Abstract: Thirty studies met our inclusion criteria. From 11 studies on osteoporosis, meta-analysis of five studies (high-certainty evidence) showed that a combination of a GP alerting system on a patient's increased risk of osteoporosis and a patient-directed intervention (including patient education and a reminder to see their GP) improves GP behaviour with regard to diagnostic bone mineral density (BMD) testing and osteoporosis medication prescribing (RR 4.44; (95% confidence interval (CI) 3.54 to 5.55; 3 studies; 3,386 participants)) for BMD and RR 1.71 (95% CI 1.50 to 1.94; 5 studies; 4,223 participants) for osteoporosis medication. Meta-analysis of two studies showed that GP alerting on its own also probably improves osteoporosis guideline-consistent GP behaviour (RR 4.75 (95% CI 3.62 to 6.24; 3,047 participants)) for BMD and RR 1.52 (95% CI 1.26 to 1.84; 3.047 participants) for osteoporosis medication) and that adding the patient-directed component probably does not lead to a greater effect (RR 0.94 (95% CI 0.81 to 1.09; 2,995 participants)) for BMD and RR 0.93 (95% CI 0.79 to 1.10; 2,995 participants) for osteoporosis medication. Of the 10 studies on low back pain, seven showed that guideline dissemination and educational opportunities for GPs may lead to little or no improvement with regard to guideline-consistent GP behaviour. Two studies showed that the combination of guidelines and GP feedback on the total number of investigations requested may have an effect on GP behaviour and result in a slight reduction in the number of tests, while one of these studies showed that the combination of guidelines and GP reminders attached to radiology reports may result in a small but sustained reduction in the number of investigation requests. Of the four studies on osteoarthritis, one study showed that using educationally influential physicians may result in improvement in guideline-consistent GP behaviour. Another study showed slight improvements in patient outcomes (pain control) after training GPs on pain management. Of three studies on shoulder pain, one study reported that there may be little or no improvement in patient outcomes (functional capacity) after GP education on shoulder pain and injection training. Of two studies on other musculoskeletal conditions, one study on pain management showed that there may be worse patient outcomes (pain control) after GP training on the use of validated assessment scales. The 12 remaining studies across all musculoskeletal conditions showed little or no improvement in GP behaviour and patient outcomes. The direction of the targeted behaviour (i.e. increasing or decreasing a behaviour) does not seem to affect the effectiveness of an intervention. The majority of the studies did not investigate the potential adverse effects of the interventions and only three studies included a cost-effectiveness analysis. Overall, there were important methodological limitations in the body of evidence, with just a third of the studies reporting adequate allocation concealment and blinded outcome assessments. While our confidence in the pooled effect estimate of interventions for improving diagnostic testing and medication prescribing in osteoporosis is high, our confidence in the reported effect estimates in the remaining studies is low. There is good-quality evidence that a GP alerting system with or without patient-directed education on osteoporosis improves guideline-consistent GP behaviour, resulting in better diagnosis and treatment rates. Interventions such as GP reminder messages and GP feedback on performance combined with guideline dissemination may lead to small improvements in guideline-consistent GP behaviour with regard to low back pain, while GP education on osteoarthritis pain and the use of educationally influential physicians may lead to slight improvement in patient outcomes and guideline-consistent behaviour respectively. However, further studies are needed to ascertain the effectiveness of such interventions in improving GP behaviour and patient outcomes.

Plain-language summary: Eleven studies evaluated interventions aiming to improve the management of osteoporosis by GPs. Five of these studies were sufficiently similar that we were able to combine their results. Our findings suggest that alerting the GP that a patient is at risk of osteoporosis and educating the patient, reminding them to visit their GP, leads to improved GP behaviour (diagnostic testing and medication prescribing). We determined that the quality or certainty of the evidence from these studies is high, so we are confident in these results. GP alerting on its own is also probably effective according to two studies and adding the patient-directed component probably does not lead to a greater effect. Of the ten studies on low back pain, seven showed that GP education and distribution of guidelines may lead to little or no improvement with regards to GPs' clinical behaviour. Two studies showed that providing GPs with guidelines and information on the total number of tests they request may have an effect on GP behaviour (resulting in a slight reduction in the number of tests). One study showed that using a combination of guidelines and GP reminders attached to test reports may result in a small but sustained reduction in the number of tests. Of the four studies on osteoarthritis, one found that GP behaviour may improve when prominent GPs are recruited to educate their colleagues. A second study showed slight improvements in patient outcomes (pain control) after training GPs on pain management. Of the three studies on shoulder pain, one study showed that there may be little or no improvement in patient outcomes (functional capacity) after GP education on shoulder pain and injection training. Of the two studies on other musculoskeletal conditions, one study on pain management showed worse patient outcomes (pain control) after GP training on the use of tools to measure pain. The 12 remaining studies across all musculoskeletal conditions showed little or no improvement in GP behaviour and patient outcomes. The majority of the studies did not investigate the potential adverse effects of the interventions and only three studies included a cost-effectiveness analysis. The direction of the targeted behaviour (i.e. increasing or decreasing a behaviour) does not seem to affect the effectiveness of an intervention. The certainty of the evidence was high from studies that examined the effectiveness of interventions to improve the management of osteoporosis by GPs, so we are confident in these findings. There were important limitations in how most of the remaining studies were conducted or reported, and we are less certain of the likely effects of these interventions to improve the management of musculoskeletal conditions.