Article

Qualitätsindikatoren für die Versorgung von Patienten mit Rückenschmerzen

Der Schmerz (impact factor: 0.88). 04/2012; 24(3):213-220. DOI:10.1007/s00482-010-0919-x pp.213-220

ABSTRACT HintergrundLumbale Rückenschmerzen sind als epidemiologisch, gesundheitsökonomisch und volkswirtschaftlich bedeutsames Gesundheitsproblem
prädestiniert für Qualitätssicherungsmaßnahmen. Die Kassenärztliche Bundesvereinigung hat im Rahmen des Projekts Ambulante
Qualitätsindikatoren (QI) und Kennzahlen (AQUIK®) 3Vorschläge zur Qualitätsmessung der Versorgung von Rückenschmerzenpatienten
erarbeitet. Ziel dieser Arbeit ist es, diese darzustellen und kritisch zu bewerten

Material und MethodenDie 3 vorgeschlagenen QIs im Bereich Alarmzeichen („red flags“), Bildgebung und Arbeitsunfähigkeitszeiten werden in Bezug
auf ihre Evidenzbasierung, Umsetzbarkeit und Epidemiologie bewertet. Dazu werden die den QIs zugrunde liegenden Leitlinien
und Originalliteratur, sowie Ergebnisse von Surveys und Beobachtungsstudien zur Leitlinienadhärenz bei Rückenschmerzen herangezogen.

ErgebnisseDie AQUIK®-Expertenrunde hat nur Alarmzeichen als umsetzbaren QI beurteilt. Trotz eines 2-stufigen Expertenverfahrens wurden
wichtige Aspekte der Epidemiologie, Operationalisierbarkeit und Verfügbarkeit von Routinedaten nicht ausreichend berücksichtigt,
sodass der Autor bei 2QIs zu einer abweichenden Bewertung kommt. Das „Red-flag-Konzept“ wird als nicht ausreichend validiert
und operationalisierbar für eine Umsetzung als QI bewertet. Bildgebung wird wegen der im internationalen Vergleich extremen
Überversorgung und bereits zur Verfügung stehender Abrechnungsdaten als geeigneter QI eingestuft.

SchlussfolgerungenDie Ableitung valider und praktikabler QIs aus den Rückenschmerzleitlinien für die Versorgung ist schwierig. Die Kernaussagen
sind nur leitende Empfehlungen, die kaum präzise zu operationalisieren und auf die Situation individueller Patienten übertragbar
sind. Pragmatische Zielbereiche, definiert als Mindest- oder Höchstanteil von Patienten, die eine bestimmte Leistung erhalten,
sind aufwendigen und komplizierten Einzelfallbewertungen vorzuziehen. Diese können, basierend auf versorgungsepidemiologischen
Daten, definiert werden. Wegen dieser Unschärfe sollte der Nutzen von QIs in Feldstudien gesichert sein, bevor sie zur Steuerung
der Versorgung eingesetzt werden.

IntroductionLow back pain (LBP) is an epidemiologically and economically relevant health care problem appropriate for quality assurance
approaches. Therefore an expert panel (AQUIK) of the National Association of Statutory Health Insurance Physicians has proposed
three quality indicators (QI) for monitoring the quality of ambulatory care for LBP. The aim of this article is to present
and evaluate the proposed QIs.

Material and methodsThe three proposed QIs relating to red flags, imaging and sick leave certificates were evaluated with regard to the underpinning
evidence, epidemiology and feasibility. Guidelines and original research as well results from surveys and observational studies
evaluating adherence to LBP guidelines were used for assessment.

ResultsThe expert panel concluded that only the recording of red flags is a relevant and feasible QI. Despite a two-stage expert
method the epidemiology of LBP, feasibility and existing routine health care data were not sufficiently taken into account.
The author’s conclusion differs in two instances. The red flag concept is not sufficiently clinically validated and recordable
to be used as a QI. Otherwise imaging is considered a suitable QI given the observed overuse and the availability of billing
data.

ConclusionDeriving valid and pragmatic QI from LBP guidelines for evaluating care for LBP is difficult. The core messages of guidelines
are only recommendations with limited precision and transferability to individual patients. For pragmatic reasons definition
of an upper or lower proportion of patients receiving a given health care service is recommended instead of tedious individual
evaluation. Reasonable estimates can be based on data from research on health care services. Because of this uncertainty QIs
should be evaluated before they are used as a steering instrument.

SchlüsselwörterQualitätsindikatoren-Rückenschmerzen-Leitlinien-Epidemiologie
KeywordsQuality indicators-Low back pain-Guidelines-Epidemiology

