical therapy of THA patients

100% (18/18)

100% (26/26)

100% (36/36)

100% (30/30)

0%

0%

0%

1.0

Post‐op complications of THA patients

11% (2/18)

15% (4/26)

6% (2/36)

13% (4/30)

4%

8%

58%

0.4

1. Intervention group pre‐intervention proportion

2. Control group pre‐intervention proportion

3. Intervention group post‐intervention proportion

4. Control group post‐intervention proportion

5. ARD = [Int post (%) minus C post (%)] minus [Int pre (%) minus C pre (%)]. The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome, according to Grimshaw 2004.

6. Risk Difference (RD) is the absolute % change post‐intervention = Int post (%) minus C post (%). This is considered to be "small" if ≤ 5%, "modest" if > 5% and ≤10%,"moderate" if > 10% but ≤ 20%, and "large" if > 20%.The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome, according to Grimshaw 2004.

7. Relative % change post = absolute % change post divided by C post (%). The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome, according to Grimshaw 2004.

8. Risk ratio (RR) = Int post (%) divided by C post (%)

C: control group; Int: intervention group; ARD: Adjusted risk difference; NS: not significant

NSAID: non‐steroidal anti‐inflammatory drug, THA: total hip arthroplasty

* There are unit of analysis errors in the reported results because the available data did not account for the effect of clustering.

Figuras y tablas -
Table 14. Osteoarthritis studies: intervention versus control (dichotomous data)
Table 15. Osteoarthritis studies: intervention 1 versus intervention 2, dichotomous data

(Study)

Intervention 1 versus intervention 2

Outcome

Int 1 pre (%) 1

Int 2 pre (%)2

Int 1 post (%)3

Int 2 post (%)4

ARD 5

Risk difference 6

(P value if reported by authors)

Relative % change post 7

Risk ratio 8

(Rahme 2005)*

Intervention 1 (aimed at GPs): 90‐minute workshop on management of osteoarthritis versus Intervention 2 (aimed at GPs): decision tree on treatment choices for osteoarthritis patients

Number of adequate prescription, according to the guidelines

51% (273/536)

51% (799/1569)

56% (251/450)

54% (712/1317)

1.7%

1.7%

3%

1

(Rahme 2005)*

Intervention 1 (aimed at GPs): 90‐minute workshop on management of osteoarthritis versus Intervention 2 (aimed at GPs): 90‐minute workshop and decision tree

Number of adequate prescription, according to the guidelines

51% (273/536)

58% (1022/1776)

56% (251/450)

62% (1008/1634)

0.7%

‐5.9%

‐10%

0.9

(Rahme 2005)*

Intervention 1 (aimed at GPs):decision tree on treatment choices for osteoarthritis patients versus Intervention 2 (aimed at GPs): 90‐minute workshop and decision tree

Number of adequate prescription, according to the guidelines

51% (799/1569)

58% (1022/1776)

54% (712/1317)

62% (1008/1634)

‐1%

‐7.6%

‐12%

0.9

(Rosemann 2007)*

Intervention (aimed at GPs): 2 interactive 8‐hour meetings focusing on arthritis self management, guideline dissemination and patient information material versus Intervention (aimed at GPs) as above plus patient case management via telephone by practice nurses

Paracetamol prescriptions

8.9% (31/345)

7.3% (25/345)

16.4%

14.1%

0.5%

2.3%

16%

1.2

Opioids

5.8% (20/345)

7.3% (25/345)

10.1%

16.0%

‐4.5%

‐5.9%

‐37%

1.2

NSAID

40% (138/345)

43.3% (149/345)

44.3%

49.7%

‐2.2%

‐5.4%

‐11%

1.2

Homeopathics

6.1% (21/345)

6.7% (23/345)

7.7%

9.6%

‐1.4%

‐1.9%

‐20%

1.2

1. Intervention 1 group pre‐intervention proportion

2. Intervention 2 group pre‐intervention proportion

3. Intervention 1 group post‐intervention proportion

4. Intervention 2 group post‐intervention proportion

5. ARD = [Int 1 post (%) minus Int 2 post (%)] minus [Int 1 pre (%) minus Int 2 pre (%)]. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

6. Risk Difference (RD) is the absolute % change post‐intervention = Int 1 post (%) minus Int 2 post (%). This is considered to be "small" if ≤ 5%, "modest" if > 5% and ≤10%,"moderate" if > 10% but ≤ 20%, and "large" if > 20%.The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome.

