title: The utilization of appropriate osteoporosis medications improves following a multifaceted educational intervention: the Canadian quality circle project (CQC) Closing the gap in postfracture care at the population level: a randomized controlled trial Assessing the long-term effect of educational reminder messages on primary care radiology referrals. Case management of arthritis patients in primary care: a cluster-randomized controlled trial. Community based intervention to optimize osteoporosis management: randomized controlled trial Shoulder acute pain in primary healthcare: is retraining effective for GP principals? SAPPHIRE--a randomized controlled trial. Rationale, design and conduct of a comprehensive evaluation of a primary care based intervention to improve the quality of life of osteoarthritis patients. The PraxArt-project: a cluster randomized controlled trial [ISRCTN87252339] Evaluation of a Theory-Informed Implementation Intervention for the Management of Acute Low Back Pain in General Medical Practice: The IMPLEMENT Cluster Randomised Trial Improving Osteoporosis Screening: Results from a Randomized Cluster Trial Improving Care of Patients At-Risk for Osteoporosis: A Randomized Controlled Trial Can evidence change the rate of back surgery? A randomized trial of community-based education. General practitioners' use of magnetic resonance imaging: an open randomized trial comparing telephone and written requests and an open randomized controlled trial of different methods of local guideline dissemination. Osteoporosis improvement: a large-scale randomized controlled trial of patient and primary care physician education. Improvement in the Undertreatment of Osteoporosis Following Hip Fracture Assessing chronic pain in general practice: Are guidelines relevant? A cluster randomized controlled trial Priming Primary Care Physicians to Treat Osteoporosis After a Fragility Fracture: An Integrated Multidisciplinary Approach Adherence to osteoporosis medications after patient and physician brief education: post hoc analysis of a randomized controlled trial. Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain Early Physician Notification of Patient Disability Risk and Clinical Guidelines After Low Back Injury: A Randomized, Controlled Trial Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial. A before and after study of the impact of academic detailing on the use of diagnostic imaging for shoulder complaints in general practice Shoulder acute pain in primary health care: is retraining GPs effective? The SAPPHIRE randomized trial: a cost-effectiveness analysis. A randomised study of two training programmes for general practitioners in the techniques of shoulder injection Knowledge transfer in family physicians managing patients with acute low back pain: a prospective randomized control trial. 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 Effectiveness of a learner-centred training programme for primary care physicians in using a patient-centred consultation style. Improving evaluation and treatment for osteoporosis following distal radial fractures. A prospective randomized intervention. Effects of training on general practitioners' management of pain in osteoarthritis: a randomized multicenter study. The impact of two educational interventions on osteoporosis diagnosis and treatment after fragility fracture: a population-based randomized controlled trial Effect of audit and feedback, and reminder messages on primary-care radiology referrals: a randomised trial Evaluation of a complex intervention for changing professional behaviour: the Evidence Based Out Reach (EBOR) Trial Electronic medical record reminder improves osteoporosis management after a fracture: a randomized, controlled trial. Physician treatment of osteoporosis in response to heel ultrasound bone mineral density reports. Implementation of the Dutch Low Back Pain Guideline for General Practitioners: A Cluster Randomized Controlled Trial Relative importance of musculoskeletal disorders as a cause of chronic health problems, disability, and health care utilization: findings from the 1990 Ontario Health Survey. A multifaceted intervention to improve treatment of osteoporosis in postmenopausal women with wrist fractures: a cluster randomized trial Influence of postal distribution of the Royal College of Radiologists' guidelines, together with feedback on radiological referral rates, on X-ray referrals from general practice: a randomized controlled trial. Impact of a general practitioner educational intervention on osteoarthritis treatment in an elderly population. Effects of Two Guideline Implementation Strategies on Patient Outcomes in Primary Care: A Cluster Randomized Controlled Trial Continuing education: a survey among general practitioners. Interventions to improve osteoporosis treatment following hip fracture. A prospective, randomized trial. Primary care referrals for lumbar spine radiography: diagnostic yield and clinical guidelines. Multifaceted intervention to improve diagnosis and treatment of osteoporosis in patients with recent wrist fracture: a randomized controlled trial Wristwatch-distal radial fracture as a marker for osteoporosis investigation: a controlled trial of patient education and a physician alerting system. Primary care clinician adherence to guidelines for the management of chronic musculoskeletal pain: results from the study of the effectiveness of a collaborative approach to pain.
abstract: Background Osteoporosis is a serious but treatable condition . However , appropriate therapy utilization of the disease remains suboptimal . Thus , the objective of the study was to change physicians ' therapy administration behavior in accordance with the Osteoporosis Canada 2002 guidelines . Methods The Project was a two year cohort study that consisted of five Quality Circle ( QC ) phases that included : 1 ) Training & Baseline Data Collection , 2 ) First Educational Intervention & First Follow-Up Data Collection 3 ) First Strategy Implementation Session , 4 ) Final Educational Intervention & Final Follow-up Data Collection , and 5 ) Final Strategy Implementation Session . A total of 340 family physicians formed 34 QCs and participated in the study . Physicians evaluated a total of 8376 , 7354 and 3673 r and omly selected patient charts at baseline , follow-up # 1 and the final follow-up , respectively . Patients were divided into three groups ; the high-risk , low-risk , and low-risk without fracture groups . The generalized estimating equations technique was utilized to model the change over time of whether physicians Results The odds of appropriate therapy was 1.29 ( 95 % CI : 1.13 , 1.46 ) , and 1.41 ( 95 % CI : 1.20 , 1.66 ) in the high risk group , 1.15 ( 95 % CI : 0.97 , 1.36 ) , and 1.16 ( 95 % CI : 0.93 , 1.44 ) in the low risk group , and 1.20 ( 95 % CI : 1.01 , 1.43 ) , and 1.23 ( 95 % CI : 0.97 , 1.55 ) in the low risk group without fractures at follow-up # 1 and the final follow-up , respectively . Conclusion QCs methodology was successful in increasing physicians ' appropriate use of osteoporosis medications in accordance with Osteoporosis Canada guidelines Background : Postfracture care is suboptimal , and strategies to address this major gap in care are necessary . We investigated whether notifications sent by mail to physicians and patients would lead to improved postfracture care . Methods : We conducted a r and omized controlled trial ( Clinical Trials.gov identifier NCT00594789 ) in the province of Manitoba , Canada , from June 2008 to May 2010 . Using medical cl aims data , we identified 4264 men and women age 50 years or older who recently reported major fractures , and who had not undergone recent bone mineral density testing or treatment for osteoporosis . Participants were r and omized to three groups : group 1 received usual care ( n = 1480 ) , patients in group 2 had mailed notification of the fracture sent to their primary care physicians ( n = 1363 ) , and group 3 had notifications sent to both physicians and patients ( n = 1421 ) . Bone mineral density testing and the start of pharmacologic treatment for osteoporosis within the following 12 months were documented . Results : Among participants in group 1 ( usual care ) , 15.8 % of women and 7.6 % of men underwent testing for bone mineral density or started pharmacologic treatment for osteoporosis . Outcome measures improved among participants in group 2 ( 30.3 % of women and 19.0 % of men , both p < 0.001 ) and group 3 ( 34.0 % of women and 19.8 % of men , both p < 0.001 ) . No additional benefit was seen with patient notification in addition to physician notification . Combining groups 2 and 3 , the absolute increase for the combined end point of bone mineral density testing or pharmacologic treatment was 14.9 % ( 16.4 % among women , 11.8 % among men ) . The number needed to notify to change patient care was 7 ( 6 for women , 6 for men ) . The adjusted odds ratio ( OR ) to change patient care in group 2 was 2.45 ( 95 % confidence interval [ CI ] 2.01–2.98 ) ; for group 3 the OR was 2.82 ( 95 % CI 2.33–3.43 ) . Interpretation : This notification system provides a relatively simple way to enhance post-fracture care AIM To investigate whether the effect of educational reminder messages for knee and lumbar spine radiographs varied over a 12 month period . MATERIAL S AND METHODS In a previous r and omized , controlled trial , educational reminder messages attached to x-ray reports were shown to be effective in reducing the number of radiograph requests by general practitioners for knee and lumbar spine radiographs . In this study , all radiology departments from the previous trial were asked for monthly referral records for the 12 month intervention period for knee and lumbar spine radiographs for each general practice . Poisson regression was used to test for a change over time in the number of referrals between control and intervention practice s. RESULTS Data were obtained for 66 % of the general practice s in the main trial . The number of referrals for both knee and lumbar spine radiographs remained consistently and statistically significantly lower in the educational reminder messages group compared with the control group ( relative risk=0.65 and 0.64 , respectively ) . There was no evidence that this difference increased or decreased throughout the 12 month period . CONCLUSIONS The effect of educational reminder messages was produced as soon as the intervention was delivered and maintained throughout the intervention period . There was no evidence of the effect of the intervention wearing off OBJECTIVE To assess whether providing information on arthritis self-management through general practitioners ( GPs ) increases the quality of life in patients with osteoarthritis and whether additional case management provided by practice nurses shows better results . METHODS We conducted a pragmatic , cluster-r and omized , controlled , 3-arm trial that included 1,021 patients from 75 primary care practice s in Germany . GPs were r and omized to intervention group I , group II , or a control group . GPs of both intervention groups participated in 2 peer group meetings . In intervention group II , additional case management was conducted via telephone by a practice nurse . The primary outcome was change in quality of life , assessed by the German version of the Arthritis Impact Measurement Scales Short Form ( AIMS 2-SF ) . Secondary outcomes were health service utilization , prescriptions , and physical activity . Data were controlled for depression using the Patient Health Question naire 9 as a potential confounder . RESULTS Of 1,125 administered question naires , 1,021 were analyzed . Compared with the control group , no significant changes occurred in intervention group I with respect to the primary outcome . Performed radiographs decreased significantly ( P = 0.050 ) , whereas prescriptions of  