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Utilisation de l'imagerie par résonance magnétique en présence de douleurs musculosquelettiques chez les personnes adultes du Québec: Stratégies et outils favorisant une utilisation optimale de l'IRM / Use of magnetic resonance imaging in the presence of musculoskeletal pain in adults in Quebec: Strategies and tools for optimal use of MRI
Québec; INESSS; 2016. tab.
Monography in French | BRISA/RedTESA, BRISA/RedTESA | ID: biblio-849525
Responsible library: BR1.1
ABSTRACT

INTRODUCTION:

La douleur d'origine musculosquelettique (DMS) est un problème de santé très commun qui englobe une vaste gamme d'affections touchant les os, les ligaments, les tendons, les muscles et les articulations. Ces douleurs parfois importantes peuvent restreindre le fonctionnement physique et porter significativement atteinte à la qualité de vie. Les causes des DMS sont multiples. L'imagerie médicale est souvent utilisée parmi les différents examens médicaux pour investiguer la cause de ces douleurs. L'imagerie par résonance magnétique (IRM) est indiquée et constitue l'instrument de choix dans plusieurs situations cliniques lors de DMS. On attribue à cet outil diagnostique de plus en plus d'indications cliniques validées par des données probantes. De plus, l'IRM remplace parfois des interventions plus effractives et plus coûteuses. Toutefois, au regard des constats découlant de diverses publications scientifiques, il existe actuellement une controverse quant à une possible surutilisation de l'IRM lors du diagnostic et du suivi des patients souffrant de DMS. La situation québécoise en
ABSTRACT

INTRODUCTION:

La douleur d'origine musculosquelettique (DMS) est un problème de santé très commun qui englobe une vaste gamme d'affections touchant les os, les ligaments, les tendons, les muscles et les articulations. Ces douleurs parfois importantes peuvent restreindre le fonctionnement physique et porter significativement atteinte à la qualité de vie. Les causes des DMS sont multiples. L'imagerie médicale est souvent utilisée parmi les différents examens médicaux pour investiguer la cause de ces douleurs. L'imagerie par résonance magnétique (IRM) est indiquée et constitue l'instrument de choix dans plusieurs situations cliniques lors de DMS. On attribue à cet outil diagnostique de plus en plus d'indications cliniques validées par des données probantes. De plus, l'IRM remplace parfois des interventions plus effractives et plus coûteuses. Toutefois, au regard des constats découlant de diverses publications scientifiques, il existe actuellement une controverse quant à une possible surutilisation de l'IRM lors du diagnostic et du suivi des patients souffrant de DMS. La situation québécoise en la matière n'est pas connue. C'est dans ce contexte que le ministère de la Santé et des Services sociaux (MSSS) a mandaté l'Institut national d'excellence en santé et en services sociaux (INESSS) pour qu'il documente cette problématique et formule des recommandations afin d'optimiser l'utilisation de l'IRM dans les cas de DMS. Pour éclairer les décideurs et les cliniciens sur cette question, l'INESSS publie un avis en trois volets i. Un portrait de l'utilisation globale de l'IRM, au Québec, et une analyse comparative avec les provinces canadiennes et autres pays ou territoires similaires; ii. Une synthèse des lignes directrices relatives aux demandes d'IRM lors de DMS; iii. Une revue des stratégies et outils pour favoriser une utilisation optimale de l'IRM. MÉTHODE Chaque volet utilise une méthode qui lui est propre pour repérer et analyser les données probantes et contextuelles. Ces analyses et revues (systématiques ou narratives) sont réalisées selon les normes de pratique édictées. Les méthodologies respectives à chacun des volets sont décrites en détail dans les documents associés. Des représentants des parties prenantes (Comité de suivi) et des experts (Comité consultatif) ont accompagné l'INESSS à différentes étapes de la production scientifique. L'équipe de projet de l'INESSS, accompagnée par le Comité consultatif, a élaboré les recommandations qui ont été ensuite soumises pour avis au Comité de suivi. Puis, le rapport préliminaire des résultats a été envoyé en révision scientifique externe.

RESULTS:

A review of systematic reviews and health technology assessment (HTA) reports was conducted to identify effective tools and strategies to promote appropriate imaging. The information was supplemented by a brief review of the grey literature from comparable jurisdictions to identify initiatives of interest. Among the organizational strategies evaluated, computerized physician order entry (CPOE) shows a moderate level of evidence in the imaging literature. It can be effective in influencing the appropriateness and volume of imaging orders, especially when certain implementation conditions are present CPOE in an integrated-care system, CPOE with integrated clinical decision support, and audit and feedback in the implementation of these tools. Clinical decision support tools, such as appropriateness criteria reminders on a standardized order form, are promising. The implementation strategy depends, among other things, on the clinical setting (hospital or ambulatory) and its level of computerization. Another organizational strategy identified is the creation of interdisciplinary MSP teams to support primary care physicians. Their role is to triage cases requiring a consultation or specialized examinations, to quickly perform a clinical evaluation of the patient's musculoskeletal system, to facilitate access to effective treatments, and to improve efficiency (including access to advanced imaging). The United Kingdom has built on these teams in its health -care system. They include health professionals with advanced training in MSP (physiotherapists, occupational therapists, primary care physicians with an interest in MSP, and others). These teams have been presented in the literature as a promising avenue for accessing timely and appropriate care and, indirectly, for appropriate imaging, and this strategy should be explored in greater depth. Financial and governance strategies are mainly illustrated by initiatives in Australia, Ontario and the United States. Financial strategies in the United States and Ontario have been implemented to limit coverage for certain examinations or the fees paid for them. Ontario uses a multifaceted intervention for low back pain that combines the aspect of differentiated remuneration, training for professionals and access to interdisciplinary teams. The impact of this project is being assessed. In the United States, the legal framework and the accreditation of imaging clinics are used to guide referral practice ethics. The objective of the Australian initiative in the area of governance was three-fold an increase in private imaging resources accredited for coverage by the public plan, a reevaluation of fees to prevent an incentive effect, and more stringent requirements with regard to examination appropriateness and to quality and safety criteria. During the midpoint evaluation, the initiatives aimed at improving imaging order appropriateness proved more difficult to implement than expected and had not yielded the desired efficiency gains, while at the same time, there had been a large increase in the number of examinations due to the opening up of coverage in private-sector imaging. Implementation strategies aimed at health professionals, such as audit and feedback and educational materials as isolated interventions, have not been shown to be statistically effective in the case of imaging, but they could have a clinically significant impact in multifaceted interventions. Medical education initiatives aimed at equipping physicians to field patient requests have not been found to have an impact on imaging utilization, but initiatives for training physicians to view differently the role of imaging in evaluating a patient are underway and should be followed. In the studies consulted, implementation strategies aimed at patients (media campaign) have not been shown to have a meaningful effect on behaviours in the medium term. Strategies aimed at better informing patients and including them in the approach to ensure appropriateness should be explored. In the diagnostic area of interest here, the literature supports the implementation of tailored strategies in health-care facilities, and there are several promising avenues reminders, CPOE and interdisciplinary MSP teams.

CONCLUSION:

The overview of the use of MRI in MSP in Québec confirms that its use is growing. A comparison with other jurisdictions shows that this use is not one of the highest and that there is probably room for increased productivity at certain existing facilities. However, there are no data for commenting on the appropriateness of these examinations. For the vast majority of the clinical indications, there is a consensus among the international appropriate use guidelines. Experts in Québec are in agreement with these indications, and clinical tools have been proposed. Of the organizational strategies for optimizing MRI appropriateness, the most promising one is CPOE with clinical decision support. Interdisciplinary MSP teams are an avenue of interest that warrants further evaluation. Financial and governance strategies have been put in place in other jurisdictions, but their impact on the efficiency of MRI in MSP varies. In implementation strategies targeting health professionals, the use of audit and feedback has not had a statistically significant impact on optimizing imaging appropriateness in MSP, but quality improvement initiatives that use audit and feedback are promising. The effectiveness of implementation strategies targeting patients should be monitored in the literature and in the ongoing initiatives in Québec. Since the implementation context is of great importance for the effectiveness of strategies and tools, a gradual implementation approach with results monitoring is recommended for the strategies proposed for Québec. Indicators for monitoring appropriateness do exist, but the feasibility of implementing them in Québec depends on the information systems. These indicators should be developed for Québec, together with CPOE.

RECOMMENDATIONS:

Several ways to optimize MRI appropriateness were raised during the discussion. In light of the available data and the Québec context, INESSS recommends -That the MSSS -Create a standardized MRI order form (with the relevant indications) for musculoskeletal pain for referring physicians; -Pilot and evaluate CPOE with clinical decision support for imaging (ideally, these systems should permit the use of collected data); -Explore the assessment of the appropriateness and feasibility of setting up interdisciplinary MSP teams in a continuum of MSP care. 1) That CISSSs and CIUSSSs -Institute the means to support quality improvement activities with audit and feedback in their clinical facilities on the appropriateness of MRI in MSP. 2) That the medical federations (the FMOQ and FMSQ) and university programs -Set up innovative activities and training and maintenance-of-compet ence tools for musculoskeletal pain in a context of intervention appropriateness.(AU)
Subject(s)
Full text: Available Collection: Tematic databases Health context: 11_ODS3_cobertura_universal / Sustainable Health Agenda for the Americas Health subject: 11_multisectoral_coordination / Goal 6: Information systems for health Database: BRISA/RedTESA Main topic: Magnetic Resonance Spectroscopy / Muscle, Skeletal / Musculoskeletal Pain Type of study: Evaluation study / Practice guideline / Health technology assessment / Prognostic study / Qualitative research Aspects: Ethical aspects / Patient-preference Demographic groups: Adult / Humans Language: French Year: 2016 Document type: Monography

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Full text: Available Collection: Tematic databases Health context: 11_ODS3_cobertura_universal / Sustainable Health Agenda for the Americas Health subject: 11_multisectoral_coordination / Goal 6: Information systems for health Database: BRISA/RedTESA Main topic: Magnetic Resonance Spectroscopy / Muscle, Skeletal / Musculoskeletal Pain Type of study: Evaluation study / Practice guideline / Health technology assessment / Prognostic study / Qualitative research Aspects: Ethical aspects / Patient-preference Demographic groups: Adult / Humans Language: French Year: 2016 Document type: Monography