Zhao Siya, Langford Aili V, Chen Qiuzhe, Lyu Meng, Yang Zhiwei, French Simon D, Williams Christopher M, Lin Chung-Wei Christine
Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, NSW, Australia.
Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.
EClinicalMedicine. 2024 Nov 13;78:102916. doi: 10.1016/j.eclinm.2024.102916. eCollection 2024 Dec.
International low back pain guidelines recommend providing education/advice to patients, discouraging routine imaging use, and encouraging judicious prescribing of analgesics. However, practice variation occurs and the effectiveness of implementation strategies to promote guideline-concordant care is unclear. This review aims to comprehensively evaluate the effectiveness of implementation strategies to promote guideline-concordant care for low back pain.
Five databases (including MEDLINE, Embase, CINAHL, CENTRAL and PEDro were searched from inception until 22nd August 2024. Randomised controlled trials (RCTs) that evaluated strategies to promote guideline-concordant care (providing education/advice, discouraging routine imaging use, and/or reducing analgesic use) among healthcare professionals or organisations were included. Two reviewers independently conducted screening, data extraction, and risk of bias assessments. The primary outcome was guideline-concordant care in the medium-term (>3 months but <12 months). The taxonomy recommended by the Cochrane Effective Practice and Organisation of Care (EPOC) group was used to categorise implementation strategies. Meta-analysis with a random-effects model was conducted where possible. This systematic review was prospectively registered in PROSPERO (registration number: CRD42023452969).
Twenty-seven RCTs with 32 reports were included. All strategies targeted healthcare professionals (7796 health professionals overseeing 34,890 patients with low back pain), and none targeted organisations. The most commonly used implementation strategies were educational materials (15/27) and educational meetings (14/27), although most studies (24/27) used more than one strategy ('multifaceted strategies'). In the medium-term, compared to no implementation, implementation strategies probably reduced the use of routine imaging (number of studies [N] = 7, odds ratio [OR] = 1.26, 95% confidence interval [CI]: 1.01-1.58, = 50%, moderate certainty evidence), but made no difference in reducing analgesic use (N = 4, OR = 1.05, 95% CI: 0.96-1.14, = 0%, high certainty evidence). Further, implementation strategies may make no difference to improve the rate of providing education/advice (N = 3, OR = 1.83, 95% CI: 0.87-3.87, = 95%, low certainty evidence), but this finding should be interpreted with caution because the sensitivity analysis showed a weak positive finding indicating unstable results that are likely to change with future research (N = 2, OR = 1.18, 95% CI: 1.04-1.35, = 0%, moderate certainty evidence). No difference was found when comparing one implementation strategy to another in the medium-term.
Implementing guideline recommendations delivered mixed effects in promoting guideline-concordant care for low back pain management.
There was no funding source for this review.
国际腰痛指南建议为患者提供教育/建议，不鼓励常规使用影像学检查，并鼓励谨慎开具镇痛药。然而，实际操作存在差异，促进符合指南护理的实施策略的有效性尚不清楚。本综述旨在全面评估促进腰痛指南一致性护理的实施策略的有效性。
检索了五个数据库（包括MEDLINE、Embase、CINAHL、CENTRAL和PEDro），从建库至2024年8月22日。纳入评估医疗专业人员或组织中促进指南一致性护理（提供教育/建议、不鼓励常规影像学检查使用和/或减少镇痛药使用）策略的随机对照试验（RCT）。两名评审员独立进行筛选、数据提取和偏倚风险评估。主要结局是中期（>3个月但<12个月）的指南一致性护理。使用Cochrane有效实践与护理组织（EPOC）小组推荐的分类法对实施策略进行分类。尽可能采用随机效应模型进行荟萃分析。本系统综述已在PROSPERO中进行前瞻性注册（注册号：CRD42023452969）。
纳入了27项RCT，共32份报告。所有策略均针对医疗专业人员（7796名医疗专业人员负责34890例腰痛患者），无一针对组织。最常用的实施策略是教育材料（15/27）和教育会议（14/27），尽管大多数研究（24/27）使用了不止一种策略（“多方面策略”）。在中期，与未实施相比，实施策略可能减少了常规影像学检查的使用（研究数量[N]=7，比值比[OR]=1.26，95%置信区间[CI]：1.01-1.58，I²=50%，中等确定性证据），但在减少镇痛药使用方面没有差异（N=4，OR=1.05，95%CI：0.96-1.14，I²=0%，高确定性证据）。此外，实施策略在提高提供教育/建议的比例方面可能没有差异（N=3，OR=1.83，95%CI：0.87-3.87，I²=95%，低确定性证据），但这一发现应谨慎解释，因为敏感性分析显示有微弱的阳性结果，表明结果不稳定，可能会随着未来研究而改变（N=2，OR=1.18，95%CI：1.04-1.35，I²=0%，中等确定性证据）。中期比较不同实施策略时未发现差异。
实施指南建议在促进腰痛管理的指南一致性护理方面产生了混合效果。
本综述没有资金来源。