acetaminophen  increased significantly ( P < 0.001 ) . In intervention group II , significant changes in the AIMS 2-SF dimensions social ( P < 0.001 ) , symptom ( P = 0.048 ) , and lower body ( P = 0.049 ) were identified . Radiographs ( P = 0.031 ) and orthopedic referrals ( P = 0.044 ) decreased whereas prescriptions of pain relievers increased significantly . CONCLUSION Improving the quality of life in patients with arthritis using arthritis self-management seems challenging . Simply providing this information through GPs is not sufficient but combining it with case management seems to be a promising approach Background Osteoporosis-related fractures are a significant public health concern . Interventions that increase detection and treatment of osteoporosis are underutilized . This pragmatic r and omised study was done to evaluate the impact of a multifaceted community-based care program aim ed at optimizing evidence -based management in patients at risk for osteoporosis and fractures . Methods This was a 12-month r and omized trial performed in Ontario , Canada . Eligible patients were community-dwelling , aged ≥55 years , and identified to be at risk for osteoporosis-related fractures . Two hundred and one patients were allocated to the intervention group or to usual care . Components of the intervention were directed towards primary care physicians and patients and included facilitated bone mineral density testing , patient education and patient-specific recommendations for osteoporosis treatment . The primary outcome was the implementation of appropriate osteoporosis management . Results 101 patients were allocated to intervention and 100 to control . Mean age of participants was 71.9 ± 7.2 years and 94 % were women . Pharmacological treatment ( alendronate , risedronate , or raloxifene ) for osteoporosis was increased by 29 % compared to usual care ( 56 % [ 29/52 ] vs. 27 % [ 16/60 ] ; relative risk [ RR ] 2.09 , 95 % confidence interval [ CI ] 1.29 to 3.40 ) . More individuals in the intervention group were taking calcium ( 54 % [ 54/101 ] vs. 20 % [ 20/100 ] ; RR 2.67 , 95 % CI 1.74 to 4.12 ) and vitamin D ( 33 % [ 33/101 ] vs. 20 % [ 20/100 ] ; RR 1.63 , 95 % CI 1.01 to 2.65 ) . Conclusions A multi-faceted community-based intervention improved management of osteoporosis in high risk patients compared with usual care . Trial Registration This trial has been registered with clinical trials.gov ( ID : NCT00465387 OBJECTIVE To address the question whether general practitioners ( GPs ) should receive practical training in shoulder problems and to test whether cortisone injections are better than anaesthetic injections for rotator cuff problems . METHODS A pragmatic split-plot , r and omized trial with a cluster factorial design , conducted in general practice s across five centres across the United Kingdom . Ninety-one practice s were r and omized to receive additional training in diagnosing and injecting rotator cuff problems or no additional training .  Two hundred patients consulting their general practice s with shoulder pain were then r and omized to receive either a corticosteroid or lignocaine injection . The main outcome was score on the British Shoulder Disability Question naire ( BSDQ ) . The Short-Form 36-item Health Survey and EuroQol at 12 months from entry to the trial were also scored . RESULTS Over the course of the trial there was a mean difference of 0.94 ( s.e . = 1.01 ) on the BSDQ score between the groups , with patients treated by the untrained group having a mean of 9.46 ( s.e . = 0.82 ) and those by the trained group having a mean of 8.51 ( s.e . = 0.60 ) . There were no statistically significant differences between the groups . Analysing by substance injected , there was a mean difference of 0.15 ( s.e . = 0.48 ) throughout the trial between the groups , with patients given the cortisone having a mean BSDQ of 9.67 ( s.e . = 0.39 ) and those given lignocaine , 9.82 ( s.e . = 0.39 ) . This was not statistically significantly different . CONCLUSIONS Training GPs in the diagnosis and treatment of shoulder disorders does not make any difference to the outcome , in terms of pain and disability , 1 yr later . Further , there is no advantage to injecting steroid in a group with predominant rotator cuff disorder . Trial registration . International St and ard R and omized Controlled Trial Number 58537244 . Trial steering committee comprised Prof. Paul Dieppe , Prof. Elaine Hay , Dr Brian Hazleman and Dr Kerenza Hood Background Osteoarthritis ( OA ) has a high prevalence in primary care . Conservative , guideline orientated approaches aim ing at improving pain treatment and increasing physical activity , have been proven to be effective in several context s outside the primary care setting , as for instance the Arthritis Self management Programs ( ASMPs ) . But it remains unclear if these comprehensive evidence based approaches can improve patients ' quality of life if they are provided in a primary care setting . Methods / Design PraxArt is a cluster r and omised controlled trial with GPs as the unit of r and omisation . The aim of the study is to evaluate the impact of a comprehensive evidence based medical education of GPs on individual care and patients ' quality of life . 75 GPs were r and omised either to intervention group I or II or to a control group . Each GP will include 15 patients suffering from osteoarthritis according to the criteria of ACR.In intervention group I GPs will receive medical education and patient education leaflets including a physical exercise program . In intervention group II the same is provided , but in addition a practice nurse will be trained to monitor via monthly telephone calls adherence to GPs prescriptions and advices and ask about increasing pain and possible side effects of medication . In the control group no intervention will be applied at all . Main outcome measurement for patients ' QoL is the GERMAN- AIMS 2-SF question naire . In addition data about patients ' satisfaction ( using a modified EUROPEP-tool ) , medication , health care utilization , comorbidity , physical activity and depression ( using PHQ-9 ) will be retrieved . Measurements ( pre data collection ) will take place in months I-III , starting in June 2005 . Post data collection will be performed after 6 months . Discussion Despite the high prevalence and increasing incidence , comprehensive and evidence based treatment approaches for OA in a primary care setting are neither established nor evaluated in Germany . If the evaluation of the presented approach reveals a clear benefit it is planned to provide this GP-centred interventions on a much larger scale Introduction This cluster r and omised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain ( LBP ) in general practice . Methods General practice s were r and omised to either  access to a guideline for acute LBP ( control ) or facilitated interactive workshops ( intervention ) . We measured behavioural predictors ( e.g. knowledge , attitudes and intentions ) and fear avoidance beliefs . We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner ( GP ) level : behavioural simulation ( clinical decision about vignettes ) and rates of x-ray and CT-scan ( medical administrative data ) . All those not involved in the delivery of the intervention were blinded to allocation . Results 47 practice s ( 53 GPs ) were r and omised to the control and 45 practice s ( 59 GPs ) to the intervention . The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information ; a minimum of 38 GPs were available from the intervention group , and a minimum of 40 GPs from the control group . For the behavioural constructs , although effect estimates were small , the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral . For behavioural simulation , intervention group GPs were more likely to adhere to guideline recommendations about x-ray ( OR 1.76 , 95%CI 1.01 , 3.05 ) and more likely to give advice to stay active ( OR 4.49 , 95%CI 1.90 to 10.60 ) . Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear ; rate ratio 0.87 ( 95%CI 0.68 , 1.10 ) for x-ray or CT-scan . Conclusions The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence -based guideline , but it did not result in statistically significant changes in actual behaviour . Trial Registration Australian New Zeal and Clinical Trials Registry Background Despite recommendations , osteoporosis screening rates among women aged 65 years and older remain low . We present results from a clustered , r and omized trial evaluating patient mailed reminders , alone and in combination with physician prompts , to improve osteoporosis screening and treatment . Methods Primary care clinics ( n = 15 ) were r and omized to usual care , mailed reminders alone , or mailed reminders with physician prompts .  Study patients were females aged 65–89 years ( N = 10,354 ) . Using automated clinical and pharmacy data , information was collected on bone mineral density testing , pharmacy dispensings , and other patient characteristics . Unadjusted/adjusted differences in testing and treatment were assessed using generalized estimating equation approaches . Results Osteoporosis screening rates were 10.8 % in usual care , 24.1 % in mailed reminder , and 28.9 % in mailed reminder with physician prompt . Results adjusted for differences at baseline indicated that mailed reminders significantly improved testing rates compared to usual care , and that the addition of prompts further improved testing . This effect increased with patient age . Treatment rates were 5.2 % in usual care , 8.4 % in mailed reminders , and 9.1 % in mailed reminders with prompt . No significant differences were found in treatment rates between those receiving mailed reminders alone or in combination with physician prompts . However , women receiving usual care were significantly less likely to be treated . Conclusions The use of mailed reminders , either alone or with physician prompts , can significantly improve  osteoporosis  screening and treatment rates among insured primary care patients ( Clinical Trials.gov number NCT00139425 ) Background Despite accurate diagnostic tests and effective therapies , the management of osteoporosis has been observed to be suboptimal in many setting s. We tested the effectiveness of an intervention to improve care in patients at-risk of osteoporosis . Design R and omized controlled trial . Participants Primary care physicians and their patients at-risk of osteoporosis , including women 65 years and over , men and women 45 and over with a prior fracture , and men and women 45 and over who recently used ≥90 days of oral glucocorticoids . InterventionA multifaceted program of education and reminders delivered to primary care physicians as well as mailings and automated telephone calls to patients . Outcome : Either undergoing a bone mineral density ( BMD ) testing or filling a prescription for a bone-active medication during the 10 months of follow-up . Results After the intervention , 144 ( 14 % ) patients in the intervention group and 97 ( 10 % ) patients in the control group received either a BMD test or filled a prescription for an osteoporosis medication . This represents a 4 % absolute increase and a 45 % relative increase ( 95 % confidence interval 9–93 % , p = 0.01 ) in osteoporosis management between the intervention and control groups . No differences between groups were observed in the incidence of fracture . Conclusion An intervention targeting primary care physicians and their at-risk patients increased the frequency of BMD testing and /or filling prescriptions for osteoporosis medications . However , the absolute percentage of at-risk patients receiving osteoporosis management remained low CONTEXT Timely adoption of clinical practice guidelines is more likely to happen when the guidelines are used in combination with adjuvant educational strategies that address