Découvrez le document de position de WONCA Europe sur l’échographie clinique ciblée en médecine générale

Ce document met en lumière l’importance croissante de l’échographie clinique ciblée (ECC) ou point of care ultrasound (POCUS) en médecine générale et les recommandations clés pour son utilisation efficace.

Le document de position, rédigé par plusieurs généralistes dont Pr. Paul Frappé , président du CMG, au nom du Conseil exécutif de WONCA Europe, met en évidence les avantages de l’ECC en médecine générale. En effet, l’ECC permet de confirmer ou d’exclure des urgences médicales, de diagnostiquer des affections de faible à moyenne complexité et de surveiller les maladies aiguës et chroniques, indépendamment des infrastructures hospitalières. Néanmoins l’ECC présente aussi des limites en absence d’une formation solide avec un sur-risque d’un sur ou sous diagnostic.

Le document met notamment l’accent sur la nécessité d’une formation adéquate et continue en échographie clinique ciblée pendant l’internat des médecins généralistes et les programmes de formation médicale continue. Une formation étape par étape et adaptée au contexte de chaque professionnel de la santé est essentielle pour garantir des résultats de haute qualité et éviter les erreurs de diagnostic. En explorant ce document, vous découvrirez comment l’ECC peut améliorer la confiance des médecins généralistes dans leurs diagnostics, accélérer le début d’un traitement efficace et réduire les références vers les soins de second recours. De plus, l’utilisation de l’ECC peut contribuer à réduire les inégalités de santé en permettant aux médecins généralistes de travailler de manière plus autonome dans des régions rurales, isolées ou sous-équipées.

En bas le document en anglais dans son intégralité :

WONCA Europe Position Paper on the use of Point-of-Care ultrasound (POCUS) in primary care (V4.3)

Author: Dr Sonia Tsukagoshi and Dr Aaron Poppleton, on behalf of WONCA Europe Executive Board
Comments: Professor Shlomo Vinker (Israel), Dr Francois Heritier (Switzerland), Dr Paul Frappé (France), Dr Dr Fabian Dupont (Germany), Dr Peter Sigmund (Austria), Dr Mihai Iacob (Romania), Prof Josep Vilaseca (Spain), Prof Mehmet Ungan (Turkey), Dr Camilla Aakjær Andersen (Denmark), Europrev, EGPRN, POCUS iGP

Statement

Point of care ultrasound (POCUS) has been introduced across a number of medical specialities, with emerging research showing promising results. We anticipate that POCUS will have an increasingly important place for specific indications within primary care over the coming years, supporting general practitioners to meet the health needs of their patient populations. We recommend that all general practitioners receive training in POCUS that is tailored to the needs of their healthcare context. This training should be delivered during general practitioners’ residency and continuing medical education programmes. Where evidence supports the use of POCUS in diagnosis, qualified general practitioners should be appropriately financed for its use in clinics, house calls and community healthcare. We support ongoing efforts to gather evidence for best practice use of POCUS, and to explore the long-term effects of POCUS use on diagnosis within primary care.

Background

POCUS is defined as ‘ultrasonography brought to the patient and performed by the provider in real time’.[1] It is designed to answer a specific clinical question or to perform a specific procedural aim and is not a replacement for a formal ultrasound examination or screening.[1, 2] POCUS has been shown to be useful to rule in or rule out medical emergencies, diagnose conditions of low to moderate complexity, and to monitoring acute and chronic illnesses independent of hospital infrastructures.[2-7] Effective use of POCUS has been demonstrated in numerous clinical specialities for a wide range of indications, including those relating to internal organs, such as the heart, lungs, and kidneys, musculoskeletal and vascular conditions, and pregnancy.[3, 4, 8-12] Exposure to and popularity of POCUS during undergraduate medical training has increased over the past decade.[13, 14]

Use of POCUS has been increasing in primary care,[5, 14] with a strong interest among residents in family medicine to incorporate POCUS training into the family medicine curriculum.[15] Indications for POCUS vary between countries, shaped by the requirements of local health systems, the scope of primary care and training of general practitioners. Benefits of POCUS within primary care include its portability, ease of operation, high acceptability amongst patients and high user satisfaction amongst both patients and doctors.[16-18] POCUS can increase doctor confidence and studies suggest it can increase accuracy in diagnosis.[19] POCUS therefore has the potential to improve patient outcomes through a rapid initiation of effective treatment and a reduction in referrals to secondary care for investigations, specialist clinics and hospitalisation.[7, 8] POCUS has the potential to reduce health inequalities and empower general practitioners who work in rural, remote, under-resourced or underserved settings.[20, 21]

However, the use of POCUS in primary care is not without limitations. As with other physical examinations (e.g. pulmonary auscultation, thyroid palpation), accuracy of POCUS is user-dependent.[1, 12, 22] Compared with auscultation/clinical examination alone, focused use of POCUS has the potential to ensure higher levels of diagnostic accuracy and reduce risk of harm.[22] Without adequate training and continuous utilisation, POCUS can lead to false reassurance, underdiagnosis, misdiagnosis, overdiagnosis and overtreatment.[2, 23] Training should be stepwise and ongoing, including adequate coverage of anatomy and physiology, procedural techniques and communication skills including standardised reporting of clinical findings, and the impact of findings on medical decision making in primary care.[4, 24, 25, x26] Maintaining competency will be an important aspect of ongoing use of POCUS within a generalist speciality.[27] More research is required to identify best practice in training, methods of assessment and quality improvement, including avoidance of overdiagnosis, within the context of primary care.

