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NIHR Signal Prompts for GPs may improve diagnosis and treatment of osteoporosis

Published on 30 August 2016

doi: 10.3310/signal-000285

Prompts for GPs with education and reminders for patients may improve “guideline consistent behaviour” and diagnosis and treatment of osteoporosis. Similar techniques aimed at improving GP management of other common musculoskeletal conditions, such as back pain, shoulder pain or osteoarthritis seem to have less clear effects.

This Cochrane review also looked at GP education, distribution of guidelines and feedback on clinician performance as a way of improving treatment for low back pain, and shoulder pain. These professional interventions led to little or no improvement in GPs behaviour or patient outcomes (such as prescriptions for pain medication and absence from work). When prominent GPs educate their colleagues about osteoarthritis, GP behaviour and patient outcomes showed slight improvements.

While adopting some reminders in the electronic medical record may help improve GPs ability to manage common musculoskeletal conditions, there is still a lack of information on what types of reminder are best and how often they need to be delivered. There is little detail on costs of implementing these systems or on whether there are different groups of patients, such as older people or the disadvantaged who might benefit more.

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Why was this study needed?

Musculoskeletal conditions such as osteoporosis, back pain and arthritis are common causes of pain and disability in the UK. One in six adults lives with a chronic musculoskeletal condition. Every year, over 20% of people consult their GP about musculoskeletal problems.

Musculoskeletal conditions are a major cause of health system spending. In 2009-10, the NHS spent £4.76 billion in this area; this is more than £13 million a day.

Some GPs may lack training and expertise in managing these conditions as musculoskeletal training was only added to the UK curriculum in 2006. This lack could result in persistent knowledge gaps around detection and medical treatment of musculoskeletal conditions and this research aimed to see which professional level interventions had been shown to improve care.

What did this study do?

This systematic review included 30 studies looking at interventions targeting GP management of musculoskeletal conditions.

Interventions for GPs included educational materials including guidelines or a management plan, and reminders including letters or electronic messages on a patient’s electronic medical record. Patient interventions could include education about the condition, given verbally or as a leaflet, appointment reminders and telephone counselling. Usual care was not described in the review, but in the largest included study meant that neither the GP nor the patient received targeted reminders.

The main outcomes for GPs related to behaviour concerning diagnosis, investigations, explanation, advice, prescribing, referral to other services and prevention. Examples included accuracy of diagnosis, adherence to guidelines and number of tests ordered.

The main outcomes for patients were symptoms such as levels of pain, use of health services and days off work or school.

Only studies focusing on osteoporosis were rated as ‘high’ or ‘moderate’ quality. We cannot be so confident in the findings of the studies on other conditions, where, for example, there was incomplete reporting of data or unclear descriptions of interventions.

What did it find?

Five randomised controlled trials of osteoporosis were similar enough for the results to be combined. There were 4,223 participants aged 50 years and older from Canada and the United States. The studies were different from each other and this limits our confidence in the results.

When a GP alerting system plus a patient-directed intervention was implemented GP behaviour was improved compared to usual care:

  • In three studies with 3,386 participants, the chance that the GP ordered a bone mineral density scan for diagnosis was increased, risk ratio [RR] 4.44 (95% confidence interval [CI] 3.54 to 5.55).
  • In five studies with 4,223 participants, the chance that the GP prescribed appropriate medication was increased, RR 1.71 (95% CI 1.50 to 1.94).

Similar increases were seen when combining the results of two studies (3,047 participants) of GP alerting alone to improve GP behaviour when compared to usual care:

  • The chance that the GP ordered a bone mineral density scan for diagnosis was increased RR 4.75 (95% CI 3.62 to 6.24).
  • The chance that the GP prescribed appropriate medication was increased RR 1.52 (95% CI 1.26 to 1.84).

Interventions for patients (such as education or appointment reminders) did not have a significant impact on GPs diagnosis or prescribing behaviour.

Studies on low back pain, osteoarthritis or shoulder pain showed little or no significant impact of interventions such as receiving guidelines, receiving feedback on numbers of tests on outcomes such as number of tests prescribed or pain.

What does current guidance say on this issue?

The Royal College of General Practitioners published a curriculum covering musculoskeletal conditions in 2016. This includes many recommendations for good practice, including familiarity with key national guidelines, communicating with patients and understanding the limitations of diagnostic tests.

There is no general NICE guidance on how to manage musculoskeletal conditions in primary care, although there are condition specific guidelines such as a 2012 guideline on assessing the risk of osteoporotic fractures.