social as well as rational influences . OBJECTIVE To implement the conservative , evidence -based approach to low-back pain recommended in national guidelines , with the anticipated effect of reducing population -based rates of surgery . DESIGN A r and omized , controlled trial . SETTING Ten communities in western Washington State with annual rates of back surgery above the 1990 national average ( 158 operations per 100,000 adults ) . PARTICIPANTS Spine surgeons , primary care physicians , patients who were surgical c and i date s , and hospital administrators . INTERVENTION The five communities r and omized to the intervention group received a package of six educational activities tailored to local needs by community planning groups . Surgeon study groups , primary care continuing medical education conferences , administrative consensus processes , videodisc-aided patient decision making , surgical outcomes management , and generalist academic detailing were serially implemented over a 30-month intervention period . OUTCOME MEASURE Quarterly observations of surgical rates . RESULTS After implementation of the intervention , surgery rates declined in the intervention communities but increased slightly in the control communities . The net effect of the intervention is estimated to be a decline of 20.9 operations per 100,000 , a relative reduction of 8.9 % ( P = 0.01 ) . CONCLUSION We were able to use scientific evidence to engender voluntary change in back pain practice patterns across entire communities AIM To determine the impact and cost-effectiveness of telephone versus written access to magnetic resonance imaging ( MRI ) , and of different strategies for disseminating locally produced guidelines , upon requests by general practitioners ( GPs ) for knee and lumbar spine investigation . MATERIAL AND METHODS Two sequential pragmatic open cluster-r and omized trials were conducted within 39 general practice s. The outcome measure in each trial was concordance of request with local guidelines . Trial 1 : practice s requested MRI by telephone or in writing . Trial 2 : all practice s received guidelines , plus either : a practice -based seminar , practice -specific audit feedback , both seminar and feedback , or neither . RESULTS A total of 414 requests were assessed in the two trials . Trial 1 : telephone access  cost pound4.86 more per request but rates of concordant requests were equivalent ( 65%/64 % : telephone/written ) . Trial 2 : compared to the control group , costs per practice were pound1911 higher in seminar group , pound1543 higher in feedback group and pound3578 higher for those receiving both . Concordance was greater following the intervention ( 74 % vs 65 % ; P < 0.05 ) , but there was no difference between the four study groups . CONCLUSIONS Method of access did not affect concordance . Written access was more cost-effective . Seminars and feedback were no more effective in modifying practice than guidelines alone , which was thus the most cost-effective option UNLABELLED We conducted a r and omized controlled trial within the setting of a large drug benefit plan for Medicare beneficiaries . Primary care physicians and their patients were r and omized to usual care , patient intervention only , physician intervention only , or both interventions . There was no difference in the probability of the primary composite endpoint ( BMD test or osteoporosis medication ) or in either of its components comparing the combined intervention group with usual care ( risk ratio = 1.04 ; 95 % CI , 0.85 - 1.26 ) . INTRODUCTION Fractures from osteoporosis are associated with substantial morbidity , mortality , and cost . However , only a minority of at-risk older adults receives screening and /or treatment for this condition . We evaluated the effect of educational interventions for osteoporosis targeting at-risk patients , primary care physicians , or both . MATERIAL S AND METHODS We conducted a r and omized controlled trial within the setting of a large drug benefit plan for Medicare beneficiaries . Primary care physicians and their patients were r and omized to usual care , patient intervention only , physician intervention only , or both interventions .  The at-risk patients were women > or=65 yr of age , men and women > or=65 yr of age with a prior fracture , and men and women > or=65 yr of age who used oral glucocorticoids .  The primary outcome studied was a composite of either undergoing a BMD test or initiating a medication used for osteoporosis . The secondary outcome was a hip , humerus , spine , or wrist fracture . RESULTS We r and omized 828 primary care physicians and their 13,455 eligible at-risk patients into four study arms . Physician and patient characteristics were very similar across all four groups . Across all four groups , the rate of the composite outcome was 10.3 per 100 person-years and did not differ between the usual care and the combined intervention groups ( p = 0.5 ) . In adjusted Cox proportional hazards models , there was no difference in the probability of the primary composite endpoint comparing the combined intervention group with usual care ( risk ratio = 1.04 ; 95 % CI , 0.85 - 1.26 ) . There was also no difference in either of the components of the composite endpoint . The probability of fracture during follow-up was 4.2 per 100 person-years and did not differ by treatment assignment ( p = 0.9 ) . CONCLUSIONS In this trial , a relatively brief program of patient and /or physician education did not work to improve the management of osteoporosis . More intensive efforts should be considered for future quality improvement programs for osteoporosis Background : Osteoporosis is a common disease characterized by decreased bone mass and increased fracture risk in postmenopausal women and the elderly . Hip fractures are among the most common consequences of osteoporosis and unfortunately usually occur late in the course of the disease . When a patient is admitted to the hospital with a fragility hip fracture , a unique opportunity for diagnosis and treatment presents itself . Fortunately , several medications have proven to be effective in lowering the risk of future fractures . The purpose s of the present study were to test the hypothesis that most fragility hip fractures go untreated and to determine whether educational efforts to raise physician awareness have led to an improvement in osteoporosis treatment rates . Methods : A retrospective cohort study was performed with use of the patient data bases at two university medical centers and one university-affiliated community hospital . The charts of 300 r and omly selected patients were sorted with use of ICD-9 ( International Classification of Diseases , Ninth Revision ) codes for femoral neck fractures . There were 100 patients from each center , with twenty-five patients from each year between 1997 and 2000 . The admitting diagnosis , mechanism of injury , admission medications , procedures performed during hospitalization , and discharge medications were then extracted and analyzed . During this period , the National Osteoporosis Foundation established guiding principles for the treatment of fragility fractures . Results : Of the seventy-five patients from all centers for each year from 1997 to 2000 , 11 % , 13 % , 24 % , and 29 % , respectively , were discharged with a prescription for some medication targeting osteopenia , either supplemental calcium or an antiosteoporotic medication ( estrogen , calcitonin , a bisphosphonate , or raloxifene ) . A trended chi-square analysis of this increase revealed a p value of < 0.001 , indicating that this improvement in treatment was unlikely due to chance alone . Fifty-eight ( 19.3 % ) of the 300 patients in the study received a prescription at the time of discharge . However , forty of these patients ( 13.3 % of the overall group ) received calcium  and only eighteen ( 6.0 % of the overall group ) received a medication to actively prevent bone resorption and treat osteoporosis . In addition , no patient underwent a bone density scan while in the hospital . Conclusions : Elderly patients and postmenopausal women who are admitted to the hospital and diagnosed with a low-energy femoral neck fracture have been undertreated for osteoporosis . However , over the four years of the present study , there was a significant increase in the rate of treatment . It is hoped that treatment rates will continue to increase in the future with continued educational efforts Objectives : To evaluate the impact of using pain assessment scales on the management of musculoskeletal chronic pain . Methods : Cluster-r and omized controlled multicentre trial in French general practice setting s. Practice s were r and omized by region before patient recruitment . The inclusion concerned patients suffering from musculoskeletal chronic pain . General practitioners assigned to the scale group used two vali date d assessment instruments ; those assigned to the control group cared for their patients according to their usual practice . The primary end-point was the level of relief obtained and the secondary changes in prescription of painkilling modalities . Results : A total of 155 general practitioners included 772 successive patients suffering from musculoskeletal chronic pain . The control group reported a mean level of relief of 50.7 % compared with one of 41.1 % in the scale group ( p<0.0001 ) . In the intervention group , physicians decreased significantly their prescription of  level two painkillers .  Conclusions . In general practice , the use of pain assessment scales is not associated with greater pain relief . The lesser level of pain relief obtained in the scale group does provide evidence that using pain assessment scales does not enhance the relief of chronic pain in patients in primary care . Guidelines which recommend the systematic use of scales for the assessment and monitoring of chronic pain are not tailored to either the context or the patients encountered in the primary care setting Objective . To evaluate 2 incremental levels of intervention design ed to increase initiation of osteoporosis treatment by primary care physicians ( PCP ) following fragility fractures ( FF ) . Methods . Women and men over age 50 years were screened for incident FF in fracture clinics , and eligible out patients were r and omly assigned to st and ard care ( SC ) or to either minimal ( MIN ) or intensive ( INT ) interventions . The MIN and INT interventions were intended to educate and motivate both patients and PCP , but differed in their frequency of contact and information content . Delivery of osteoporosis medication was confirmed with pharmacists .  