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Abstract：
BACKGROUND: Strategies to enhance clinicians\' adherence to validated imaging decision rules and increase the appropriateness of imaging remain unclear.
OBJECTIVE: To evaluate the effectiveness of various implementation strategies for increasing clinicians\' use of five validated imaging decision rules (Ottawa Ankle Rules, Ottawa Knee Rule, Canadian C-Spine Rule, National Emergency X-Radiography Utilization Study and Canadian Computed Tomography Head Rule).
METHODS: Systematic review.
METHODS: The inclusion criteria were experimental, quasi-experimental study designs comprising randomised controlled trials (RCTs), non-randomised controlled trials, and single-arm trials (i.e. prospective observational studies) of implementation interventions in any care setting. The search encompassed electronic databases up to March 11, 2024, including MEDLINE (via Ovid), CINAHL (via EBSCO), EMBASE (via Ovid), Cochrane CENTRAL, Web of Science, and Scopus. Two reviewers assessed the risk of bias of studies independently using the Cochrane Effective Practice and Organization of Care Group (EPOC) risk of bias tool. The primary outcome was clinicians\' use of decision rules. Secondary outcomes included imaging use (indicated, non-indicated and overall) and knowledge of the rules.
RESULTS: We included 22 studies (5-RCTs, 1-non-RCT and 16-single-arm trials), conducted in emergency care settings in six countries (USA, Canada, UK, Australia, Ireland and France). One RCT suggested that reminders may be effective at increasing clinicians\' use of Ottawa Ankle Rules but may also increase the use of ankle radiography. Two RCTs that combined multiple intervention strategies showed mixed results for ankle imaging and head CT use. One combining educational meetings and materials on Ottawa Ankle Rules reduced ankle injury imaging among ED physicians, while another, with similar efforts plus clinical practice guidelines and reminders for the Canadian CT Head Rule, increased CT imaging for head injuries. For knowledge, one RCT suggested that distributing guidelines had a limited short-term impact but improved clinicians\' long-term knowledge of the Ottawa Ankle Rules.
CONCLUSIONS: Interventions such as pop-up reminders, educational meetings, and posters may improve adherence to the Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian CT Head Rule. Reminders may reduce non-indicated imaging for knee and ankle injuries. The uncertain quality of evidence indicates the need for well-conducted RCTs to establish effectiveness of implementation strategies.
OBJECTIVE: To evaluate the effectiveness of various implementation strategies for increasing clinicians\' use of five validated imaging decision rules (Ottawa Ankle Rules, Ottawa Knee Rule, Canadian C-Spine Rule, National Emergency X-Radiography Utilization Study and Canadian Computed Tomography Head Rule).
METHODS: Systematic review.
METHODS: The inclusion criteria were experimental, quasi-experimental study designs comprising randomised controlled trials (RCTs), non-randomised controlled trials, and single-arm trials (i.e. prospective observational studies) of implementation interventions in any care setting. The search encompassed electronic databases up to March 11, 2024, including MEDLINE (via Ovid), CINAHL (via EBSCO), EMBASE (via Ovid), Cochrane CENTRAL, Web of Science, and Scopus. Two reviewers assessed the risk of bias of studies independently using the Cochrane Effective Practice and Organization of Care Group (EPOC) risk of bias tool. The primary outcome was clinicians\' use of decision rules. Secondary outcomes included imaging use (indicated, non-indicated and overall) and knowledge of the rules.
RESULTS: We included 22 studies (5-RCTs, 1-non-RCT and 16-single-arm trials), conducted in emergency care settings in six countries (USA, Canada, UK, Australia, Ireland and France). One RCT suggested that reminders may be effective at increasing clinicians\' use of Ottawa Ankle Rules but may also increase the use of ankle radiography. Two RCTs that combined multiple intervention strategies showed mixed results for ankle imaging and head CT use. One combining educational meetings and materials on Ottawa Ankle Rules reduced ankle injury imaging among ED physicians, while another, with similar efforts plus clinical practice guidelines and reminders for the Canadian CT Head Rule, increased CT imaging for head injuries. For knowledge, one RCT suggested that distributing guidelines had a limited short-term impact but improved clinicians\' long-term knowledge of the Ottawa Ankle Rules.
CONCLUSIONS: Interventions such as pop-up reminders, educational meetings, and posters may improve adherence to the Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian CT Head Rule. Reminders may reduce non-indicated imaging for knee and ankle injuries. The uncertain quality of evidence indicates the need for well-conducted RCTs to establish effectiveness of implementation strategies.