7. Relative % change post = absolute % change post divided by Int 2 post (%). The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

8. Risk ratio (RR) = Int 1 post (%) divided by Int 2 post (%)

Int 1: intervention 1 group; Int 2: Intervention 2 group; ARD: adjusted risk difference; NS: not significant, NSAID: non‐steroidal anti‐inflammatory drug

* There are unit of analysis errors in the reported results because the available data did not account for the effect of clustering.

Figuras y tablas -
Table 15. Osteoarthritis studies: intervention 1 versus intervention 2, dichotomous data
Table 16. Osteoarthritis studies: intervention 1 versus intervention 2 continuous data

(Study)

Intervention 1 versus Intervention 2

Outcome

Int 1 pre mean (SD)1

Int 2 pre mean (SD)2

Int 1 post mean (SD)3

Int 2 post mean (SD)4

MD 5

Relative % change 6

Adjusted relative % change7

SMD8

(P value)9

(Rosemann 2007)*

Intervention (aimed at GPs): 2 interactive 8‐hour meetings focusing on arthritis self management, guideline dissemination and patient information material versus Intervention (aimed at GPs) as above plus patient case management via telephone by practice nurses

Quality of life (AIMS2‐SF scores) Lower body

2.67 (1.88)

3.01 (2.11)

2.48 (1.1)

2.61 (1.4)

‐0.13

‐5%

0%

‐0.1

Quality of life (AIMS2‐SF scores) Upper body

1.47 (2.25)

1.68 (2.44)

1.43 (1.5)

1.62 (1.3)

‐0.19

‐12%

‐6%

‐0.1

Quality of life (AIMS2‐SF scores) Symptom

4.87 (2.13)

5.02 (2.29)

4.51 (1.0)

4.42 (1.8)

0.09

2%

12%

0.1

Quality of life (AIMS2‐SF scores) Affect

2.89 (1.35)

3.04 (1.39)

2.92 (0.8)

2.98 (0.9)

‐0.06

‐2%

‐1%

‐0.1

Quality of life (AIMS2‐SF scores) Social

4.52 (1.88)

4.79 (1.80)

4.43 (0.6)

4.736 (1.2)

‐0.31

‐6%

‐25%

‐0.3

GP contacts

4.56 (6.13)

5.01 (5.78)

4.44 (1.7)

4.9 (1.6)

0.46

9%

37%

0.3

Referrals to orthopaedics

1.58 (3.43)

1.76 (3.52)

1.49 (0.4)

1.52 (1.3)

0.03

2%

‐9%

0.0

Radiographs

0.82 (3.12)

0.80 (3.01)

0.75 (0.6)

0.71 (0.4)

‐0.04

‐6%

‐1%

‐0.1

Non‐medical practitioners

0.11 (3.01)

0.50 (4.20)

0.09 (0.4)

0.47 (0.4)

0.38

81%

‐45%

0.9

Physiotherapy

4.70 (9.10)

5.22 (10.03)

4.63 (0.6)

5.08 (0.6)

0.45

9%

35%

0.7

Acupuncture

0.83 (3.45)

0.77 (3.99)

0.8 (1.3)

0.72 (1.3)

‐0.08

‐11%

0%

‐0.1

1. Intervention 1 group pre‐intervention mean (standard deviation)

2. Intervention 2 group pre‐intervention mean (standard deviation)

3. Intervention 1 group post‐intervention mean (standard deviation)

4. Intervention 2 group postintervention mean (standard deviation)

5. Mean Difference (MD)=Difference between post‐intervention means. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

6. Relative percentage change post‐intervention = (Int1 post mean ‐ Int2 post mean)/Int2 post mean. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

7. Adjusted relative percentage change= (Int1 post mean‐Int2 post mean)‐(Int1 pre mean ‐ Int2 pre mean)/Int2 post mean. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome.

8. SMD=Standardised Mean Difference=(Int1 post mean‐Int2 post mean)/SD pooled. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

9. P value reported by study authors

AIMS2‐SF: Arthritis Impact Measurement Scales Short Form

* There are unit of analysis errors in the reported results because the available data did not account for the effect of clustering.