Treatment rates were analyzed using an intention-to-treat approach . Results . At inclusion , 74.3 % of 881 out patients with FF were untreated . Followup at 12 months was completed in 92.3 % of patients . Up to 90 % of patients treated at inclusion remained treated at 12 months . Among patients who initially were untreated , 18.8 % in the SC group , 40.4 % in the MIN , and 53.2 % in the INT groups were treated at 12 months . Change in treatment rates ( adjusted for age and initial treatment ) increased significantly after both MIN and INT . Only the INT intervention significantly increased treatment rates in patients with previous fractures . Negative predictors of change in treatment status included non-major FF , age younger than 65 years , and male sex . Conclusion . Both interventions significantly increased initiation of osteoporosis treatment . Our multidisciplinary intervention builds on existing first-line structures and uses minimal specialized re sources . Iterative and systematic interventions in the context of clinical care may modify the approach of PCP to osteoporosis management after FF and narrow the care gap in the long term OBJECTIVE To examine whether adherence to osteoporosis medications can be improved by educational interventions targeted at primary care physicians ( PCPs ) and patients . STUDY DESIGN Post hoc analysis of data collected as part of a prospect i ve r and omized controlled trial to improve initiation of osteoporosis management such as bone mineral density testing or osteoporosis drug initiation . METHODS The trial was conducted among patients at risk for osteoporosis enrolled in Horizon Blue Cross Blue Shield of New Jersey . For a 3-month period , r and omly selected PCPs and their patients received education about osteoporosis diagnosis and treatment . The PCPs received face-to-face education by trained pharmacists , while patients received letters and automated telephone calls . The control group received no education . We assessed medication adherence during 10 months following the start of the intervention using the medication possession ratio ( MPR ) , the ratio of available medication to the total number of days studied . RESULTS These analyses included 1867 patients ( 972 r and omized to the intervention group and 875 to the control group ) and their 436 PCPs . During 10 months following the intervention , the median MPRs were 74 % ( interquartile range [ IQR ] , 19%-93 % ) for the intervention group and 73 % ( IQR , 0%-93 % ) for the control group ( P = .18 ) . The median times until medication discontinuation after the intervention were 85 days ( IQR , 58 - 174 days ) for the intervention group and 79 days ( IQR , 31 - 158 days ) for the control group . CONCLUSION The educational intervention did not significantly improve medication compliance or persistence with osteoporosis drugs OBJECTIVE : The effect of clinical guidelines on re source utilization for complex conditions with substantial barriers to clinician behavior change has not been well studied . We report the impact of a multifaceted guideline implementation intervention on primary care clinician utilization of radiologic and specialty services for the care of acute low back pain . DESIGN : Physician groups were r and omized to receive guideline education and individual feedback , supporting patient education material s , both , or neither . The impact on guideline adherence and re source utilization was evaluated during the 12-month period before and after implementation . PARTICIPANTS : Fourteen physician groups with 120 primary care physician and associate practitioners from 2 group model HMO practice s. INTERVENTIONS : Guideline implementation utilized an education/audit/feedback model with local peer opinion leaders . The patient education component included written and videotaped material s on the care of low back pain . MAIN RESULTS : The clinician intervention was associated with an absolute increase in guideline -consistent behavior of 5.4 % in the intervention group versus a decline of 2.7 % in the control group ( P=.04 ) . The patient education intervention produced no significant change in guideline -consistent behavior , but was poorly adopted . Patient characteristics including duration of pain , prior history of low back pain , and number of visits during the illness episode were strong predictors of service utilization and guideline -consistent behavior . CONCLUSIONS : Implementation of an education and feedback-supported acute low back pain care guideline for primary care clinicians was associated with an increase in guideline -consistent behavior . Patient education material s did not enhance guideline effectiveness . Implementation barriers could limit the utility of this approach in usual care setting Study Design . Back‐injured workers with high disability risk scores on a predictive question naire participated in a r and omized , controlled trial of physician notification , with outcomes follow‐up 3 months after injury . Objectives . To test whether physician intervention improves return to work and self‐ assessment outcomes for people at relatively high risk for disability . Summary of Background Data . Only a small number of back‐injured workers suffer significant disability . Ouick identification of these people would facilitate more efficient targeting and trials of interventions . Controlling variations in practice through practice guidelines has been recommended as a promising strategy for improving care and reducing disability . Methods . Workers filing back injury reports responded to a disability prediction question naire . Those with high risk scores were r and omly assigned to control or intervention groups . Patient‐ design ated physicians in the intervention group received two letters identifying the patient 's risk and making recommendations for care , including the Agency for Health Care Policy and Research 's algorithms for acute low back pain . Predictive accuracy of the question naire and efficacy of physician intervention were evaluated on the basis of work status and self‐ assessment s 3 months after injury . Results . Of the 268 workers completing the question naire portion of the study , 32 ( 12 % ) were out of work because of back pain 3 months after injury . The question naire 's predictive accuracy included maximum κ of 0.277 and a receiver operating curve area of 0.78 . Fifty‐three people completed the physician intervention trial . The intervention had no significant impact on return to work , self‐assessed pain , or satisfaction with health care . Conclusions . Stratification of back‐injured people according to disability risk can can increase intervention efficiency by identifying those who require treatment and sparing those who do not . The apparent failure of risk notification and practice guidelines to reduce disability in this study may be improved by different application methods in the future BACKGROUND The Royal College of General Practitioners ( RCGP ) has produced guidelines for the management of acute low back pain in primary care . AIM To investigate the impact on patient management of an educational strategy to promote these guidelines among general practitioners ( GPs ) . DESIGN OF STUDY Group r and omised controlled trial , using the health centre as the unit of r and omisation . SETTING Primary care teams in north-west Engl and . METHOD Twenty-four health centres were r and omly allocated to an intervention or control arm . Practice s in the intervention arm were offered outreach visits to promote national guidelines on acute low back pain , as well as access to fast-track physiotherapy and to a triage service for patients with persistent symptoms . RESULTS Twenty-four centres were r and omised . Two thous and , one hundred and eighty-seven eligible patients presented with acute low back pain during the study period : 1049 in the intervention group and 1138 in the control group . There were no significant differences between study groups in the proportion of patients who were referred for X-ray , issued with a sickness certificate , prescribed opioids or muscle relaxants , or who were referred to secondary care , but significantly more patients in the intervention group were referred to physiotherapy or the back pain unit ( difference in proportion = 12.2 % , 95 % confidence interval [ CI ] = 2.8 % to 21.6 % ) . CONCLUSION The management of patients presenting with low back pain to primary care was mostly unchanged by an outreach educational strategy to promote greater adherence to RCGP guidelines among GPs . An increase in referral to physiotherapy or educational programmes followed the provision of a triage service Background The aim of this study was to assess the impact that Academic Detailing ( AD ) had on General Practitioners ' use of diagnostic imaging for shoulder complaints in general practice and their knowledge and confidence to manage shoulder pain . Methods One-to-one Academic Detailing ( AD ) for management of shoulder pain was delivered to 87 General Practitioners ( GPs ) in metropolitan Adelaide , South Australia , together with locally developed clinical guidelines and a video/DVD on how to examine the shoulder . Three months after the initial AD a further small group or an individual follow up session was offered . A 10-item question naire to assess knowledge about the shoulders was administered before , immediately after , and 3 months after AD , together with questions to assess confidence to manage shoulder complaints . The number of requests for  plain film ( X-ray ) and ultrasound ( US ) imaging of the shoulder was obtained for the intervention group as well as a r and om comparison group of 90 GP 's from the same two Divisions . The change in the rate of requests was assessed using a log Poisson GEE with adjustment for clustering at the practice level . A linear mixed effects model was used to analyse changes in knowledge . Results In an average week 54 % of GPs reported seeing fewer than 6 patients with shoulder problems . Mean ( SD ) GP knowledge score before , immediately after and 3-months after AD , was 6.2/10 ( 1.5 ) ; 8.6/10 ( 0.96 ) and ; 7.2/10 ( 1.5 ) respectively ( p < 0.0001 ) . Three months after AD , GPs reported feeling able to take a more meaningful history , more confident managing shoulder pain , and felt their management of shoulder pain had improved . Requests for ultrasound imaging were approximately 43.8 % higher in the period 2 years before detailing compared to six months after detailing ( p < 0.0001 ) , but an upward trend toward baseline was observed in the period 6 months to 1 year after AD . There was no statistically significant change in the rate of requests from before to after AD for plain-radiographs ( p = 0.11 ) . No significant changes in the rate of requests over time were observed in the control groups . Conclusion These results provide evidence that AD together with education material s and guidelines can improve GPs ' knowledge and confidence to manage shoulder problems and reduce the use of imaging , at least in the short term OBJECTIVES To assess the cost-effectiveness of providing practical training to general practitioners ( GPs ) in shoulder problems , and administering a local anaesthetic ( lignocaine ) vs steroidal ( cortisone ) injection . METHODS A cost-effectiveness analysis conducted alongside a cluster r and omized trial with a factorial design , in general practice s across five centres within the UK . A total of 155 participant GPs were r and omized to receive training or no training with 200 participants r and omized to either lignocaine or cortisone .  