BackgroundComputerised clinical decision support (CDS) can potentially better inform decisions, and it can help with the management of information overload. It is perceived to be a key component of a learning health care system. Despite its increasing implementation worldwide, it remains uncertain why the effect of CDS varies and which factors make CDS more effective.ObjectiveTo examine which factors make CDS strategies more effective on a number of outcomes, including adherence to recommended practice, patient outcome measures, economic measures, provider or patient satisfaction, and medical decision quality.MethodsWe identified randomised controlled trials, non-randomised trials, and controlled before-and-after studies that directly compared CDS implementation with a given factor to CDS without that factor by searching CENTRAL, MEDLINE, EMBASE, and CINAHL and checking reference lists of relevant studies. We considered CDS with any objective for any condition in any healthcare setting. We included CDS interventions that were either displayed on screen or provided on paper and that were directed at healthcare professionals or targeted at both professionals and patients. The reviewers screened the potentially relevant studies in duplicate. They extracted data and assessed risk of bias in independent pairs or individually followed by a double check by another reviewer. We summarised results using medians and interquartile ranges and rated our certainty in the evidence using the GRADE system.ResultsWe identified 66 head-to-head trials that we synthesised across 14 comparisons of CDS intervention factors. Providing CDS automatically versus on demand led to large improvements in adherence. Displaying CDS on-screen versus on paper led to moderate improvements and making CDS more versus less patient-specific improved adherence modestly. When CDS interventions were combined with professional-oriented strategies, combined with patient-oriented strategies, or combined with staff-oriented strategies, then adherence improved slightly. Providing CDS to patients slightly increased adherence versus CDS aimed at the healthcare provider only. Making CDS advice more explicit and requiring users to respond to the advice made little or no difference. The CDS intervention factors made little or no difference to patient outcomes. The results for economic outcomes and satisfaction outcomes were sparse.ConclusionMultiple factors may affect the success of CDS interventions. CDS may be more effective when the advice is provided automatically and displayed on-screen and when the suggestions are more patient-specific. CDS interventions combined with other strategies probably also improves adherence. Providing CDS directly to patients may also positively affect adherence. The certainty of the evidence was low to moderate for all factors.Trial registrationPROSPERO, CRD42016033738Electronic supplementary materialThe online version of this article (10.1186/s13012-018-0790-1) contains supplementary material, which is available to authorized users.

ObjectivesThe present study investigated (1) trends in the prevalence and incidence of knee osteoarthritis over a 20-year period (1996–2015); (2) trends in multimorbidity and (3) trends in drug prescriptions.DesignRegistry-based study.SettingPrimary healthcare, Flanders, Belgium.ParticipantsData were collected from Intego, a general practice-based morbidity registration network. In the study period between 1996 and 2015, data from 440 140 unique patients were available.Outcome measuresTrends in prevalence and incidence rate of knee osteoarthritis were computed using joinpoint regression analysis. The mean disease count was calculated to assess trends in multimorbidity. In addition, the number of drug prescriptions was identified by the Anatomical Therapeutic Chemical Classification code and trends were equally recorded with joinpoint regression.ResultsThe total age-standardised prevalence of knee osteoarthritis increased from 2.0% in 1996 to 3.6% in 2015. An upward trend was observed with an average annual percentage change (AAPC) of 2.5 (95% CI 2.2 to 2.9). In 2015, the prevalence rates in the 10 year age groups from the 45–54 years age group onwards were 3.1%, 5.6%, 9.0% and 13.9%, to reach 15.0% in people aged 85 years and older. The incidence remained stable with 3.75‰ in 2015 (AAPC=−0.5, 95% CI −1.4 to 0.5). The mean disease count significantly increased from 1.63 to 2.34 (p<0.001) for incident cases with knee osteoarthritis. Finally, we observed a significantly positive trend in the overall prescription of acetaminophen (AAPC=6.7, 95% CI 5.6 to 7.7), weak opioids (AAPC=4.0, 95% CI 0.9 to 7.3) and glucosamine (AAPC=8.6, 95% CI 2.4 to 15.1). Oral non-steroidal anti-inflammatory drugs were most prescribed, with a prevalence rate of 29.8% in 2015, but remained stable during the study period (AAPC=0.0, 95% CI −1.1 to 1.1).ConclusionsIncreased prevalence, multimorbidity, and number of drug prescriptions confirm an increased burden of knee osteoarthritis. In future, these trends can be used to prioritise initiatives for improvement in care.