Figuras y tablas -
Table 16. Osteoarthritis studies: intervention 1 versus intervention 2 continuous data
Table 17. Shoulder studies: intervention versus control, continuous data

(Study)

Intervention

Outcome

Int pre mean (SD)1

C pre mean (SD)2

Int post mean (SD)3

C post mean (SD)4

MD 5

Relative % change 6

Adjusted relative % change7

SMD8

(P value)9

(Watson 2008)

Intervention: 60‐minute lecture on shoulder disorders, handouts, training in injection techniques versus control group (usual care)

British Shoulder Disability Questionnaire (BSDQ)

12.22 (4.21)

13.11 (4.43)

8.51 (0.60)

9.46 (0.82)

0.95

10%

1%

0.2

(P=0.36)

Short form 36 item (SF‐36) Health Survey ‐ physical component score

37.78 (8.69)

35.96 (8.93)

40.55 (0.60)

40.80 (0.90)

‐0.25

‐1%

‐5%

0.0

(P=0.82)

Short form 36 item (SF‐36) Health Survey ‐ mental component score

45.42 (13.33)

44.64 (13.09)

46.81 (0.93)

45.64 (1.28)

1.17

3%

1%

0.1

(P=0.47)

1. Intervention group pre‐intervention mean (standard deviation)

2. Control group pre‐intervention mean (standard deviation)

3. Intervention group post‐intervention mean (standard deviation)

4. Control group pos‐tintervention mean (standard deviation)

5. Mean Difference (MD)=Difference between post‐intervention means. The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome, according to Grimshaw 2004.

6. Relative percentage change post‐intervention = (Int post mean ‐ Control post mean)/Control post mean

7. Adjusted relative percentage change= (Int post mean‐Control post mean)‐(Int pre mean ‐ Control pre mean)/Control post mean. The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome.

8. SMD=Standardised Mean Difference=(Int post mean‐Control post mean)/SD pooled. The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome, according to Grimshaw 2004.

9. P value reported by study authors

Figuras y tablas -
Table 17. Shoulder studies: intervention versus control, continuous data
Table 18. Shoulder studies: intervention 1 versus intervention 2, continuous data

(Study)

Intervention 1 versus Intervention 2

Outcome

Int 1 pre mean (SD)1

Int 2 pre mean (SD)2

Int 1 post mean (SD)3

Int 2 post mean (SD)4

MD 5

Relative % change 6

Adjusted relative % change7

SMD8

(P value)9

(Gormley 2003*)

Shoulder injection training on mannequins versus shoulder injection training on mannequins and real patients

Shoulder injections performed by general practitioner

3.5

3.4

4.5

7.8

‐3.3

‐42%

‐44%

(P=0.02)

Referrals to shoulder injection clinics

2.3

2.0

1.5

0.6

‐0.9

‐150%

‐100%

(P=0.36)

Referrals to physiotherapy

5.9

5.6

4.7

3.2

‐1.5

‐47%

‐38%

(P=0.20)

1. Intervention 1 group pre‐intervention mean (standard deviation)

2. Intervention 2 group pre‐intervention mean (standard deviation)

3. Intervention 1 group post‐intervention mean (standard deviation)

4. Intervention 2 group postintervention mean (standard deviation)

5. Mean Difference (MD)=Difference between post‐intervention means. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

6. Relative percentage change post‐intervention = (Int1 post mean ‐ Int2 post mean)/Int2 post mean. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

7. Adjusted relative percentage change= (Int1 post mean‐Int2 post mean)‐(Int1 pre mean ‐ Int2 pre mean)/Int2 post mean. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome.

8. SMD=Standardised Mean Difference=(Int1 post mean‐Int2 post mean)/SD pooled. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

9. P value reported by study authors

* The study does not report SD and therefore we were not able to calculate the SMD

Figuras y tablas -
Table 18. Shoulder studies: intervention 1 versus intervention 2, continuous data
Table 19. Other musculoskeletal conditions studies: Intervention versus control, continuous data

(Study)

Intervention

Outcome

Int pre mean (SD)1

C pre mean (SD)2

Int post mean (SD)3

C post mean (SD)4

MD 5

Relative % change 6

Adjusted relative % change7

SMD8

(P value)9

(Huas 2006)

Training of general practitioners on the use of 2 validated assessment instruments for pain versus control group (usual care)

Pain relief a week after last consultation with general practitioner

41.1 (4.6)

50.7 (4.8)

‐9.6

‐19%

‐2

(P=0.0004)

Pain relief a week after last consultation with general practitioner not including patients on Level 3 analgesics

40.8 (4.0)

50.7 (4.2)

‐9.9

‐20%

‐2.4

(P=0.0001)

Level 1 analgesic treatment (as defined by WHO classification system)

34.7 (10.6)

