Hayden Jill A, Ogilvie Rachel, Stewart Samuel Alan, French Simon, Campbell Samuel, Magee Kirk, Slipp Patrick, Wells George, Stiell Ian
1Department Community Health and Epidemiology, Dalhousie University, 5790 University Avenue, Halifax, NS B3H 1V7 Canada.
2School of Rehabilitation Therapy, Queen's University, Louise D. Acton Building, 31 George St, Kingston, ON K7L 3N6 Canada.
Diagn Progn Res. 2019 Jan 14;3:1. doi: 10.1186/s41512-019-0047-8. eCollection 2019.
Low back pain is one of the most common and disabling health problems in Canada and internationally. In most cases, low back pain is a benign, self-limiting condition that can be managed with little diagnostic investigation or treatment. Yet contrary to clinical practice guideline recommendations, diagnostic imaging (here meaning X-ray, MRI, CT) is commonly used in the assessment of low back pain. Diagnostic imaging is of limited value in most cases, exposing patients to unnecessary radiation and leading to increased health services use and worse patient health outcomes. The Choosing Wisely campaign has highlighted the need to reduce diagnostic imaging for low back pain; however, no clinical decision rules are available.
This project will develop a clinical decision support tool for appropriate use of diagnostic imaging for patients with low back pain in the emergency department. We will conduct a prospective cohort study at five Canadian emergency departments. The study will follow recommendations for prediction model development and testing. The study population will be 4000 patients presenting to the emergency department with low back pain. We will assess potential clinical indications of emergent-cause (i.e., "red flag" items), including clinical characteristics and past history. Our outcome, emergent-cause for low back pain such as fracture, cancer, infection, or cauda equina syndrome, will be assessed at discharge and at 1-, 3-, and 12-month follow-up periods using information from self-report and health administrative data. We will construct and assess the performance of a multivariable prediction model that has strong measurement properties, presented as a clinical decision support tool acceptable to knowledge users.
Practice guidelines describe "red flags" for which diagnostic imaging is likely appropriate. However, recommendations across guidelines are discordant, and few studies have evaluated these criteria to determine which characteristics best predict emergent etiology that warrant diagnostic imaging. A clinical decision support tool, that recommends diagnostic imaging where appropriate, has the potential to improve clinical care and patient outcomes and reduce costs associated with managing low back pain patients.
腰痛是加拿大乃至全球最常见且使人丧失劳动能力的健康问题之一。在大多数情况下，腰痛是一种良性的自限性疾病，无需过多诊断性检查或治疗即可得到控制。然而，与临床实践指南的建议相悖，诊断性影像学检查（此处指X线、磁共振成像、计算机断层扫描）在腰痛评估中却被广泛使用。在大多数情况下，诊断性影像学检查价值有限，会使患者遭受不必要的辐射，并导致医疗服务使用增加以及患者健康结局变差。明智选择运动强调了减少腰痛诊断性影像学检查的必要性；然而，目前尚无临床决策规则。
本项目将开发一种临床决策支持工具，用于指导急诊科腰痛患者合理使用诊断性影像学检查。我们将在加拿大的五个急诊科开展一项前瞻性队列研究。该研究将遵循预测模型开发和测试的建议。研究对象将是4000名因腰痛就诊于急诊科的患者。我们将评估紧急病因的潜在临床指征（即“红旗”项目），包括临床特征和既往史。我们的结局指标——腰痛的紧急病因，如骨折、癌症、感染或马尾综合征，将在出院时以及1个月、3个月和12个月的随访期，通过自我报告和卫生行政数据进行评估。我们将构建并评估一个具有强大测量属性的多变量预测模型的性能，该模型将作为知识使用者可接受的临床决策支持工具呈现。
实践指南描述了可能适合进行诊断性影像学检查的“红旗”症状。然而，各指南之间的建议并不一致，很少有研究评估这些标准以确定哪些特征最能预测需要进行诊断性影像学检查的紧急病因。一种能在适当情况下推荐诊断性影像学检查的临床决策支持工具，有可能改善临床护理和患者结局，并降低管理腰痛患者的相关成本。