Medicolegal considerations vary across countries and frequently change. This will require providers and institutions to understand local regulatory requirements and legal frameworks to mitigate the potential risks of POCUS. Even, the stethoscope, a tool routinely used by physicians for over 200 years has its limitations and failings.[28] Reviews of POCUS-associated litigation within secondary care have not identified cases relating to the use of POCUS, but rather to the lack of POCUS use when the technology was available.[29-31] Assessing medicolegal risk is a preventative process to avoid harm, whether to the patient, provider, or institution. Efforts must be made to gather evidence for guidelines on appropriate (and inappropriate) use of POCUS within primary care, in addition to the long-term impact on patient prognosis. We anticipate that specific regulatory frameworks for POCUS in General Practice are likely to evolve with an increased emphasis on quality and safety. We support the development of licensure and availability of General Practitioners to undertake POCUS in countries where this is not currently available.

Conclusion

POCUS is an accessible and promising medical tool capable of increasing diagnostic value and accuracy within primary care. It has the potential to reduce healthcare costs, patient travel, waiting times, and need for referral to secondary care services. It does however have potential risks of underdiagnosis, misdiagnosis, overdiagnosis and overtreatment. We recommend that all general practitioners receive tailored curriculum-based training in POCUS during residency and continuing medical education programmes, with adequate financial provision to undertake POCUS within primary care. We suggest that open dialogue and partnership with providers, administrators, and regulatory agencies experienced in POCUS will enable development of strategies to improve availability, provider performance, patient outcomes and minimisation of risk.

References

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2. Andersen CA, Holden S, Vela J, Rathleff MS, Jensen MB. Point-of-care ultrasound in general practice: a systematic review. The Annals of Family Medicine. 2019 Jan 1;17(1):61-9.

3. Sorensen, B., & Hunskaar, S. (2019). Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations. The Ultrasound Journal, 11(1). doi: 10.1186/s13089-019-0145-4

4. American Academy of Family Physicians. Recommended curriculum guidelines for family medicine residents: point of care ultrasound. AAFP Reprint No. 290D. https://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint290D_POCUS.pdf. Published Dec 2016. Accessed Apr 27, 2018.

5. Myklestul, H., Skonnord, T., & Brekke, M. (2020). Point-of-care ultrasound (POCUS) in Norwegian general practice. Scandinavian Journal Of Primary Health Care, 38(2), 219-225. doi: 10.1080/02813432.2020.1753385

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8. Aakjær Andersen, C., Brodersen, J., Davidsen, A., Graumann, O., & Jensen, M. (2020). Use and impact of point-of-care ultrasonography in general practice: a prospective observational study. BMJ Open, 10(9), e037664. doi: 10.1136/bmjopen-2020-037664

9. Løkkegaard, T., Todsen, T., Nayahangan, L., Andersen, C., Jensen, M., & Konge, L. (2020). Point-of-care ultrasound for general practitioners: a systematic needs assessment. Scandinavian Journal Of Primary Health Care, 38(1), 3-11. doi: 10.1080/02813432.2020.1711572

10. Jose L. Diaz-Gomez, Paul H. Mayo and Seth J. Koenig, Point-of-Care Ultrasonography.N Engl J Med 2021;385:1593-602. DOI: 10.1056/NEJMra19160628.

11. Rodríguez-Contreras FJ, Calvo-Cebrián A, Díaz-Lázaro J, Cruz-Arnés M, León-Vázquez F, del Carmen Lobón-Agúndez M, Palau-Cuevas FJ, Henares-García P, Gavilán-Martínez F, Fernández-Plaza S, Prieto-Zancudo C. Lung Ultrasound Performed by Primary Care Physicians for Clinically Suspected Community-Acquired Pneumonia: A Multicenter Prospective Study. The Annals of Family Medicine. 2022 May 1;20(3):227-36.

12. Dietrich CF, Goudie A, Chiorean L, Cui XW, Gilja OH, Dong Y, Abramowicz JS, Vinayak S, Westerway SC, Nolsøe CP, Chou YH, Blaivas M. Point of Care Ultrasound: A WFUMB Position Paper. Ultrasound Med Biol. 2017 Jan;43(1):49-58. 