What are the implications?

The current research suggests that simple interventions for GPs such as guideline prompts may help improve diagnostic testing and drug treatment of osteoporosis. More high-quality research would increase our confidence that GP reminders are effective for other conditions.

Cost effectiveness, local IT systems and relevance of some interventions in a UK context are other factors to consider when evaluating whether these types of interventions might be commissioned locally.

Consensus processes and discussions between health professionals are a potential topic for future research. A 2014 survey of GPs showed strong support for small interactive group meetings as a method for improving guidelines adherence.

Citation and Funding

Tzortziou Brown V, Underwood M, Mohamed N, et al. Professional interventions for general practitioners on the management of musculoskeletal conditions. Cochrane Database Syst Rev. 2016;(5):CD007495.

Cochrane UK and the EPOC Cochrane Review Group are supported by NIHR infrastructure funding. This project was also supported by a grant from Arthritis Research UK.

Bibliography

Arthritis and Musculoskeletal Alliance. About musculoskeletal disorders. London: ARMA; 2014.

Arthritis UK. The musculoskeletal calculator. Chesterfield: Arthritis UK; 2016.

Leslie WD, LaBine L, Klassen P, et al. Closing the gap in postfracture care at the population level: a randomized controlled trial. CMAJ. 2012;184(3):290-296.

Lugtenberg M, Burgers JS, Han D et al. General practitioners' preferences for interventions to improve guideline adherence. J Eval Clin Pract. 2014;20(6):820-6.

Majumdar SR, Johnson JA, Lier DA et al. Persistence, reproducibility, and cost-effectiveness of an intervention to improve the quality of osteoporosis care after a fracture of the wrist: results of a controlled trial. Osteoporos Int. 2007;18(3):261-70.

NICE. Osteoporosis: assessing the risk of fragility fracture. CG146. London: National Institute for Health and Care Excellence; 2012.

RCGP. The RCGP curriculum: clinical modules. 3.20 Care of people with musculoskeletal conditions. London: Royal College of General Practitioners; 2016.

Why was this study needed?

Musculoskeletal conditions such as osteoporosis, back pain and arthritis are common causes of pain and disability in the UK. One in six adults lives with a chronic musculoskeletal condition. Every year, over 20% of people consult their GP about musculoskeletal problems.

Musculoskeletal conditions are a major cause of health system spending. In 2009-10, the NHS spent £4.76 billion in this area; this is more than £13 million a day.

Some GPs may lack training and expertise in managing these conditions as musculoskeletal training was only added to the UK curriculum in 2006. This lack could result in persistent knowledge gaps around detection and medical treatment of musculoskeletal conditions and this research aimed to see which professional level interventions had been shown to improve care.

What did this study do?

This systematic review included 30 studies looking at interventions targeting GP management of musculoskeletal conditions.

Interventions for GPs included educational materials including guidelines or a management plan, and reminders including letters or electronic messages on a patient’s electronic medical record. Patient interventions could include education about the condition, given verbally or as a leaflet, appointment reminders and telephone counselling. Usual care was not described in the review, but in the largest included study meant that neither the GP nor the patient received targeted reminders.

The main outcomes for GPs related to behaviour concerning diagnosis, investigations, explanation, advice, prescribing, referral to other services and prevention. Examples included accuracy of diagnosis, adherence to guidelines and number of tests ordered.

The main outcomes for patients were symptoms such as levels of pain, use of health services and days off work or school.

Only studies focusing on osteoporosis were rated as ‘high’ or ‘moderate’ quality. We cannot be so confident in the findings of the studies on other conditions, where, for example, there was incomplete reporting of data or unclear descriptions of interventions.

What did it find?

Five randomised controlled trials of osteoporosis were similar enough for the results to be combined. There were 4,223 participants aged 50 years and older from Canada and the United States. The studies were different from each other and this limits our confidence in the results.

When a GP alerting system plus a patient-directed intervention was implemented GP behaviour was improved compared to usual care:

  • In three studies with 3,386 participants, the chance that the GP ordered a bone mineral density scan for diagnosis was increased, risk ratio [RR] 4.44 (95% confidence interval [CI] 3.54 to 5.55).
  • In five studies with 4,223 participants, the chance that the GP prescribed appropriate medication was increased, RR 1.71 (95% CI 1.50 to 1.94).

