Professional interventions for general practitioners on the management of musculoskeletal conditions

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

doi:10.1002/14651858.CD007495.pub2

Cochrane Database of Systematic Reviews

Профессиональные вмешательства для врачей общей практики по тактике ведения состояний/заболеваний опорно‐двигательного аппарата

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DOI:

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

Base de datos:

Cochrane Database of Systematic Reviews

Versión publicada:

06 mayo 2016see what's new

Tipo:

Intervention

Etapa:

Review

Grupo Editorial Cochrane:

Grupo Cochrane de Práctica y organización sanitaria efectivas

Copyright:

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

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Humans;

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.

Figure 1

Prisma study flow diagram.

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Figure 2

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

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Figure 3

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

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Figure 4

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

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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.

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Analysis 1.1

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

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Analysis 1.2

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

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Analysis 2.1

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

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Analysis 2.2

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

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Analysis 3.1

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

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Analysis 3.2

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

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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.

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 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.

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.

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)

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

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

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

(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.

(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.

(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

(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.

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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)

(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.

(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.

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%

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%

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%

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]

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