Bamji A N, Erhardt C C, Price T R, Williams P L
Queen Mary's Hospital, Sidcup, Kent.
Br J Rheumatol. 1996 Nov;35(11):1172-4. doi: 10.1093/rheumatology/35.11.1172.
As a two-phase exercise in inter-district audit, with the emphasis on critical evaluation of routine clinical practice, three rheumatologists each examined the same 44 patients with shoulder pain, and recorded their diagnosis and the investigations and treatment they would carry out. In the first phase, 26 patients were seen by each rheumatologist separately; there was complete diagnostic agreement in only 46%, with wide variation in the frequency of requests for standard investigations, but all three rheumatologists recommended steroid injections for most patients. In the second phase, all three rheumatologists examined a further 18 patients together, discussed the symptoms and signs, and recorded their diagnoses separately. There was complete agreement in 78%. The presence of more than one lesion, and differences in the interpretation of certain physical signs, partly explain the lack of agreement in Phase 1. Treatment of specific shoulder lesions is highly concordant, with injection the major treatment modality, followed by physiotherapy. Perhaps the different diagnoses reached, and the fact that treatment might therefore be administered for the wrong diagnosis, may explain some treatment failures. Also, recruitment of patients for studies of the treatment of shoulder lesions requires care to avoid selection of a heterogeneous group.
作为一项跨地区审计的两阶段活动，重点是对常规临床实践进行批判性评估，三位风湿病学家各自检查了44例肩部疼痛患者，并记录了他们的诊断以及他们将进行的检查和治疗。在第一阶段，每位风湿病学家分别诊治26例患者；完全诊断一致的仅占46%，标准检查请求的频率差异很大，但所有三位风湿病学家都建议对大多数患者进行类固醇注射。在第二阶段，三位风湿病学家一起检查了另外18例患者，讨论了症状和体征，并分别记录了他们的诊断。完全一致的占78%。存在多个病变以及对某些体征的解释存在差异，部分解释了第一阶段缺乏一致性的原因。特定肩部病变的治疗高度一致，注射是主要治疗方式，其次是物理治疗。也许所达成的不同诊断以及因此可能因错误诊断而进行治疗这一事实，可以解释一些治疗失败的情况。此外，招募肩部病变治疗研究的患者需要谨慎，以避免选择异质性群体。