Similar increases were seen when combining the results of two studies (3,047 participants) of GP alerting alone to improve GP behaviour when compared to usual care:

  • The chance that the GP ordered a bone mineral density scan for diagnosis was increased RR 4.75 (95% CI 3.62 to 6.24).
  • The chance that the GP prescribed appropriate medication was increased RR 1.52 (95% CI 1.26 to 1.84).

Interventions for patients (such as education or appointment reminders) did not have a significant impact on GPs diagnosis or prescribing behaviour.

Studies on low back pain, osteoarthritis or shoulder pain showed little or no significant impact of interventions such as receiving guidelines, receiving feedback on numbers of tests on outcomes such as number of tests prescribed or pain.

What does current guidance say on this issue?

The Royal College of General Practitioners published a curriculum covering musculoskeletal conditions in 2016. This includes many recommendations for good practice, including familiarity with key national guidelines, communicating with patients and understanding the limitations of diagnostic tests.

There is no general NICE guidance on how to manage musculoskeletal conditions in primary care, although there are condition specific guidelines such as a 2012 guideline on assessing the risk of osteoporotic fractures.

What are the implications?

The current research suggests that simple interventions for GPs such as guideline prompts may help improve diagnostic testing and drug treatment of osteoporosis. More high-quality research would increase our confidence that GP reminders are effective for other conditions.

Cost effectiveness, local IT systems and relevance of some interventions in a UK context are other factors to consider when evaluating whether these types of interventions might be commissioned locally.

Consensus processes and discussions between health professionals are a potential topic for future research. A 2014 survey of GPs showed strong support for small interactive group meetings as a method for improving guidelines adherence.

Citation and Funding

Tzortziou Brown V, Underwood M, Mohamed N, et al. Professional interventions for general practitioners on the management of musculoskeletal conditions. Cochrane Database Syst Rev. 2016;(5):CD007495.

Cochrane UK and the EPOC Cochrane Review Group are supported by NIHR infrastructure funding. This project was also supported by a grant from Arthritis Research UK.

Bibliography

Arthritis and Musculoskeletal Alliance. About musculoskeletal disorders. London: ARMA; 2014.

Arthritis UK. The musculoskeletal calculator. Chesterfield: Arthritis UK; 2016.

Leslie WD, LaBine L, Klassen P, et al. Closing the gap in postfracture care at the population level: a randomized controlled trial. CMAJ. 2012;184(3):290-296.

Lugtenberg M, Burgers JS, Han D et al. General practitioners' preferences for interventions to improve guideline adherence. J Eval Clin Pract. 2014;20(6):820-6.

Majumdar SR, Johnson JA, Lier DA et al. Persistence, reproducibility, and cost-effectiveness of an intervention to improve the quality of osteoporosis care after a fracture of the wrist: results of a controlled trial. Osteoporos Int. 2007;18(3):261-70.

NICE. Osteoporosis: assessing the risk of fragility fracture. CG146. London: National Institute for Health and Care Excellence; 2012.

RCGP. The RCGP curriculum: clinical modules. 3.20 Care of people with musculoskeletal conditions. London: Royal College of General Practitioners; 2016.

Professional interventions for general practitioners on the management of musculoskeletal conditions

Published on 7 May 2016

Tzortziou Brown, V.,Underwood, M.,Mohamed, N.,Westwood, O.,Morrissey, D.