0 0
 · 
0 Bookmarks
 · 
36 Views
  • Source
    Article: Screening for malignancy in low back pain patients: a systematic review.
    Nicholas Henschke, Christopher G Maher, Kathryn M Refshauge
    [show abstract] [hide abstract]
    ABSTRACT: To describe the accuracy of clinical features and tests used to screen for malignancy in patients with low back pain. A systematic review was performed on all available records on MEDLINE, EMBASE, and CINAHL electronic databases. Studies were considered eligible if they investigated a cohort of low back pain patients, used an appropriate reference standard, and reported sufficient data on the diagnostic accuracy of tests. Two authors independently assessed methodological quality and extracted data to calculate positive (LR+) and negative (LR-) likelihood ratios. Six studies evaluating 22 different clinical features and tests were identified. The prevalence of malignancy ranged from 0.1 to 3.5%. A previous history of cancer (LR+ = 23.7), elevated ESR (LR+ = 18.0), reduced hematocrit (LR+ = 18.2), and overall clinician judgement (LR+ = 12.1) increased the probability of malignancy when present. A combination of age > or =50 years, a previous history of cancer, unexplained weight loss, and failure to improve after 1 month had a reported sensitivity of 100%. Overall, there was poor reporting of methodological quality items, and very few studies were performed in community primary care settings. Malignancy is rare as a cause of low back pain. The most useful features and tests are a previous history of cancer, elevated ESR, reduced hematocrit, and clinician judgement.
    European Spine Journal 10/2007; 16(10):1673-9. · 1.97 Impact Factor
  • Source
    Article: A systematic review identifies five "red flags" to screen for vertebral fracture in patients with low back pain.
    Nicholas Henschke, Christopher G Maher, Kathryn M Refshauge
    [show abstract] [hide abstract]
    ABSTRACT: To determine the accuracy of clinical features in diagnosing vertebral fracture in low back pain patients and assess the psychometric properties of the Quality Assessment of Studies of Diagnostic Accuracy Included in Systematic Reviews (QUADAS) scale. A diagnostic systematic review was performed on all available records in MEDLINE, CINAHL, and EMBASE. Studies were considered eligible if they investigated clinical features associated with vertebral fracture in a cohort of low back pain patients. All eligible studies were assessed for methodological quality using the QUADAS scale, and two authors extracted true-positive, true-negative, false-positive, and false-negative data for each clinical feature. Twelve studies were identified by the review, investigating 51 clinical features. Five clinical features were useful to raise or lower the probability of vertebral fracture: age>50 years (likelihood ratio [LR]+=2.2, LR-=0.34), female gender (LR+=2.3, LR-=0.67), major trauma (LR+=12.8, LR-=0.37), pain and tenderness (LR+=6.7, LR-=0.44), and a distracting painful injury (LR+=1.7, LR-=0.78). The QUADAS had low internal consistency, and only three items had high inter-rater reliability. There was inadequate reporting of many methodological quality items. Five clinical features were identified that can be used to screen for vertebral fracture. The psychometric properties of the QUADAS scale raise concerns about its use to rate the quality of low back pain diagnosis studies.
    Journal of Clinical Epidemiology 02/2008; 61(2):110-118. · 4.27 Impact Factor
  • Article: Utilization of medical services for the treatment of acute low back pain: conformance with clinical guidelines.
    W S Schroth, J M Schectman, E G Elinsky, J C Panagides
    [show abstract] [hide abstract]
    ABSTRACT: To assess the utilization of diagnostic and therapeutic medical services for the management of acute low back pain in a primary care setting, and to determine whether such utilization conforms to suggested guidelines for the management of this condition. A retrospective chart audit of consecutive cases of acute low back pain. Specific elements of the diagnostic and therapeutic approach were judged appropriate or inappropriate based on comparison with published recommendations supported by the medical literature. The primary care adult practice of a university-affiliated health maintenance organization. One hundred eighty-three patients presenting with acute low back pain of musculoskeletal origin. According to suggested guidelines for the care of acute low back pain, 26% of plain lumbar x-rays (10/38), 66% of computed tomography (CT) and magnetic resonance imaging (MRI) scans (12/18), and 82% (23/28) of subspecialty referrals were categorized as inappropriate. Among patients without indications for these services, 12% (10/85) had received lumbar x-rays, 7% (12/168) had received lumbar MRI or CT scans, and 14% (23/168) had received subspecialty referrals. Underutilization of these services had occurred in 71% (70/98) of patients with an indication for plain lumbar radiography, and 47% (7/15) of patients with potential indications for surgical referral or CT/MRI scanning. Neither overutilization nor underutilization had led to adverse outcomes or delays in diagnosis in this small sample. According to guidelines from the medical literature, the primary care physicians in this study both overutilized and underutilized diagnostic and referral services in cases of acute low back pain. It is necessary to determine whether underutilization of plain lumbar radiography adversely affects diagnostic accuracy and whether overutilization of other services improves important clinical outcomes, given the generally benign natural history of this condition.
    Journal of General Internal Medicine 7(5):486-91. · 2.83 Impact Factor

Show more

Data provided are for informational purposes only. Although carefully collected, accuracy cannot be guaranteed. The impact factor represents a rough estimation of the journal's impact factor and does not reflect the actual current impact factor. Publisher conditions are provided by RoMEO. Differing provisions from the publisher's actual policy or licence agreement may be applicable.

Full-text

View
1 Download
Available from

Keywords

Bildgebung und Arbeitsunfähigkeitszeiten werden
 
Dazu werden
 
definiert als Mindest- oder Höchstanteil von Patienten
 
eine bestimmte Leistung erhalten
 
ErgebnisseDie AQUIK®-Expertenrunde hat nur Alarmzeichen als umsetzbaren QI beurteilt
 
Feldstudien gesichert sein
 
given health care service
 
health care services
 
HintergrundLumbale Rückenschmerzen sind als epidemiologisch
 
observational studies
 
pragmatic reasons definition
 
red flag concept
 
red flags
 
relevant health care problem appropriate
 
routine health care data
 
sind aufwendigen und komplizierten Einzelfallbewertungen vorzuziehen
 
Statutory Health Insurance Physicians
 
Umsetzbarkeit und Epidemiologie bewertet
 
Ziel dieser Arbeit ist es
 
„red flags“
 

J.F. Chenot