42.9 (18.4)

29.6 (9.9)

34.2 (12.4)

‐4.6

‐13%

11%

‐0.3

(P=0.38)

Level 2 analgesic treatment (as defined by WHO classification system)

42.2 (5.9)

44.1 (19.6)

35.4 (6.3)

47.7 (8.8)

‐12.3

‐26%

‐22%

‐0.9

(P=0.003)

Level 3 analgesic treatment (as defined by WHO classification system)

7.5 (5.6)

2.5 (2.1)

7.2 (4.7)

1.8 (2.5)

5.4

300%

22%

1.2

(P=0.007)

Co‐analgesics (antidepressants, anxiolytics, anti‐epileptics)

46.0 (7.6)

38.7 (7.5)

38.4 (11.4)

33.0 (15.1)

5.4

16%

‐6%

0.7

(P=0.38)

Other drugs (non‐psychotropic muscle relaxants)

21.6 (7.1)

27.3 (13.5)

19.0 (5.3)

22.9 (11.5)

‐3.9

‐17%

8%

‐0.4

(P=0.34)

Non‐medicinal treatment (physiotherapy, homeopathy, acupuncture, compression bandages, etc)

44.3 (10.2)

44.9 (11.1)

33.8 (11.8)

39.3 (12.5)

‐5.5

‐14%

‐12%

‐0.5

(P=0.30)

1. Intervention group pre‐intervention mean (standard deviation)

2. Control group pre‐intervention mean (standard deviation)

3. Intervention group post‐intervention mean (standard deviation)

4. Control group pos‐tintervention mean (standard deviation)

5. Mean Difference (MD)=Difference between post‐intervention means. The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome, according to Grimshaw 2004.

6. Relative percentage change post‐intervention = (Int post mean ‐ Control post mean)/Control post mean

7. Adjusted relative percentage change= (Int post mean‐Control post mean)‐(Int pre mean ‐ Control pre mean)/Control post mean. The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome.

8. SMD=Standardised Mean Difference=(Int post mean‐Control post mean)/SD pooled. The direction of effect has been adjusted so that a positive result represents a beneficial intervention outcome, according to Grimshaw 2004.

9. P value reported by study authors

Figuras y tablas -
Table 19. Other musculoskeletal conditions studies: Intervention versus control, continuous data
Table 20. Other musculoskeletal studies: Intervention versus a different intervention, dichotomous data

(Study)

Intervention 1 versus intervention 2

Outcome

Int 1 pre (%) 1

Int 2 pre (%)2

Int 1 post (%)3

Int 2 post (%)4

ARD 5

Risk difference 6

(P value if reported by authors)

Relative % change post 7

Risk ratio 8

(Robling 2002)*

Guidelines and seminar versus guideline dissemination by post*

Concordant requests

79% (23/29)

79% (32/41)

0%

0%

1

(Robling 2002)*

Guidelines and feedback versus guideline dissemination by post*

Concordant requests

67% (21/32)

79% (32/41)

‐12.1%

‐15%

0.8

(Robling 2002)*

Guidelines, seminar and feedback versus guideline dissemination by post*

Concordant requests

71% (27/37)

79% (32/41)

‐7.6%

‐10%

0.9

(Robling 2002)*

Guidelines and seminar versus guidelines and feedback*

Concordant requests

79% (23/29

67% (21/32)

12.1%

18%

1.2

(Robling 2002)*

Guidelines and seminar versus guidelines, seminar and feedback*

Concordant requests

79% (23/29)

71% (27/37)

7.6%

11%

1.1

(Robling 2002)*

Guidelines and feedback versus guidelines, seminar and feedback*

Concordant requests

67% (21/32)

71% (27/37)

‐4.5%

‐6%

0.9

(Eccles 2001)**

Feedback on number of knee radiographs 6 months before and 6 months after the intervention plus guideline dissemination versus guideline dissemination

Knee radiographs concordant with guidelines

22% (52/240)

25% (83/328)

‐3.6%

‐14%

0.9

(Eccles 2001)**

Reminder messages on radiograph reports plus guideline dissemination versus guideline dissemination

Knee radiographs concordant with guidelines

31% (26/85)

25% (83/328)

5.3%

21%

1.2

(Eccles 2001)**

Feedback on number of knee radiographs 6 months before and 6 months after the intervention plus guideline dissemination plus reminder messages on radiograph reports versus guideline dissemination

Knee radiographs concordant with guidelines

28% (70/252)

25% (83/328)