Health care costs , quality -adjusted life years ( QALYs ) and incremental cost per QALY gained over 1 year estimated from a health system and a societal perspective were the main outcomes measured . RESULTS Over 1 year , training GPs costs on average an additional pound sterling 211 ( 95 % credibility interval - pound sterling 237 , pound sterling 661 ) than no training and produces higher mean QALYs ( 0.075 ; -0.004 , 0.154 ) per patient , yielding an incremental cost-effectiveness ratio of pound sterling 2813 per QALY gained for trained GPs . Over the same period of 1 year , lignocaine costs an average of pound sterling 122 more ( - pound sterling 232 , pound sterling 476 ) than cortisone and produces virtually no differential gain in mean QALYs ( 0.001 ; -0.068 , 0.070 ) , yielding an incremental cost per QALY gained of pound sterling 122,000 for lignocaine compared with cortisone . Across a range of cost-effectiveness thresholds , cortisone is as cost effective to inject as lignocaine . The probability that training is cost effective is above 0.95 at thresholds above pound sterling 20,000 . CONCLUSIONS Providing practical training to GPs about shoulder problems is cost effective and there is little uncertainty regarding this decision . The choice between lignocaine and cortisone is more uncertain and it is likely that there is significant value of further research to reduce this uncertainty . TRIAL REGISTRATION The International St and ard R and omised Controlled Trial Number is 58 537 244 Objectives : To evaluate the impact of two different modes of shoulder injection training on the level of confidence and number of injections performed by  general practitioners ( GPs ) Methods : Demographic details , and information on referrals for shoulder problems , shoulder joint injection activity , and confidence in the six months before training were obtained for 40 GP principals at baseline . St and ardised training in the techniques of shoulder joint injection using rubber mannequins was given to all GPs . Twenty of these GPs were r and omly allocated to receive additional training on patients in hospital joint injection clinics . Six months after both forms of training the shoulder injection and referral activities of all GPs were reassessed . Results : Both training groups had comparable demographic characteristics and baseline clinical activity . GPs who had additional training with patients reported a marked increase in their level of confidence in performing shoulder injections and the number performed . The number of shoulder referrals did not differ between the groups Conclusion : Training on patients in addition to conventional training on mannequins increased GPs ’ shoulder injection activity and their level of confidence . Hospital injection clinics may provide a suitable setting in which to train GPs interested in developing their shoulder joint injection skills BACKGROUND CONTEXT The process through which new scientific developments are incorporated into clinical practice is referred to as " knowledge transfer " and is currently the subject of great interest in many areas of clinical medicine . Family physicians managing patients with acute low back pain have been shown to have a poor overall rate of concordance with clinical practice guideline -recommended treatments . New methods need to be developed to help physicians bridge the guideline implementation gap . PURPOSE To determine the efficacy of a knowledge transfer method that communicates clinical practice guidelines to family physicians and their patients using patient-specific , physician-to-physician communications . STUDY DESIGN A prospect i ve r and omized controlled study . PATIENT SAMPLE 428 patients with acute mechanical low back pain and accepted Workers ' Compensation Board cl aims were studied . OUTCOME MEASURES Concordance with specific clinical practice guideline -derived history taking items , physical examination procedures and treatment recommendations was determined . METHODS Patients with acute mechanical back pain of less than 4 weeks duration and accepted Workers ' Compensation Board cl aims were r and omly assigned to one of three groups . In Group 1 ( control group ) neither the patients nor their family physicians received any information concerning the guidelines . In Group 2 , family physicians alone or as well as their patients ( Group 3 ) received a summary of clinical practice guidelines at approximately 2 weeks postinjury . In addition , both Groups 2 and 3 received reminders summarizing the recommended guidelines for patients at three specific stages of their clinical course . All guideline correspondence was addressed to a specific family physician or patient , signed by the study physician-investigators , and specified the patient by name . RESULTS Family physicians in the control and intervention groups demonstrated a high degree of concordance with the guideline -recommended history taking and physical examination procedures , but were generally highly discordant with guideline -recommended treatments . Significant improvement in guideline -concordant treatments was seen only with diminished recommendations of prolonged bed rest and passive therapies and an increase in recommended aerobic exercise . Concordance with guideline recommendations relating to the use of spinal manipulative therapy was poor in all study groups . CONCLUSIONS A knowledge transfer method that involved patient-specific , physician-to-physician communication to family physicians or their patients at three stages of the patient 's clinical course was largely unsuccessful in improving concordance with guideline treatment recommendations Introduction Older patients with fragility fractures are not commonly tested or treated for osteoporosis . Compared to usual care , a previously reported intervention led to 30 % absolute increases in osteoporosis treatment within 6 months of wrist fracture . Our objective was to examine longer-term outcomes , reproducibility , and cost-effectiveness of this intervention . Methods We conducted an extended analysis of a non-r and omized controlled trial with blinded ascertainment of outcomes that compared a multifaceted intervention to usual care controls .  Patients > 50 years with a wrist fracture treated in two Emergency Departments in the province of Alberta , Canada were included ; those already treated for osteoporosis were excluded . Overall , 102 patients participated in this study ( 55 intervention and 47 controls ; median age : 66 years ; 78 % were women ) . The interventions consisted of faxed physician reminders that contained osteoporosis treatment guidelines endorsed by opinion leaders and patient counseling . Controls received usual care ; at 6-months post-fracture , when the original trial was completed , all controls were crossed-over to intervention . The main outcomes were rates of osteoporosis testing and treatment within 6 months ( original study ) and 1 year ( delayed intervention ) of fracture , and 1-year persistence with treatments started . From the perspective of the healthcare payer , the cost-effectiveness ( using a Markov decision-analytic model ) of the intervention was compared with usual care over a lifetime horizon . Results Overall , 40 % of the intervention patients ( vs. 10 % of the controls ) started treatment within 6 months post-fracture , and 82 % ( 95%CI : 67–96 % ) had persisted with it at 1-year post-fracture . Delaying the intervention to controls for 6 months still led to equivalent rates of bone mineral density ( BMD ) testing ( 64 vs. 60 % in the original study ; p = 0.72 ) and osteoporosis treatment ( 43 vs. 40 % ; p = 0.77 ) as previously reported . Compared with usual care , the intervention strategy was dominant – per patient , it led to a $ 13 Canadian ( U.S. $ 9 ) cost savings and a gain of 0.012 quality -adjusted life years . Base-case results were most sensitive to assumptions about treatment cost ; for example , a 50 % increase in the price of osteoporosis medication led to an incremental cost-effectiveness ratio of $ 24,250 Canadian ( U.S. $ 17,218 ) per quality -adjusted life year gained . Conclusions A pragmatic intervention directed at patients and physicians led to substantial improvements in osteoporosis treatment , even when delivered 6-months post-fracture . From the healthcare payer ’s perspective , the intervention appears to have led to both cost-savings and gains in life expectancy OBJECTIVE The aim of the present study was to find out if a training programme adapted to family physicians with several years of clinical experience changes their behaviour when they deal with fibromyalgic patients in the sense of introducing the communication skills that define the ' patient-centred ' approach . METHODS A r and omized , and simple blind , educative study was carried out . Twenty full-time family physicians were invited to participate . They were allocated r and omly to two groups : an intervention and a control group . A total of 110 patients were recruited from people attending physicians ' surgeries for the first time and who complained of generalized pain that finally fulfilled criteria for generalized musculoskeletal chronic pain/fibromyalgia . This was done for an entire year . The intervention group received an 18 hour intensive course . One week after the course , all doctors carried out a video-recorded encounter with a patient who played the part of a typical fibromyalgia clinical case . The interviews were coded by an observer blind to the training status of the participants , using the GATHARES-CP question naire . All patients were contacted by telephone during a 1 - 2-month period by a different interviewer who was ' blinded ' to the patient 's experimental status . They were asked to respond to three questions that represent the key components of patient-centred style . RESULTS The average score on the GATHARES-CP question naire was 11.3 + /- 0.9 and 9 + /- 2.3 , for doctors from the intervention and control groups , respectively ( P < 0.01 ) . For 11 items , scores were higher in the intervention group . The patients ' answers to all three questions showed statistically significant differences in a positive direction for the trained doctors . CONCLUSIONS The doctors improved the use of strategies and skills for carrying out patient-centred consultations after they had received an interactive course . The doctors ' behaviour appeared to have changed as much in a more experimental situation as in the actual consultations . Moreover , the gain was observed immediately after the intervention was completed , and after having run for a variable period of time up to 1 year BACKGROUND Fragility fractures are associated with a significant increase in the risk of future fracture , but the rates of evaluation to identify osteoporosis after such injuries are low . The purpose of this study was to determine the rates of evaluation and treatment of osteoporosis following distal radial fractures and to test two interventions in the outpatient clinic to improve evaluation and treatment rates . METHODS In the first part of the study , the medical records of 298 consecutive patients treated for a fragility fracture of the distal part of the radius were review ed . Primary outcome measures were a bone mineral density examination and treatment with osteoporosis medication within six months after the fracture . In the second part of the study , fifty patients with a fragility fracture of the distal part of the radius were prospect ively r and omized to receive one of two interventions . These consisted of ( 1 ) the orthopaedic surgeon ordering a bone mineral density examination and forwarding the results to the primary care physician or ( 2 ) the orthopaedic surgeon sending a letter to the primary care physician outlining guidelines for osteoporosis screening . Patients were contacted at six months after the fracture to determine the rates of evaluation and treatment for osteoporosis . RESULTS The first part of the study revealed that , following a distal radial fracture , 21.3 % of 240 patients had a bone mineral density examination and 78.7 % were never screened . Osteopenia was the most common diagnosis among those screened ( 57 % ) . Most ( 72.5 % ) of the 240 patients received no medication , whereas 6.7 % received calcium and vitamin D ; 11.3 % , bisphosphonates ; 2.5 % , hormone replacement therapy ; and 7.1 % , a combination regimen . The treatment rate for the patients who had undergone a bone mineral density examination was 2.5-fold higher than the rate for those who had not had bone mineral density testing ( 53 % compared with 21 % , p < 0.001 ) . In the second part of the study , the patients r and omized to Intervention 1 had two to threefold greater rates of bone mineral density testing ( 93 % compared with 30 % , p < 0.001 ) , discussion of osteoporosis with their primary care physician ( 89 % compared with 35 % , p < 0.001 ) , and initiation of osteoporosis therapy ( 74 % compared with 26 % , p < 0.001 ) compared with patients r and omized to Intervention 2 . CONCLUSIONS Rates of evaluation and treatment for osteoporosis after fragility fractures remain low ( 21.3 % and 27.5 % , respectively ) . Patients who undergo a bone mineral density examination are more likely to receive treatment . Ordering a bone mineral density examination in the orthopaedic clinic can dramatically improve osteoporosis evaluation and treatment rates following fragility fractures of the distal part of the radius OBJECTIVE To evaluate the effects of a short interactive training program for general practitioners ( GP ) on pain management in patients with osteoarthritis ( OA ) . METHODS A multicenter , parallel-group study . GP were r and omized to receive training on relationships and communication , pain evaluation , prescription , and negotiation of a patient contract or to a control group receiving a presentation about obtaining consent in trials . Outcomes were patient assessment s of pain and functional ability . We invited 1500 GP to take part in the study . Those who volunteered to receive the training recruited out patients from May 2001 to April 2002 . Patients participating in the evaluation of the effects of the general practitioners ' training had lower limb OA and pain on motion [ > or = 40 mm on a visual analog scale ( VAS ) ] and had indications for treatment with acetaminophen . The primary endpoint : sum of patient pain relief based on the daily VAS self-evaluation during the 2 weeks of the trial . RESULTS In total , 180 GP ( 84 trained , 96 nontrained ) enrolled 842 patients ( 414 and 428 , respectively ) . Mean baseline VAS pain was 63 + /- 14 mm . Patients in the trained-GP group had better overall pain relief ( 316 + /- 290 mm/day vs 265 + /- 243 mm ; p < 0.0001 ) , greater improvement in Lequesne and WOMAC scores ( p < 0.0001 ) , and better overall perception of treatment ( p = 0.002 ) .  