Implementation of the Ottawa ankle rules in France. A multicenter randomized controlled trial
G. R. Auleley, P. Ravaud, B. Giraudeau, L. Kerboull, R. Nizard, P. Massin, C. Garreau de Loubresse, C. Vallee and P. Durieux
Delegation a l'Evaluation Medicale-Direction de la Prospective et de l'Information Medicale, Assistance Publique-Hopitaux de Paris, France. philippe.ravaud@cch.ap-hop-paris.fr
OBJECTIVES: To assess the impact of the implementation of the Ottawa ankle
rules on radiography requests in French hospitals during a 5-month
intervention period and the impact of using posters alone to sustain the
effect of the rules during a 5-month postintervention period. DESIGN:
Multicenter randomized controlled trial preceded and followed by
observational studies of radiological practices. SETTING: The emergency
departments of 5 Paris university teaching hospitals of the Assistance
Publique-Hopitaux de Paris. PATIENTS: A total of 2218, 1911, and 851
patients-all aged 18 years and older-who were seen for acute ankle or
midfoot injuries in emergency departments during preintervention,
intervention, and postintervention periods, respectively. INTERVENTION:
Implementation of the Ottawa ankle rules by emergency department physicians
in the intervention hospitals (using meetings, posters, pocket cards, and
data forms). During the postintervention period, posters alone were used to
sustain the intervention effect. MAIN OUTCOME MEASURE: Percentage of
patients for whom radiography was requested. RESULTS: During the
preintervention period, 98% and 98.5% of patients were referred for
radiography in the intervention and control groups, respectively. During
the intervention period, the mean proportions of patients referred for
radiography by physicians was 78.9% in the intervention group and 99% in
the control group (P=.03). Between preintervention and intervention
periods, a relative reduction of 22.4% (95% confidence interval [CI],
19.8%-24.9%) in radiography requests was observed in the intervention
group, while requests increased by 0.5% (95% CI, 0%-1.4%) in the control
group. During the postintervention period, the proportion of radiography
requests in the intervention hospitals was lower than the proportion
observed in the preintervention period (83.1% vs 98%). CONCLUSIONS:
Implementation of the Ottawa ankle rules significantly reduced radiography
requests in French hospitals. Using a minimal postintervention
implementation strategy, the effect of this intervention decreased but
persisted after it was discontinued.
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