2.5%

10%

1.1

(Eccles 2001)**

Feedback on number of knee radiographs 6 months before and 6 months after the intervention plus guideline dissemination versus reminder messages on radiograph reports plus guideline dissemination

Knee radiographs concordant with guidelines

22% (52/240)

31% (26/85)

‐8.9%

‐29%

0.7

1. Intervention 1 group pre‐intervention proportion

2. Intervention 2 group pre‐intervention proportion

3. Intervention 1 group post‐intervention proportion

4. Intervention 2 group post‐intervention proportion

5. ARD = [Int 1 post (%) minus Int 2 post (%)] minus [Int 1 pre (%) minus Int 2 pre (%)]. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

6. Risk Difference (RD) is the absolute % change post‐intervention = Int 1 post (%) minus Int 2 post (%). This is considered to be "small" if ≤ 5%, "modest" if > 5% and ≤10%,"moderate" if > 10% but ≤ 20%, and "large" if > 20%.The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome.

7. Relative % change post = absolute % change post divided by Int 2 post (%). The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

8. Risk ratio (RR) = Int 1 post (%) divided by Int 2 post (%)

Int 1: intervention 1 group; Int 2: Intervention 2 group; ARD: adjusted risk difference; NS: not significant

*The results have been re‐calculated taking into account the reported Intercluster Correlation (ICC=0.0269) and average cluster size 12.5 according to chapter 16.3.4 of the Cochrane Handbook, Higgins 2011a.

** The data reported above for the study by Eccles 2001 does not account for clustering. We did not have access to sufficient information to adjust the data for clustering.

Figuras y tablas -
Table 20. Other musculoskeletal studies: Intervention versus a different intervention, dichotomous data
Table 21. Other musculoskeletal studies: Intervention versus a different intervention, continuous data

(Study)

Intervention 1 versus Intervention 2

Outcome

Int 1 pre mean (SD)1

Int 2 pre mean (SD)2

Int 1 post mean (SD)3

Int 2 post mean (SD)4

MD 5

Relative % change 6

Adjusted relative % change7

SMD8

(P value)9

(Eccles 2001)*

Feedback on number of knee radiographs 6 months before and 6 months after the intervention plus guideline dissemination versus guideline dissemination

Number of knee radiographs per 1000 patients

7.03 (5.1)

6.67 (3.9)

6.32 (4.0)

7.02 (3.6)

0.7

10%

15%

0.2

(NR)

(Eccles 2001)*

Reminder messages on radiograph reports plus guideline dissemination versus guideline dissemination

Number of knee radiographs per 1000 patients

7.18 (5.0)

6.67 (3.9)

5.22 (3.6)

7.02 (3.6)

1.8

26%

33%

0.5

(P< 0.05)

(Eccles 2001)*

Feedback on number of knee radiographs 6 months before and 6 months after the intervention plus guideline dissemination plus reminder messages on radiograph reports versus guideline dissemination

Number of knee radiographs per 1000 patients

9.34 (6.1)

6.67 (3.9)

5.21 (3.7)

7.02 (3.6)

1.8

26%

64%

0.5

(NR)

(Eccles 2001)*

Feedback on number of knee radiographs 6 months before and 6 months after the intervention plus guideline dissemination versus reminder messages on radiograph reports plus guideline dissemination

Number of knee radiographs per 1000 patients

7.03 (5.1)

7.18 (5.0)

6.32 (4.0)

5.22 (3.6)

‐1.1

‐21%

‐24%

‐0.3

(NR)

1. Intervention 1 group pre‐intervention mean (standard deviation)

2. Intervention 2 group pre‐intervention mean (standard deviation)

3. Intervention 1 group post‐intervention mean (standard deviation)

4. Intervention 2 group postintervention mean (standard deviation)

5. Mean Difference (MD)=Difference between post‐intervention means. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

6. Relative percentage change post‐intervention = (Int1 post mean ‐ Int2 post mean)/Int2 post mean. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

7. Adjusted relative percentage change= (Int1 post mean‐Int2 post mean)‐(Int1 pre mean ‐ Int2 pre mean)/Int2 post mean. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome.

8. SMD=Standardised Mean Difference=(Int1 post mean‐Int2 post mean)/SD pooled. The direction of effect has been adjusted so that a positive result represents a beneficial intervention 1 outcome, according to Grimshaw 2004.