Acetaminophen use was slightly higher in the trained group ; however , the difference in pain relief remained statistically significant ( p = 0.0003 ) after adjustment for this difference . CONCLUSION This is the first study to demonstrate a positive effect of physician training on patients with a painful condition Summary This study assessed whether osteoporosis diagnosis and treatment after an osteoporotic fracture  can be increased by providing osteoporosis reading material to patients and family doctors or by watching a videocassette about osteoporosis . Educating patients about osteoporosis had little impact on whether a woman received an osteoporosis diagnosis or treatment . Introduction The purpose of this study was to investigate the impact of two education-based interventions on osteoporosis diagnosis and treatment in women ≥50 years of age after fragility fracture . Methods Six to eight months after fracture , women were r and omized into three groups : ( 1 ) control , ( 2 ) written material s , or ( 3 ) videocassette and written material s. Written material s for both the patient and physician detailed osteoporosis , fragility fracture , and available treatments ; written material s for physicians were provided through patients . The educational videocassette presented similar information as the written material , but in greater depth . Rates of osteoporosis diagnosis and treatment following intervention were compared among groups using survival analysis methods . Statistical significance was set at p < 0.0167 . Results At r and omization , 1,174 women were without osteoporosis diagnosis and treatment , and after follow-up , 12 % of the control group , 15 % of the written material s group ( p = 0.073 ) , and 16 % ( p = 0.036 ) of the videocassette and written material s group were diagnosed with osteoporosis ( statistical comparisons to control ) . Treatment rates were 8 % for the control group , 12 % for the written material s group ( p = 0.052 ) , and 11 % for the videocassette and written material s group ( p = 0.157 ) . At r and omization , 1,314 women were without treatment and after follow-up therapy was initiated in 10 % of the control group , 13 % of the written material s group ( p = 0.107 ) , and 13 % of the videocassette and written material s group ( p = 0.238 ) . Conclusions The educational interventions assessed in this trial were not satisfactory to increase osteoporosis diagnosis or treatment in recently fractured women to a clinical ly meaningful degree BACKGROUND Radiological tests are often used by general practitioners ( GPs ) . These tests can be overused and contribute little to clinical management . We aim ed to assess two methods of reducing GP requests for radiological tests in accordance with the UK Royal College of Radiologists ' guidelines on lumbar spine and knee radiographs . METHODS We assessed audit and feedback , and educational reminder messages in six radiology departments and 244 general practice s that they served . The study was a before- and -after , pragmatic , cluster r and omised controlled trial with a 232 factorial design . A r and om subset of GP patients ' records were examined for concordance with the guidelines . The main outcome measure was number of radiograph requests per 1000 patients per year . Analysis was by intention to treat . FINDINGS The effect of  educational reminder messages  ( ie , the change in request rate after intervention ) was an absolute change of -1.53 ( 95 % CI -2.5 to -0.57 ) for lumbar spine and of -1.61 ( -2.6 to -0.62 ) for knee radiographs , both relative reductions of about 20 % . The effect of audit and feedback  was an absolute change of -0.07 ( -1.3 to 0.9 ) for lumbar spine of 0.04 ( -0.95 to 1.03 ) for knee radiograph requests , both relative reductions of about 1 % . Concordance between groups did not differ significantly . INTERPRETATION 6-monthly feedback of audit data is ineffective but the routine attachment of educational reminder messages to radiographs is effective and does not affect quality of referrals . Any department of radiology that h and les referrals from primary care could deliver this intervention to good effect Objectives : To identify the effect of a complex intervention ( educational outreach visits by pharmacists ) design ed to change general practitioners ' ( GPs ' ) prescribing on each step of a hypothesised pathway of change leading to the final primary trial outcome of change in prescribing . Method : The study was undertaken in six health authorities in the North of Engl and and six in London . We described three steps leading to this outcome : the general practice s agreeing to participate ; GPs in each practice attending the outreach visit conducted by the pharmacists ; and the GPs ' prescribing practice being influenced by these visits . The outcomes of each step were assessed using a combination of quantitative and qualitative methods . Results : Of the 102 practice s r and omly selected , 75 ( 73.5 % ) agreed to participate . The odds of all the doctors attending the outreach meeting  in small practice s ( i.e. 1 - 2 partners ) was 6.7 ( 95 % CI : 4.4 - 23.5 ) compared with other practice s ( i.e. > 3 partners ) . Although the pharmacists reported that they had established a good rapport at 100 ( 72 % ) first visits and had agreed management plans for 110 ( 79 % ) of these visits , they were confident that the practice was likely to alter its prescribing in only 41 % of these visits . Pharmacists ' and GPs ' satisfaction with the outreach visits did not necessarily lead to prescribing changes after the practice visit , and the GPs ' knowledge of the guidelines promoted by the pharmacists did not necessarily translate into changes in clinical practice . The main barriers to the implementation of guidelines identified by the pharmacists at the follow-up visits were organisational difficulties , the GPs ' scepticism of the evidence presented to them and the doctors ' lack of interest in changing their prescribing behaviour . Conclusions : Although our study is limited by a post hoc rather than a pre hoc design , it provides a pragmatic approach to underst and ing the factors influencing the pathway of change in prescribing behaviour in response to academic outreach visits OBJECTIVES Osteoporosis treatment rates after a fracture are low . This study evaluated methods to increase guideline -recommended osteoporosis care postfracture . DESIGN Participants were r and omly assigned to  usual care or one of two interventions . Analysis of primary outcomes used electronic data and linear regression . SETTING A Pacific Northwest nonprofit health maintenance organization . PARTICIPANTS Female patients aged 50 to 89 who suffered a fracture in 1999 and had not received bone mineral density ( BMD ) measurement or medication for osteoporosis ( n=311 ) and their primary care providers ( n=159 ) . INTERVENTION Patient-specific clinical guideline advice to the primary care provider delivered by electronic medical record ( EMR ) message or electronic reminder to the provider plus an educational letter mailed to the patient . MEASUREMENTS BMD measurement and osteoporosis medication . RESULTS At 6 months , provider reminder result ed in 51.5 % of patients receiving BMD measurement or osteoporosis medication , provider reminder plus patient education result ed in 43.1 % , and usual care result ed in 5.9 % ( P<.001 ) . The effect of provider advice combined with patient education was not significantly different from provider advice alone ( P=.88 ) . Patients aged 60 to 69 were 18 % ( 95 % confidence interval=3 - 34 ) more likely to receive BMD measurement or an osteoporosis medication than those aged 80 to 89 . CONCLUSION Patient-specific postfracture advice to the provider through an EMR message significantly increased BMD measurement and osteoporosis medication . As EMRs become more widespread , this intervention could improve osteoporosis management for many postfracture patients . Future research should identify barriers to and facilitators of care for older , high-risk patients Optimal information that should be included in ultrasound ( US ) heel bone mineral density ( BMD ) reports is not known . If additional information about further evaluation of patients with low heel BMD  were included in reports , would responses for treatment improve ? We screened people at health fairs using the Sahara heel US machine . For those with a T-score of < /= 1.0 , letters were sent to their primary care physician notifying them of the result . Physicians were r and omly assigned to ( 1 ) a st and ard letter , which recommended central bone density screening ( dual X-ray absorptiometry [ DXA ] ) and treatment if the BMD was low ; or ( 2 ) an extended letter , which also outlined treatment strategies based on recommended subsequent central DXA scan results for a T-score of < 1.50 and also if < 2.00 . The extended letter only increased the frequency of DXA testing from 30.1 to 37.2 % ( not a significant increase ) . Of 88 people with heel BMD < /= 1.00 and not previously on any treatment , 25 of 45 ( 56 % ) were treated ( calcium , estrogens , bisphosphonates , or calcitonin or a combination ) after physicians received a st and ard letter and 30 of 43 ( 70 % ) after an extended letter ( one-sided p = 0.084 ) . Of people with T < /= 1.9 , and initially taking nothing more than calcium , 5 of 36 ( 13.9 % ) received additional treatment after physicians received a st and ard letter vs 9 of 41 ( 22.0 % ) after an extended letter ( one-sided p = 0.180 ) . For those with T < /= 1.0 because of the screen 25 of 197 ( 12.7 % ) received additional treatment . One hundred forty-six of 194 ( 75 % ) individuals and received treatment with calcium or other medications , and 74 of 173 ( 43 % ) of individuals before screening and 141 of 195 ( 72 % ) after physicians received letters took calcium . Physicians regarded calcium alone as adequate treatment in many cases . There was no marked increase in treatment when additional information was provided to physicians regarding evaluation and treatment for low US heel BMD results Study Design . Cluster r and omized controlled trial for a multifaceted implementation strategy . Objectives . To assess the effectiveness of tailored  interventions ( multifaceted implementation strategy ) to implement the  Dutch low back pain guideline for general practitioners with regard to