Cochrane Database Syst Rev Volume 5 , 2016

BACKGROUND: Musculoskeletal conditions require particular management skills. Identification of interventions which are effective in equipping general practitioners (GPs) with such necessary skills could translate to improved health outcomes for patients and reduced healthcare and societal costs. OBJECTIVES: To determine the effectiveness of professional interventions for GPs that aim to improve the management of musculoskeletal conditions in primary care. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), 2010, Issue 2; MEDLINE, Ovid (1950 - October 2013); EMBASE, Ovid (1980 - Ocotber 2013); CINAHL, EbscoHost (1980 - November 2013), and the EPOC Specialised Register. We conducted cited reference searches using ISI Web of Knowledge and Google Scholar; and handsearched selected issues of Arthritis and Rheumatism and Primary Care-Clinics in Office Practice. The latest search was conducted in November 2013. SELECTION CRITERIA: We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies of professional interventions for GPs, taking place in a community setting, aiming to improve the management (including diagnosis and treatment) of musculoskeletal conditions and reporting any objective measure of GP behaviour, patient or economic outcomes. We considered professional interventions of any length, duration, intensity and complexity compared with active or inactive controls. DATA COLLECTION AND ANALYSIS: Two review authors independently abstracted all data. We calculated the risk difference (RD) and risk ratio (RR) of compliance with desired practice for dichotomous outcomes, and the mean difference (MD) and standardised mean difference (SMD) for continuous outcomes. We investigated whether the direction of the targeted behavioural change affects the effectiveness of interventions. MAIN RESULTS: Thirty studies met our inclusion criteria.From 11 studies on osteoporosis, meta-analysis of five studies (high-certainty evidence) showed that a combination of a GP alerting system on a patient's increased risk of osteoporosis and a patient-directed intervention (including patient education and a reminder to see their GP) improves GP behaviour with regard to diagnostic bone mineral density (BMD) testing and osteoporosis medication prescribing (RR 4.44; (95% confidence interval (CI) 3.54 to 5.55; 3 studies; 3,386 participants)) for BMD and RR 1.71 (95% CI 1.50 to 1.94; 5 studies; 4,223 participants) for osteoporosis medication. Meta-analysis of two studies showed that GP alerting on its own also probably improves osteoporosis guideline-consistent GP behaviour (RR 4.75 (95% CI 3.62 to 6.24; 3,047 participants)) for BMD and RR 1.52 (95% CI 1.26 to 1.84; 3.047 participants) for osteoporosis medication) and that adding the patient-directed component probably does not lead to a greater effect (RR 0.94 (95% CI 0.81 to 1.09; 2,995 participants)) for BMD and RR 0.93 (95% CI 0.79 to 1.10; 2,995 participants) for osteoporosis medication.Of the 10 studies on low back pain, seven showed that guideline dissemination and educational opportunities for GPs may lead to little or no improvement with regard to guideline-consistent GP behaviour. Two studies showed that the combination of guidelines and GP feedback on the total number of investigations requested may have an effect on GP behaviour and result in a slight reduction in the number of tests, while one of these studies showed that the combination of guidelines and GP reminders attached to radiology reports may result in a small but sustained reduction in the number of investigation requests.Of the four studies on osteoarthritis, one study showed that using educationally influential physicians may result in improvement in guideline-consistent GP behaviour. Another study showed slight improvements in patient outcomes (pain control) after training GPs on pain management.Of three studies on shoulder pain, one study reported that there may be little or no improvement in patient outcomes (functional capacity) after GP education on shoulder pain and injection training.Of two studies on other musculoskeletal conditions, one study on pain management showed that there may be worse patient outcomes (pain control) after GP training on the use of validated assessment scales.The 12 remaining studies across all musculoskeletal conditions showed little or no improvement in GP behaviour and patient outcomes.The direction of the targeted behaviour (i.e. increasing or decreasing a behaviour) does not seem to affect the effectiveness of an intervention. The majority of the studies did not investigate the potential adverse effects of the interventions and only three studies included a cost-effectiveness analysis.Overall, there were important methodological limitations in the body of evidence, with just a third of the studies reporting adequate allocation concealment and blinded outcome assessments. While our confidence in the pooled effect estimate of interventions for improving diagnostic testing and medication prescribing in osteoporosis is high, our confidence in the reported effect estimates in the remaining studies is low. AUTHORS' CONCLUSIONS: There is good-quality evidence that a GP alerting system with or without patient-directed education on osteoporosis improves guideline-consistent GP behaviour, resulting in better diagnosis and treatment rates.Interventions such as GP reminder messages and GP feedback on performance combined with guideline dissemination may lead to small improvements in guideline-consistent GP behaviour with regard to low back pain, while GP education on osteoarthritis pain and the use of educationally influential physicians may lead to slight improvement in patient outcomes and guideline-consistent behaviour respectively. However, further studies are needed to ascertain the effectiveness of such interventions in improving GP behaviour and patient outcomes.

In this review, local consensus processes means including participating health providers in discussion to ensure that they agree that the chosen clinical problem is important. Another purpose is to check that the guideline or approach to managing the condition or disease is appropriate.

Expert commentary

Musculoskeletal problems account for up to a fifth of general practice consultations and often cause significant disability and chronic pain. This review found mixed effects of interventions to improve GPs care across a range of musculoskeletal conditions. Alerting systems targeting GPs improved investigation and prescribing for osteoporosis. For low back pain, relatively passive approaches, such as distributing guidelines alone, had little or no effect while feedback on performance or educational reminders attached to radiology reports produced small improvements in guideline adherence. Overall, efforts to change clinical behaviour can be cost-effective but it remains tricky to predict with reasonable confidence which intervention will work best for a given problem.

Robbie Foy, Professor of Primary Care, University of Leeds