摘要：
背景：提高临床医生对经过验证的成像决策规则的依从性和提高成像适当性的策略仍不清楚。
目的：为了评估各种实施策略的有效性，以增加临床医生使用五种经过验证的成像决策规则（OttawaAnkleRules，渥太华膝盖规则，加拿大C-脊柱规则,国家紧急X射线照相利用研究和加拿大计算机断层扫描头规则）。
方法：系统评价。
方法：纳入标准是实验性的，准实验研究设计，包括随机对照试验（RCT），非随机对照试验，以及在任何护理环境中实施干预措施的单臂试验(即前瞻性观察性研究)。搜索范围涵盖截至2024年3月11日的电子数据库，包括MEDLINE（通过Ovid），CINAHL（通过EBSCO），EMBASE（通过Ovid），科克伦中部,WebofScience,还有Scopus.两名审阅者使用Cochrane有效实践和护理组织（EPOC）偏倚风险工具独立评估了研究偏倚的风险。主要结果是临床医生使用决策规则。次要结果包括影像学使用（指示，非指示和总体)和规则知识。
结果：我们纳入了22项研究(5-RCT，1个非RCT和16个单臂试验)，在六个国家的紧急护理环境中进行(美国，加拿大,英国,澳大利亚,爱尔兰和法国）。一项RCT表明，提醒可能对增加临床医生使用渥太华踝关节规则有效，但也可能增加踝关节X线摄影的使用。结合多种干预策略的两个RCT在踝关节成像和头部CT使用方面显示出混合的结果。其中一项结合了有关渥太华踝关节规则的教育会议和材料，减少了ED医师的踝关节损伤成像，而另一个,通过类似的努力，加上临床实践指南和加拿大CT头部规则的提醒，增加头部损伤的CT成像。为了知识，一项RCT提示,分发指南的短期影响有限,但提高了临床医生对渥太华踝关节规则的长期认识.
结论：弹出式提醒等干预措施，教育会议,海报可以提高对渥太华脚踝规则的遵守，渥太华膝盖规则，和加拿大CT负责人规则。提醒可能会减少膝盖和脚踝受伤的非指示成像。证据质量的不确定性表明，需要进行良好的RCT来确定实施策略的有效性。
目的：为了评估各种实施策略的有效性，以增加临床医生使用五种经过验证的成像决策规则（OttawaAnkleRules，渥太华膝盖规则，加拿大C-脊柱规则,国家紧急X射线照相利用研究和加拿大计算机断层扫描头规则）。
方法：系统评价。
方法：纳入标准是实验性的，准实验研究设计，包括随机对照试验（RCT），非随机对照试验，以及在任何护理环境中实施干预措施的单臂试验(即前瞻性观察性研究)。搜索范围涵盖截至2024年3月11日的电子数据库，包括MEDLINE（通过Ovid），CINAHL（通过EBSCO），EMBASE（通过Ovid），科克伦中部,WebofScience,还有Scopus.两名审阅者使用Cochrane有效实践和护理组织（EPOC）偏倚风险工具独立评估了研究偏倚的风险。主要结果是临床医生使用决策规则。次要结果包括影像学使用（指示，非指示和总体)和规则知识。
结果：我们纳入了22项研究(5-RCT，1个非RCT和16个单臂试验)，在六个国家的紧急护理环境中进行(美国，加拿大,英国,澳大利亚,爱尔兰和法国）。一项RCT表明，提醒可能对增加临床医生使用渥太华踝关节规则有效，但也可能增加踝关节X线摄影的使用。结合多种干预策略的两个RCT在踝关节成像和头部CT使用方面显示出混合的结果。其中一项结合了有关渥太华踝关节规则的教育会议和材料，减少了ED医师的踝关节损伤成像，而另一个,通过类似的努力，加上临床实践指南和加拿大CT头部规则的提醒，增加头部损伤的CT成像。为了知识，一项RCT提示,分发指南的短期影响有限,但提高了临床医生对渥太华踝关节规则的长期认识.
结论：弹出式提醒等干预措施，教育会议,海报可以提高对渥太华脚踝规则的遵守，渥太华膝盖规则，和加拿大CT负责人规则。提醒可能会减少膝盖和脚踝受伤的非指示成像。证据质量的不确定性表明，需要进行良好的RCT来确定实施策略的有效性。