adherence to guideline recommendations . Summary of Background Data . Guidelines for the management of low back pain in primary care have been developed in various countries , but little is known about the optimal implementation strategy . A multifaceted implementation strategy was developed to overcome identified barriers to the implementation of the Dutch low back pain guideline for general practitioners . Methods . General practitioners were r and omized to an intervention or a control group . The general practitioners in the intervention group ( n = 21 ) received tailored interventions consisting of the Dutch low back pain guideline for general practitioners , a 2-hour educational and clinical practice workshop ; two scientific articles on low back pain management ; the guideline for occupational physicians ; a tool for patient education ; and a tool for reaching agreement on low back care with physical , exercise , and manual therapists . The control group ( n = 20 ) received no intervention . The participating general practitioners were asked to recruit consecutive patients with a new episode of low back pain as the main reason for consultation . General practitioners completed registration forms of each individual consultation with regard to the main outcome measures : advice and information , referral to other health-care providers , and prescription of medication . Results . Forty-one of the 67 r and omized general practitioners reported on a total of 616 consultations for 531 patients with nonspecific low back pain . The advice and explanation provided by the general practitioners , the prescription of paracetamol or nonsteroidal anti-inflammatory drugs , and prescription of pain medication on atime contingent or a pain contingent basis showed no statistically significant differences between the intervention and control groups . There were also no differences in overall referral rate . However , in follow-up consultations fewer patients were referred to a physical or exercise therapist by the general practitioners in the intervention group than in the control group . Conclusions . The multifaceted intervention strategy modestly improved implementation ( for parts of the recommendations in ) the Dutch low back pain guideline by general practitioners and produced small concomitant changes in patient management . The implementation strategy produced fewer referrals to therapists during follow-up consultations OBJECTIVE Musculoskeletal disorders ( MSD ) are a leading cause of morbidity in the population , yet their prominence seems to be insufficiently appreciated . We describe the ranking compared with other major body systems of the prevalence of MSD , including arthritis and rheumatism , and back/neck disorders , as a cause of chronic health problems , longterm disability , restricted activity days , consultation with health professionals , and use of both prescription and nonprescription drugs . METHODS We analyzed data from the 1990 Ontario Health Survey , a stratified r and om sample of the household dwelling population in Ontario , based on 45,650 individuals aged 16 years and over . RESULTS MSD ranked first in prevalence as the cause of chronic health problems , longterm disabilities , and consultations with a health professional and ranked 2nd for restricted activity days and use of both prescription and nonprescription drugs . No other body systems ranked invariably within the top 2 ranks for the morbidity indices examined . Even when compared to other major disease groups , arthritis and rheumatism ranked consistently in the top 3 and back/neck disorders also ranked high . MSD were mentioned as a reason for 40 % of all chronic conditions , 54 % of all longterm disability , 24 % of restricted activity days and almost 20 % of health care utilization . The impact of MSD was even greater in the 65 and over age group . CONCLUSIONS MSD have a major role in the health profile of the population . This high burden of illness should be considered in planning health care services and setting research priorities Summary In a cluster r and omized trial , we evaluated the effect of a multifaceted intervention ( directed at both patient and primary care physician ) on the rates of testing and treatment of osteoporosis  in postmenopausal women within six months of their wrist fracture . Compared to usual care , women in the intervention practice s were three times more likely to receive bone mineral density testing and prescribed osteoporosis treatments . Introduction Postmenopausal women with wrist fractures are at increased risk of future fragility fractures , yet they frequently do not receive evaluation and treatment for osteoporosis . We set out to evaluate a multifaceted intervention design ed to improve management of osteoporosis in older women with recent wrist fractures . Methods Cluster r and omized trial of 270 women cared for in 119 primary care practice s. We recruited postmenopausal women with an acute wrist fracture from the emergency departments of hospitals in southeastern Ontario , Canada . Family practice s were r and omly assigned to either the intervention or usual care . The intervention consisted of a mailed reminder with a summary of treatment guidelines and letter sent to the primary care physician , in addition to an educational package and letter to the women . The primary outcome was the proportion of women prescribed osteoporosis therapy within 6 months of their fracture . Results The mean age of women was 69(10.9 ) years . The intervention increased the proportion of women started on osteoporosis medications ( 28 % vs. 10 % ) of controls , adjusted OR 3.45 , 95 % CI , 1.58–7.56 , p = 0.002 ) and the proportion who had a bone mineral density ( BMD ) test ( 53.3 % vs. 26 % ) of controls , OR 3.38 , 95 % CI , 1.83–6.26 , p < 0.001 ) . In addition to the intervention , having a female physician was a predictor of increased testing and treatment rates . Conclusion A multifaceted intervention significantly improved rates of osteoporosis treatment and BMD testing in postmenopausal women with wrist fractures BACKGROUND The Royal College of Radiologists ( RCR ) have produced regularly up date d guidelines on radiological referrals since 1990 . A small study in 1992 showed postal distribution of guidelines reduced general practitioners ' referrals over the subsequent 9 weeks . However there have been no r and omized trials of the longer term effects of radiological guidelines and feedback on referral rates on X-ray requests from primary care . OBJECTIVES To see if the introduction of radiological guidelines into general practice s together with feedback on referral rates reduces the number of GP radiological requests over one year ; and to explore GPs'attitudes to the guidelines . METHODS Sixty-nine practice s referring patients to St George 's Healthcare Trust were r and omly allocated to intervention or control groups . In February 1995 a GP version of the RCR guidelines was sent to each GP in the 33 practice s in the intervention group . After 9 months intervention , practice s were sent revised guidelines with individual feedback on the number of examinations requested in the past 6 months . The total number of requests per practice was compared for the year before and the year after the introduction of the guidelines . Control practice s were sent the guidelines at the end of the study . All doctors were sent a question naire about the guidelines . RESULTS A total of 43 778 radiological requests were made during the two years 1994 - 1996 . In practice s receiving the guidelines there was a 20 % reduction in requests for spinal examinations compared with control practice s ( P < 0.05 ) . This corresponded to the effect reported by GPs . There was also a 10 % difference between the groups in the total number of requests made , but due to wide inter practice variation in referral rates this failed to reach statistical significance . CONCLUSIONS Introduction of radiological guidelines together with feedback on referral rates was effective in reducing the number of requests for spinal examinations over one year . Wider use of GP-orientated guidelines with regular updating and feedback might save costs and reduce unnecessary irradiation of patients PURPOSE We examined whether a continuing medical education intervention increased general practitioners ' ability to select the proper pharmacological treatment for patients with osteoarthritis . SUBJECTS AND METHODS Eight towns in Quebec , Canada were r and omly allocated to one of four intervention options , workshop and decision tree , workshop , decision tree , or no intervention .  All general practitioners practicing in each town were eligible to participate . We evaluated all dispensed prescriptions for either a  cyclooxygenase (COX)-2 inhibitor , nonselective nonsteroidal anti-inflammatory drug or acetaminophen  written by eligible general practitioners between May 2000 and June 2001 to elderly patients suffering from osteoarthritis . We used a multi-level Bayesian hierarchical model to assess the impact of the interventions on prescription adequacy . RESULTS We analyzed 5318 dispensed prescriptions written by 249 general practitioners in the five-month preintervention period and 4610 dispensed prescriptions written by the same physicians in the five-month postintervention period . A score of zero or one was given to every prescription , with one indicating prescription adequacy according to guidelines provided during the interventions . Bayesian hierarchical models showed some improvement in scores in the post- versus preintervention periods in all four groups . The probability of an improvement in the towns allocated the workshop and decision tree over the control was 94 % , compared with 74 % in the workshop group and 55 % in the decision tree group . CONCLUSION An interactive approach offered by peers and complemented by easy to use guidelines may enhance the general practitioner 's ability to manage osteoarthritis patients Study Design . Cluster r and omized controlled trial . Objective . To improve quality of care for patients with low back pain ( LBP ) a multifaceted general practitioner education alone and in combination with motivational counseling by practice nurses  has been implemented in German general practice s. We studied effects on functional capacity ( main outcome ) , days in pain , physical activity , quality of life , or days of sick leave ( secondary outcomes ) compared with no intervention . Summary of Background Data . International research has lead to the development of the German LBP guideline for general practitioners . However , there is still doubt about the most effective implementation strategy . Although effects on process of care have been observed frequently , changes in patient outcomes are rarely seen . Methods . We recruited 1378 patients with LBP in 118 general practice s , which were r and omized to 1 of 3 study arms : a multifaceted guideline implementation ( GI ) , GI plus training of practice nurses in motivational counseling ( MC ) , and the postal dissemination of the guideline ( controls , C ) . Data were collected ( question naires and patient interviews ) at baseline and after 6 and 12 months . Multilevel mixed effects modeling was used to adjust for clustering of data and potential confounders . Results . After 6 months , functional capacity was higher in the intervention groups with a cluster adjusted mean difference of 3.650 between the MC group and controls ( 95 % CI = 0.320–6.979 , P = 0.032 ) and 2.652 between the GI group and controls ( 95 % CI = −0.704 to 6.007 , P = 0.120 ) . Intervention effects were more pronounced regarding days in pain per year with an average reduction of 16 ( GI ) to 17 days ( MC ) after 6 months ( 12 and 9 days after 12 months ) compared with controls . Conclusion . Active implementation of the German LBP guideline results