Nikles Jane, Yelland Michael, Bayram Clare, Miller Graeme, Sterling Michele
RECOVER Injury Research Centre NHMRC Centre of Research Excellence in Recovery Following Road Traffic Injuries The University of Queensland, Herston, Australia.
School of Medicine, Griffith University, Brisbane, Qld, Australia.
BMC Musculoskelet Disord. 2017 Dec 29;18(1):551. doi: 10.1186/s12891-017-1899-0.
Whiplash Associated Disorders (WAD) are common and costly, and are usually managed initially by general practitioners (GPs). How GPs manage WAD is largely unstudied, though there are clinical guidelines. Our aim was to ascertain the rate of management (percentage of encounters) of WAD among patients attending Australian general practice, and to review management of these problems, including imaging, medications and other treatments.
We analysed data from 2013 to 2016 collected by different random samples of approximately 1000 general practitioners (GPs) per year. Each GP collected data about 100 consecutive consultations for BEACH (Bettering the Evaluation and Care of Health), an Australian national study of general practice encounters. Main outcome measures were: the proportion of encounters involving management of WAD; management including imaging, medications and other treatments given; appropriateness of treatment assessed against published clinical guidelines.
Of 291,100 encounters from 2919 GP participants (a nationally representative sample), WAD were managed at 137 encounters by 124 GPs (0.047%). Management rates were 0.050% (females) and 0.043% (males). For 63 new cases (46%), 19 imaging tests were ordered, most commonly neck/cervical spine x-ray (52.6% of tests for new cases), and neck/cervical spine CT scan (31.6%). One or more medications were prescribed/supplied for 53.3% of WAD. NSAIDs (11.7 per 100 WAD problems) and compound analgesics containing paracetamol and opioids (10.2 per 100 WAD problems) were the commonest medications used by GPs overall. Paracetamol alone was used in 8 per 100 WAD problems. The most frequent clinical/procedural treatments for WAD were physical medicine/rehabilitation (16.1 per 100 WAD problems), counselling (6.6), and general advice/education (5.8).
GPs refer about 30% of new cases for imaging (possibly overutilising imaging), and prescribe a range of drugs, approximately 22% of which are outside clinical guidelines. These findings suggest a need for further education of GPs, including indications for imaging after whiplash injury, identification of those more likely to develop chronic WAD, and medication management guidelines. WAD carry a large personal and economic burden, so the impact of improvements in GP management is potentially significant.
挥鞭样损伤相关疾病（WAD）很常见且代价高昂，通常最初由全科医生（GP）进行管理。尽管有临床指南，但全科医生如何管理WAD在很大程度上尚未得到研究。我们的目的是确定在澳大利亚全科医疗就诊的患者中WAD的管理率（就诊百分比），并回顾这些问题的管理情况，包括影像学检查、药物治疗和其他治疗。
我们分析了2013年至2016年每年由不同的约1000名全科医生随机样本收集的数据。每位全科医生收集了关于澳大利亚全国性全科医疗就诊研究BEACH（改善健康评估与护理）的100次连续会诊的数据。主要结局指标为：涉及WAD管理的就诊比例；包括影像学检查、药物治疗和其他治疗的管理情况；根据已发表的临床指南评估治疗的适当性。
在2919名全科医生参与者（全国代表性样本）的291,100次会诊中，124名全科医生在137次会诊中管理了WAD（0.047%）。管理率女性为0.050%，男性为0.043%。对于63例新病例（46%），开出了19项影像学检查，最常见的是颈部/颈椎X光（新病例检查的52.6%）和颈部/颈椎CT扫描（31.6%）。53.3%的WAD患者开具/提供了一种或多种药物。非甾体抗炎药（每100例WAD问题中11.7例）和含对乙酰氨基酚和阿片类药物的复合镇痛药（每100例WAD问题中10.2例）是全科医生总体上最常用的药物。仅使用对乙酰氨基酚的情况为每100例WAD问题中有8例。WAD最常见的临床/程序性治疗是物理医学/康复（每100例WAD问题中16.1例）、咨询（6.6例）和一般建议/教育（5.8例）。
全科医生将约30%的新病例转诊进行影像学检查（可能存在影像学检查过度使用的情况），并开出一系列药物，其中约22%超出临床指南。这些发现表明需要对全科医生进行进一步教育，包括挥鞭样损伤后影像学检查的指征、识别更易发展为慢性WAD的患者以及药物管理指南。WAD带来巨大的个人和经济负担，因此全科医生管理改善的影响可能很大。
