A critical review of guidelines for low back pain treatment

This review was just published in the May 2006 issue of the European Spine Journal:

Arnau J, Vallano A, Lopez A, Pellisé F, Delgado M, Prat N. A critical review of guidelines for low back pain treatment. European Spine Journal 2006; 15(5):543-553.

Main problem: Little is known about the methodological quality of guidelines for low back pain treatment. We evaluated the methods used by the developers according to established standards.
Methods: PubMed, guideline databases, and the World Wide Web were used to identify guidelines. Seventeen guidelines met the inclusion criteria: interventions for low back pain stated, recommendations based on or explicitly linked to evidence, and English version available. Guidelines were evaluated independently by two appraisers using a practical tool for this purpose, Users Guides to the Medical Literature, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument.
Results: Thirteen guidelines (76%) specified the most important therapies applied, but only nine (53%) included a complete description of the target population. Explicit processes to identify, select, and combine evidence were described in only six guidelines (35%). Few guidelines (3; 18%) explicitly considered all main outcomes when formulating therapeutic recommendations, and none contained a process to determine the relative value of different outcomes. Methodological criteria for grading the strength of the recommendations varied, and were often insufficiently specified. None of the guidelines assessed the impact of uncertainty associated with the evidence and values used. According to AGREE the quality score was highest for the scope and purpose, and clarity and presentation domains, and lowest for editorial independence and applicability. With regard to the recommendations, there was consensus for some of the interventions for acute pain (analgesics and NSAIDs, maintaining physical activity, and avoiding excessive bed rest), but explicit recommendations were lacking or ambiguous for 41% of the interventions. Most of the guidelines did not contemplate specific recommendations for chronic pain.
Conclusions: A small number of the available guidelines for low back pain treatment achieved acceptable results for specific quality criteria. In general, the methods to develop the guidelines therapeutic recommendations need to be more rigorous, more explicit and better explained. In addition, greater importance should be placed on the recommendations for chronic pain.
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Systematic review of the literature on assessment, feedback and physicians’ clinical performance: BEME Guide No. 7

This new BEME guide was just published in the March 2006 issue of Medical Teacher: [full text by subscription]

Veloski J, Boex JR, Grasberger MJ, Evans A, Wolfson DB. Systematic review of the literature on assessment, feedback and physicians’ clinical performance: BEME Guide No. 7. Med Teach March 2006; 28(2):117-128.

Background and context: There is a basis for the assumption that feedback can be used to enhance physicians’ performance. Nevertheless, the findings of empirical studies of the impact of feedback on clinical performance have been equivocal.

Objectives: To summarize evidence related to the impact of assessment and feedback on physicians’ clinical performance.

Search strategy: The authors searched the literature from 1966 to 2003 using MEDLINE, HealthSTAR, the Science Citation Index and eight other electronic databases. A total of 3702 citations were identified.

Inclusion and exclusion criteria: Empirical studies were selected involving the baseline measurement of physicians’ performance and follow-up measurement after they received summaries of their performance.

Data extraction: Data were extracted on research design, sample, dependent and independent variables using a written protocol.

Data synthesis: A group of 220 studies involving primary data collection was identified. However, only 41 met all selection criteria and evaluated the independent effect of feedback on physician performance. Of these, 32 (74%) demonstrated a positive impact. Feedback was more likely to be effective when provided by an authoritative source over an extended period of time. Another subset of 132 studies examined the effect of feedback combined with other interventions such as educational programmes, practice guidelines and reminders. Of these, 106 studies (77%) demonstrated a positive impact. Two additional subsets of 29 feedback studies involving resident physicians in training and 18 studies examining proxy measures of physician performance across clinical sites or groups of patients were reviewed. The majority of these two subsets also reported that feedback had positive effects on performance.

Headline results: Feedback can change physicians’ clinical performance when provided systematically over multiple years by an authoritative, credible source.

Conclusions: The effects of formal assessment and feedback on physician performance are influenced by the source and duration of feedback. Other factors, such as physicians’ active involvement in the process, the amount of information reported, the timing and amount of feedback, and other concurrent interventions, such as education, guidelines, reminder systems and incentives, also appear to be important. However, the independent contributions of these interventions have not been well documented in controlled studies. It is recommended that the designers of future theoretical as well as practical studies of feedback separate the effects of feedback from other concurrent interventions.