in slightly better outcomes during 6 months follow-up than its postal dissemination . Results are more distinct when practice nurses are trained in motivational counseling A survey of perceptions of continuing education -- content , methods and current provision -- was undertaken among all established general practitioners in one health region of the UK using a postal question naire . Interviews were conducted with a small r and om sample of respondents and with a larger sample of non-respondents to the question naire . Data from the question naire and interviews demonstrated overall a wide diversity of content and methods of continuing education perceived as appropriate , with duration of experience and involvement in undergraduate teaching or postgraduate training as significant determinants . The findings are used to review , critically , current provision of continuing education for general practice and to suggest ways in which future provision might reflect the range of educational need perceived by doctors BACKGROUND Treatment of osteoporosis following a hip fracture has been notoriously poor . Many efforts have been made to improve treatment rates . The purpose of this study was to determine whether a perioperative inpatient intervention program , involving patient education and providing a list of questions for the primary care physician , increased the percentage of patients in whom osteoporosis was addressed following a hip fracture . METHODS A prospect i ve , r and omized trial involving eighty patients who had been admitted to an academic medical center with a low-energy hip fracture was conducted . During their hospitalization , the study group patients were engaged in a fifteen-minute discussion regarding the association between osteoporosis and hip fractures , the efficacy of dual-energy x-ray absorptiometry scans in the diagnosis of osteoporosis and of bisphosphonates in its treatment , and the importance of medical follow-up for osteoporosis management . These patients were also provided with five questions regarding osteoporosis treatment to be given to their primary medical physician , and they were reminded about the questions during a follow-up telephone call six weeks later . The patients in the control group received a brochure describing methods for preventing falls . Both groups were contacted by telephone at six months after discharge to determine whether osteoporosis had been addressed . Positive indicators of intervention included assessment of bone mineral density with dual-energy x-ray absorptiometry and initiation of antiresorptive therapy .  RESULTS The average age in each group was eighty-two years , and 78 % of the patients were female . Four patients in each group did not survive through the six-month follow-up period and were excluded from the trial . Fifteen ( 42 % ) of the thirty-six patients who had been r and omized to the study group , compared with only seven ( 19 % ) of the thirty-six patients in the control group , had their osteoporosis addressed by their primary physician . This difference between the groups was significant ( p = 0.036 ) . CONCLUSIONS Patients who were provided with information and questions for their primary care physician about osteoporosis were more likely to receive appropriate therapeutic intervention than were patients who had not received the information and questions . Orthopaedic surgeons have a unique opportunity to improve the rate of osteoporosis treatment in the perioperative period following a hip fracture by educating patients and directing them toward channels for long-term osteoporosis management BACKGROUND Primary care requests for radiographs of the lumbar spine have come under increasing scrutiny . Guidelines aim ing to reduce unnecessary radiographs by limiting referrals to patients at high risk of serious disease have been widely distributed . Trial evidence suggests that guidelines can reduce radiography referrals . It is not clear whether this reduction has been achieved in routine practice . AIM This study , using routine data , was conducted to measure trends in pnmary care referrals for lumbar spine radiography at two hospitals between 1994 and 1999 . DESIGN OF STUDY Analysis of primary care requests for lumbar spine radiography from computerised records . SETTING Addenbrooke 's Hospital , Cambridge ( 1 July 1994 to 30 June 1999 ) , and Ipswich General Hospital ( 1 July 1995 to 30 June 1999 ) , United Kingdom . METHOD All primary care requests for lumbar radiography were identified electronically from computerised information systems . A r and om sample of 2100 radiography reports were classified according to clinical importance . These classifications were used to examine whether the proportion of radiographs demonstrating potentially more serious findings had increased between 1994 and 1999 . RESULTS There was no evidence that primary care referrals for radiography of the lumbar spine had decreased between 1994 and 1999 at either hospital . General practitioners did not progressively refer more high-risk patients for lumbar radiography . Only a small proportion of patients had important radiographic findings that might warrant specialist referral or specific therapy . CONCLUSION The implementation of diagnostic guidelines offers much to the NHS . However in these two hospitals , the reduction in radiograph utilisation evident in trials was not achieved . Guideline development is a re source intensive process ; distribution must be supported by more effective implementation strategies Background : Older patients who experience a fragility fracture are at high risk of future fractures but are rarely tested or treated for osteoporosis . We developed a multifaceted intervention directed at older patients with wrist fractures ( in the form of telephone-based education )  and their physicians ( in the form of guidelines endorsed by opinion leaders , supported by reminders ) to improve the quality of osteoporosis care . Methods : In a r and omized controlled trial with blinded ascertainment of outcomes , we compared our intervention with usual care ( provision of printed educational material s to patients ) .  Eligible patients were those older than 50 years of age who had experienced a wrist fracture and were seen in emergency departments and fracture clinics ; we excluded those who were already being treated for osteoporosis . The primary outcome was  bisphosphonate treatment within 6 months after the fracture . Secondary outcomes included bone mineral density testing , “ appropriate care ” ( consisting of bone mineral density testing with treatment if bone mass was low ) and quality of life . Results : We screened 795 patients for eligibility and r and omly assigned 272 to the intervention ( 137 patients ) or control ( 135 patients ) group . The median age was 60 years ; 210 ( 77 % ) of the subjects were women , and 130 ( 48 % ) reported a previous fracture as an adult . Six months after the fracture , 30 ( 22 % ) of the intervention patients , as compared with 10 ( 7 % ) of the control patients , were receiving  bisphosphonate therapy  for osteoporosis ( adjusted relative risk [ RR ] 2.6 , 95 % confidence interval [ CI ] 1.3–5.1 , p = 0.008 ) . Intervention patients were more likely than control patients to undergo bone mineral density testing ( 71/137 [ 52 % ] v. 24/135 [ 18 % ] ; adjusted RR 2.8 , 95 % CI 1.9–4.2 , p < 0.001 ) and to receive appropriate care ( 52/137 [ 38 % ] v. 15/135 [ 11 % ] ; adjusted RR 3.1 , 95 % CI 1.8–5.3 , p < 0.001 ) . There were no differences between the groups in other outcomes . One patient died , and 4 others experienced recurrent fracture . Interpretation : A multifaceted intervention directed at high-risk patients and their physicians substantially increased rates of testing and treatment for osteoporosis . Nevertheless , more than half of the patients in the intervention group were not receiving appropriate care 6 months after their fracture , which suggests that additional strategies should be explored . ( Clinical Trials.gov trial register no. NCT00152321 . This article reports a controlled trial to investigate the effectiveness of patient education and a physician alerting system in altering secondary osteoporosis prevention after a low-trauma ( fragility ) wrist fracture and to record the current rate of osteoporosis investigation following such fractures . Fifty-one women and men aged 50 years or older with a low-trauma wrist fracture were identified ( 41 women and 10 men ; mean age [ 95 % CI ] , 71.51 [ 67.31 - 74.81 ] ) . The intervention group received a four-part intervention aim ed at both the patient and the family physician in addition to the usual care for the fracture . The control group only received usual care for the fracture . Data were collected for both groups at six weeks and six months . Results indicate that 92 % of the intervention subjects were investigated for osteoporosis , compared with the usual-care group , in which only 23 % were investigated . Early osteoporosis intervention has the potential to limit disease impact , and h and therapists can play a key role in early identification of osteoporosis OBJECTIVE We assessed primary care clinician-provided guideline -concordant care as documented in patients ' medical records , predictors of documented guideline -concordant care , and its association with pain-related functioning . Patients were participants in a r and omized trial of collaborative care for chronic musculoskeletal pain . The intervention featured patient and primary care clinician education , symptom monitoring and feedback to clinicians by the intervention team . METHODS To assess concordance with the evidence -based treatment guidelines upon which our intervention was based , we developed an 8-item chart review tool , the  Pain Process Checklist ( PPC ) . We then review ed electronic medical records for 365 veteran patients treated by 42 primary care clinicians over 12 months . Intervention status , demographic , and clinical variables were tested as predictors of PPC scores using generalized estimating equations ( GEE ) . GEE was also used to test whether PPC scores predicted treatment response ( ≥30 % decrease in Rol and -Morris Disability Question naire score ) . RESULTS Rates of documented guideline -concordant care varied widely among PPC items , from 94 % of patients having pain addressed to 17 % of patients on opioids having side effects addressed . Intervention status was unrelated to item scores , and PPC-7 totals did not differ significantly between intervention and treatment-as-usual patients ( 61.2 % , st and ard error [ SE ] = 3.3 % vs 55.2 % , SE = 2.6 % , P = 0.15 ) . In a multivariate model , higher PPC-7 scores were associated with receiving a prescription for opioids ( odds ratio [ OR ] = 1.07 , P = 0.007 ) and lower PPC-7 scores with patient age ( 10-year difference OR = 0.97 , P = 0.004 ) . Finally , intervention patients who received quantitative pain and depression assessment s were less likely to respond to treatment ( assessed vs not : 18 % vs 33 % , P = 0.008 , and 13 % vs 28 % , P = 0.001 , respectively ) . CONCLUSIONS As measured by medical record review , additional training and clinician feedback did not increase provision of documented guideline -concordant pain care , and adherence to guidelines by primary care clinicians did not improve clinical outcomes for patients with chronic musculoskeletal pain
target: 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 .
  There is good- quality evidence that a GP alerting system with or without patient-directed education on osteoporosis improves guideline -consistent GP behaviour , result ing 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 .
background: 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 .
  We investigated whether the direction of the targeted behavioural change affects the effectiveness of interventions .