13. Dinh VA, Fu JY, Lu S, et al. Integration of ultrasound in medical education at United States medical schools: a national survey of directors’ experiences. J Ultrasound Med. 2016;35(2):413- 419.

14. Touhami D, Merlo C, Hohmann J, Essig S. The use of ultrasound in primary care: longitudinal billing and cross-sectional survey study in Switzerland. BMC Fam Pract. 2020 Jul 1;21(1):127.

15. Peng S, Micks T, Braganza D, Sue K, Woo M, Rogers P, Freedman S, Lewis J, Hu S, Varner C, Patel N. Canadian national survey of family medicine residents on point-of-care ultrasound training. Canadian Family Physician. 2019 Dec 1;65(12):e523-30.

16. Andersen, C., Brodersen, J., Rudbæk, T., & Jensen, M. (2021). Patients’ experiences of the use of point-of-care ultrasound in general practice – a cross-sectional study. BMC Family Practice, 22(1). doi: 10.1186/s12875-021-01459-z

17. Andersen CA, Davidsen AS, Brodersen J, Graumann O, Jensen MB. Danish general practitioners have found their own way of using point-of-care ultrasonography in primary care: a qualitative study. BMC Fam Pract. 2019 Jun 28;20(1):89. 

18. Iacob M., Saftoiu A., Bumbulut C., Georgescu R.,Badea R., Evidence at the Point of Care Ultrasonography in Family Medicine. WONCA Copenhagen Conference, 2016, Book of abstracts, EGPRN Workshop, 79:173, https://www.researchgate.net/publication/323847614_79Evidence_at_the_Point_of_Care_Ultrasonography_in_Family_Medicine

19. Leidi A, Saudan A, Soret G, Rouyer F, Marti C, Stirnemann J, Reny JL, Grosgurin O. Confidence and use of physical examination and point-of-care ultrasonography for detection of abdominal or pleural free fluid. A cross-sectional survey. Intern Emerg Med. 2022 Jan;17(1):113-122.

20. Tanael M. Use of point-of-care ultrasonography in primary care to redress health inequities. The Journal of the American Board of Family Medicine. 2021 Jul 1;34(4):853-5.

21. Ellington LE, Gilman RH, Chavez MA, et al. Lung ultrasound as a diagnostic tool for radiographically-confirmed pneumonia in low resource settings. Respir Med. 2017;128:57-64.

22. Diprose W, Verster F, Schauer C. Re-examining physical findings with point-of-care ultrasound: a narrative review. The New Zealand Medical Journal (Online). 2017 Jan 27;130(1449):46.

23. Leidi A, Rouyer F, Marti C, Reny JL, Grosgurin O. Point of care ultrasonography from the emergency department to the internal medicine ward: current trends and perspectives. Internal and emergency medicine. 2020 Apr;15(3):395-408.

24. Andersen CA, Guetterman TC, Fetters MD, Brodersen J, Davidsen AS, Graumann O, Jensen MB. General Practitioners’ Perspectives on Appropriate Use of Ultrasonography in Primary Care in Denmark: A Multistage Mixed Methods Study. Ann Fam Med. 2022 May-Jun;20(3):211-219.

25. Andersen CA, Hedegård HS, Løkkegaard T, Frølund J, Jensen MB. Education of general practitioners in the use of point-of-care ultrasonography: a systematic review. Fam Pract. 2021 Jul 28;38(4):484-494.

26. Homar, V., Gale, Z.K., Lainscak, M. et al. Knowledge and skills required to perform point-of-care ultrasonography in family practice – a modified Delphi study among family physicians in Slovenia. BMC Fam Pract 21, 56 (2020).

27. The European Federation for Ultrasound in Medicine and Biology (EFUMB) Minimum training recommendations for the practice of medical ultrasound. Ultraschall Med 2006, 27(1):79-105.

28. Arts L, Lim EHT, can de Ven, PM, Jeunks L, Tuinman PR. The diagnostic accuracy of lung auscultation in adult patients with acute pulmonary pathologies: a meta-analysis. Sci Rep  (2020) 10(1):7347

29. Conlon, T.W., Yousef, N., Mayordomo-Colunga, J. et al. Establishing a risk assessment framework for point-of-care ultrasound. Eur J Pediatr 181, 1449–1457 (2022).

30. Reaume M, Farishta M, Costello JA, Gibb T, Melgar TA (2021) Analysis of lawsuits related to diagnostic errors from point-of-care ultrasound in internal medicine, paediatrics, family medicine and critical care in the USA. Postgrad Med J 2021 Jan;97(1143):55–58

31. Blaivas M, Pawl R (2012) Analysis of lawsuits filed against emergency physicians for point-of-care emergency ultrasound examination performance and interpretation over a 20-year period. Am J Emerg Med 30(2):338–341

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