Awareness and use of the Ottawa Ankle and Knee Rules in 5 countries: Can publication alone be enough to change practice?

Study objectives: We evaluate the international diffusion of the Ottawa Ankle and Knee Rules and determine emergency physicians' attitudes toward clinical decision rules in general. Methods: We conducted a cross-sectional, self-administered mail survey of random samples of 500 members each of the American College of Emergency Physicians, Canadian Association of Emergency Physicians, British Association for Accident and Emergency Medicine, Spanish Society for Emergency Medicine, and all members (n=1,350) of the French Speaking Society of Emergency Physicians, France. Main outcome measures were awareness of the Ottawa Ankle and Knee Rules, reported use of these rules, and attitudes toward clinical decision rules in general. Results: A total of 1,769 (57%) emergency physicians responded, with country-specific response rates between 49% (United States and France) and 79% (Canada). More than 69% of physicians in all countries, except Spain, were aware of the Ottawa Ankle Rules. Use of the Ottawa Ankle Rules differed by country with more than 70% of all responding Canadian and United Kingdom physicians reporting frequent use of the rules compared with fewer than one third of US, French, and Spanish physicians. The Ottawa Knee Rule was less well known and less used by physicians in all countries. Most physicians in all countries viewed decision rules as intended to improve the quality of health care (>78%), a convenient source of advice (>67%), and good educational tools (>61%). Of ail physicians, those from the United States held the least positive attitudes toward decision rules. Conclusion: This constitutes the largest international survey of emergency physicians' attitudes toward and use of clinical decision rules. Striking differences were apparent among countries with regard to knowledge and use of decision rules. Despite similar awareness in the United States, Canada, and the United Kingdom, US physicians appeared much less likely to use the Ottawa Ankle Rules. Future research should investigate factors leading to differences in rates of diffusion among countries and address strategies to enhance dissemination and implementation of such rules in the emergency department.