The University of Sydney, Sydney Musculoskeletal Health, Sydney, NSW, Australia, PO Box M179, Priti Kharel - Level 10 North, King George V Building, Royal Prince Alfred Hospital, Missenden Road, 2050.
Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.
BMC Emerg Med. 2024 May 17;24(1):84. doi: 10.1186/s12873-024-00996-x.
Strategies to enhance clinicians' adherence to validated imaging decision rules and increase the appropriateness of imaging remain unclear.
To evaluate the effectiveness of various implementation strategies for increasing clinicians' use of five validated imaging decision rules (Ottawa Ankle Rules, Ottawa Knee Rule, Canadian C-Spine Rule, National Emergency X-Radiography Utilization Study and Canadian Computed Tomography Head Rule).
Systematic review.
The inclusion criteria were experimental, quasi-experimental study designs comprising randomised controlled trials (RCTs), non-randomised controlled trials, and single-arm trials (i.e. prospective observational studies) of implementation interventions in any care setting. The search encompassed electronic databases up to March 11, 2024, including MEDLINE (via Ovid), CINAHL (via EBSCO), EMBASE (via Ovid), Cochrane CENTRAL, Web of Science, and Scopus. Two reviewers assessed the risk of bias of studies independently using the Cochrane Effective Practice and Organization of Care Group (EPOC) risk of bias tool. The primary outcome was clinicians' use of decision rules. Secondary outcomes included imaging use (indicated, non-indicated and overall) and knowledge of the rules.
We included 22 studies (5-RCTs, 1-non-RCT and 16-single-arm trials), conducted in emergency care settings in six countries (USA, Canada, UK, Australia, Ireland and France). One RCT suggested that reminders may be effective at increasing clinicians' use of Ottawa Ankle Rules but may also increase the use of ankle radiography. Two RCTs that combined multiple intervention strategies showed mixed results for ankle imaging and head CT use. One combining educational meetings and materials on Ottawa Ankle Rules reduced ankle injury imaging among ED physicians, while another, with similar efforts plus clinical practice guidelines and reminders for the Canadian CT Head Rule, increased CT imaging for head injuries. For knowledge, one RCT suggested that distributing guidelines had a limited short-term impact but improved clinicians' long-term knowledge of the Ottawa Ankle Rules.
Interventions such as pop-up reminders, educational meetings, and posters may improve adherence to the Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian CT Head Rule. Reminders may reduce non-indicated imaging for knee and ankle injuries. The uncertain quality of evidence indicates the need for well-conducted RCTs to establish effectiveness of implementation strategies.
增强临床医生对已验证成像决策规则的依从性并提高成像的适宜性的策略仍不清楚。
评估各种实施策略对增加临床医生使用五种已验证成像决策规则（渥太华踝关节规则、渥太华膝关节规则、加拿大颈椎规则、国家紧急 X 射线利用研究和加拿大计算机断层扫描头部规则）的有效性。
系统评价。
纳入标准为实验性、准实验研究设计，包括随机对照试验（RCT）、非随机对照试验和任何护理环境中的单臂试验（即前瞻性观察研究）的实施干预。检索范围包括电子数据库，截至 2024 年 3 月 11 日，包括 MEDLINE（通过 Ovid）、CINAHL（通过 EBSCO）、EMBASE（通过 Ovid）、Cochrane 有效实践和组织护理组（EPOC）偏倚风险工具。两位审查员独立使用 Cochrane 有效实践和组织护理组（EPOC）偏倚风险工具评估研究的偏倚风险。主要结局是临床医生对决策规则的使用。次要结局包括成像使用（指示性、非指示性和总体）和对规则的了解。
我们纳入了 22 项研究（5 项 RCT、1 项非 RCT 和 16 项单臂试验），这些研究在六个国家（美国、加拿大、英国、澳大利亚、爱尔兰和法国）的急诊护理环境中进行。一项 RCT 表明，提醒可能有助于增加临床医生对渥太华踝关节规则的使用，但也可能增加踝关节 X 射线的使用。两项结合了多种干预策略的 RCT 对踝关节成像和头部 CT 使用的结果不一。一项结合了渥太华踝关节规则教育会议和材料的研究减少了急诊医师对踝关节损伤的成像，而另一项类似的研究，加上加拿大 CT 头部规则的临床实践指南和提醒，增加了头部损伤的 CT 成像。关于知识，一项 RCT 表明，分发指南具有短期影响有限，但可改善临床医生对渥太华踝关节规则的长期了解。
弹出式提醒、教育会议和海报等干预措施可能会提高对渥太华踝关节规则、渥太华膝关节规则和加拿大 CT 头部规则的依从性。提醒可能会减少膝关节和踝关节损伤的非指示性成像。证据质量不确定表明需要进行精心设计的 RCT 来确定实施策略的有效性。