9. P value reported by study authors

*The above data reported above for Eccles 2001 was adjusted for clustering by the authors

Figuras y tablas -
Table 21. Other musculoskeletal studies: Intervention versus a different intervention, continuous data
Table 22. Summary of median absolute effect sizes (risk difference) of dichotomous outcomes for interventions aiming to increase or decrease a clinical behaviour

Table 23: Summary of median absolute effect sizes (risk difference) of dichotomous outcomes for interventions aiming to increase or decrease a clinical behaviour

Study characteristic: behaviour targeted

Number of comparisons (n studies)

Median absolute effect size

Interquartile range

Range

Increase an existing clinical behaviour according to guidelines

68 (14)

5%

0.6% to 12.6%

‐7.8% to 57.2%

Decrease an existing clinical behaviour according to guidelines

26 (7)

1.1%

‐1.1% to 3%

‐12.6% to 30.1%

Figuras y tablas -
Table 22. Summary of median absolute effect sizes (risk difference) of dichotomous outcomes for interventions aiming to increase or decrease a clinical behaviour
Table 23. Summary of median effect sizes (risk difference) of dichotomous outcomes for interventions aiming to increase or decrease a clinical behaviour (including only comparisons from Low Back Pain studies)

Table 24: Summary of median effect sizes (risk difference) of dichotomous outcomes for interventions aiming to increase or decrease a clinical behaviour (including only comparisons from Low Back Pain studies)

Study characteristic: behaviour targeted

Number of comparisons (n studies)

Median absolute effect size

Interquartile range

Range

Increase an existing clinical behaviour according to guidelines

18 (2)

3.7%

‐0.8% to 6.9%

‐4.7% to 12.8%

Decrease an existing clinical behaviour according to guidelines

23 (6)

0.5%

‐1.1% to 2.4%

‐12.6% to 30.1%

Figuras y tablas -
Table 23. Summary of median effect sizes (risk difference) of dichotomous outcomes for interventions aiming to increase or decrease a clinical behaviour (including only comparisons from Low Back Pain studies)
Table 24. Summary of median effect sizes (risk difference) of dichotomous outcomes for interventions aiming to increase or decrease a clinical behaviour (including only comparisons from Osteoarthritis studies)

Table 25: Summary of median effect sizes (risk difference) of dichotomous outcomes for interventions aiming to increase or decrease a clinical behaviour (including only comparisons from Osteoarthritis studies)

Study characteristic: behaviour targeted

Number of comparisons (n studies)

Median absolute effect size

Interquartile range

Range

Increase an existing clinical behaviour according to guidelines

18 (3)

6.3%

‐0.2% to 10%

‐7.8% to 57.2%

Decrease an existing clinical behaviour according to guidelines

3 (1)

7.8%

6.1% to 13.4%

4.4% to 18.9%

Figuras y tablas -
Table 24. Summary of median effect sizes (risk difference) of dichotomous outcomes for interventions aiming to increase or decrease a clinical behaviour (including only comparisons from Osteoarthritis studies)
Comparison 1. Meta‐analysis of osteoporosis studies evaluating physician and patient interventions versus usual care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Bone Mineral Density Show forest plot

3

3386

Risk Ratio (M‐H, Fixed, 95% CI)

4.44 [3.54, 5.55]

2 Osteoporosis medication Show forest plot

5

4223

Risk Ratio (M‐H, Fixed, 95% CI)

1.71 [1.50, 1.94]

Figuras y tablas -
Comparison 1. Meta‐analysis of osteoporosis studies evaluating physician and patient interventions versus usual care
Comparison 2. Meta‐analysis of osteoporosis studies evaluating physician‐only interventions versus usual care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Bone mineral density Show forest plot

2

3047

Risk Ratio (M‐H, Fixed, 95% CI)

4.75 [3.62, 6.24]

2 Osteoporosis medication Show forest plot

2

3047

Risk Ratio (M‐H, Fixed, 95% CI)

1.52 [1.26, 1.84]

Figuras y tablas -
Comparison 2. Meta‐analysis of osteoporosis studies evaluating physician‐only interventions versus usual care
Comparison 3. Meta‐analysis of osteoporosis studies evaluating physician only interventions versus physician and patient interventions

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Bone mineral density Show forest plot

2

2995

Odds Ratio (M‐H, Fixed, 95% CI)

0.93 [0.77, 1.12]

2 Medication Show forest plot

2

2995

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.79, 1.10]

Figuras y tablas -
Comparison 3. Meta‐analysis of osteoporosis studies evaluating physician only interventions versus physician and patient interventions