This study showed large variations in adherence to quality indicators in OA management by physiotherapists. Improvement strategies should focus on quality indicators related to long-term treatment options.

Rationale, aims and objectives Guidelines for patients with knee osteoarthritis (OA) are suboptimally implemented in clinical care. To improve guideline adherence, patients' perceived barriers and facilitators in current care were investigated.Methods Eleven patients with knee OA were extensively interviewed using a semistructured script based on quality indicators. Directed content analysis, within the framework of Grol and Wensing, was performed to describe barriers and facilitators in 6 domains: guideline, health care professional, patient, social environment, organization, and financial context. Data were analyzed using NVIVO 10 software. ResultsIn total, 38 barriers, at all 6 domains, were identified. The most frequently mentioned barriers were in the domains of the patient and the health care professional, namely, patients' disagreement with guidelines recommendations, negative experience with drugs, patients' limited comprehension of the disease process, and poor communication by the health care professional.The patients' disagreement with recommendations is further explained by the following barriers:"insistence on medical imaging," "fear that physiotherapy aggravates pain," and "perception that knee OA is not a priority health issue". Patients also reported 20 facilitators, all of which are listed as opposing barriers. There is thus a clear need for interventions to improve guideline adherence to obtain optimal care for the patients. However, to allow effective intervention strategies, first qualitative research is needed that addresses possible barriers and facilitators to guideline adherence in current care. 17 To date, barriers and facilitators have mainly been studied from the health care professionals' perspective. 18 However, patients play a crucial role in upgrading care to better guideline adherence as their experiences, preferences, concerns, and care management can substantially influence the decision-making process for optimal knee OA management. Conclusions 19-21Therefore, the aim of this study was to investigate barriers and facilitators in current care of knee OA from the patients' perspective.2 | METHODS | Study designTo identify barriers and facilitators in the management of knee OA, semistructured face-to-face interviews were conducted with patients.The interview script was based on the Belgian set of quality indicators. 16 This study was described in accordance with the consolidated criteria for reporting Qualitative Research (COREQ checklist). 22 | Study populationPatients with knee OA were recruited in 3 different settings: from the interviewers' (JD) general practice population, from the patient population of GP practices in the same region, and finally by an advertisement in the monthly magazine of the national federation for patients with rheumatic diseases. In the GP settings, a search was performed by the GP in the electronic health record to select eligible patients with a diagnosis of knee OA.The inclusion criteria for this study were as follows: (1) clinical and/or ra...

Background Knee osteoarthritis is a common problem, but often underdiagnosed and undertreated in primary care as compared to evidence-based guidelines. Educational outreach visits are an effective strategy to improve guideline adherence, but its contribution to knee osteoarthritis management is largely unknown. The aim of this study was to evaluate the overall effectiveness of educational outreach visits on process quality indicators for knee osteoarthritis management, more specifically on the referral for physical therapy. Methods An educational intervention study, non-randomized and controlled, was designed for general practitioners (GPs) in Belgium. During four months, 426 GPs were visited by academic detailers and allocated to the intervention group. The control group was selected from GPs not visited by academic detailers during the study period. Six months post-intervention, both groups received a questionnaire with two case-vignettes to measure the effectiveness of the educational outreach. Outcomes were assessed with a Belgian set of quality indicators for knee osteoarthritis management and focused on the number of prescriptions for appropriate physical therapy (i.e. muscle strengthening, aerobic, functional or range of motion exercises) and the adherence to eight additional quality indicators related to knee osteoarthritis management. For the analysis, multivariable logistic regression models were used and Generalized Estimating Equations to handle the correlation between the multiple results per GP. Results The intervention group showed a tendency to prescribe more frequently at least one appropriate physical therapy for a case (43.8%), compared to the control group (31.3%, p = 0.057). Muscle strengthening exercises were the most frequently prescribed therapy with 37.0% in the intervention versus 26.9% in the control group. The adherence to the other quality indicators showed no significant difference between the intervention and control group and varied between 8.9 and 100% in the intervention group. Conclusions This intervention did not alter significantly the adherence to quality indicators and in particular the probability of prescribing physical therapy. To change general practitioners’ prescription behavior, more extensive or combined interventional approaches seem warranted. Electronic supplementary material The online version of this article (10.1186/s12909-019-1504-3) contains supplementary material, which is available to authorized users.