Prognosis or "curabo effect?": physician prediction and patient outcome of surgery for low back pain and sciatica

STUDY DESIGN

Prospective study with patient and physician questionnaires, clinical records, and imaging.

OBJECTIVE

To compare physician expectations of surgery for sciatica and patient outcome.

SUMMARY OF BACKGROUND DATA

Physician accuracy in identifying individual patient prognosis is important for therapeutic decisions.

METHODS

A total of 197 consecutive patients with low back pain and/or sciatica who underwent low back surgery in the University Hospital of Lausanne, Switzerland.

RESULTS

Physicians predicted "a great improvement" of quality of life after surgery for 79% and "moderate improvement" for 20% (1% others); 39% of patients had no "minimal clinically important difference" in back pain after surgery, despite physician prediction of "great improvement." Correlations between physician expectation and various dimensions of patient outcome were not significant, and agreement with patient global judgment of 1-year outcome was poor (kappa = 0.03). However, in a subgroup where the indication for treatment was not considered appropriate, physician prediction of "great improvement" was followed by greater improvement outcome on SF-36 mental component score (P = 0.05), mental health (0.02), and general health (0.03) compared with patients where the physician did not predict "great improvement."

CONCLUSION

Despite clear average improvement, surgeons tended to give overly optimistic predictions that were not correlated with patient outcome. For patients receiving a treatment not meeting explicit criteria of appropriateness, more optimistic physician expectation was associated with better improvement of psychological dimensions. Besides prognostic ability, the influence of physician expectation on patient outcome is discussed and the concept of "curabo effect" (differentiated from "placebo effect") proposed.

Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study

BACKGROUND

The quality of colon cleansing is a major determinant of quality of colonoscopy. To our knowledge, the impact of bowel preparation on the quality of colonoscopy has not been assessed prospectively in a large multicenter study. Therefore, this study assessed the factors that determine colon-cleansing quality and the impact of cleansing quality on the technical performance and diagnostic yield of colonoscopy.

METHODS

Twenty-one centers from 11 countries participated in this prospective observational study. Colon-cleansing quality was assessed on a 5-point scale and was categorized on 3 levels. The clinical indication for colonoscopy, diagnoses, and technical parameters related to colonoscopy were recorded.

RESULTS

A total of 5832 patients were included in the study (48.7% men, mean age 57.6 [15.9] years). Cleansing quality was lower in elderly patients and in patients in the hospital. Procedures in poorly prepared patients were longer, more difficult, and more often incomplete. The detection of polyps of any size depended on cleansing quality: odds ratio (OR) 1.73: 95% confidence interval (CI)[1.28, 2.36] for intermediate-quality compared with low-quality preparation; and OR 1.46: 95% CI[1.11, 1.93] for high-quality compared with low-quality preparation. For polyps >10 mm in size, corresponding ORs were 1.0 for low-quality cleansing, OR 1.83: 95% CI[1.11, 3.05] for intermediate-quality cleansing, and OR 1.72: 95% CI[1.11, 2.67] for high-quality cleansing. Cancers were not detected less frequently in the case of poor preparation.

CONCLUSIONS

Cleansing quality critically determines quality, difficulty, speed, and completeness of colonoscopy, and is lower in hospitalized patients and patients with higher levels of comorbid conditions. The proportion of patients who undergo polypectomy increases with higher cleansing quality, whereas colon cancer detection does not seem to critically depend on the quality of bowel preparation.

Extraintestinal manifestations of Crohn's disease

In each case of extraintestinal manifestations of Crohn's disease, active disease, if present, should be treated to induce remission, which may positively influence the course of most concomitant extraintestinal manifestations. For some extraintestinal manifestations, however, a specific treatment should be introduced. This latter part of disease management will be discussed in this chapter, in particular for pyoderma gangrenosum, uveitis, spondylarthropathy--axial arthropathy--and primarysclerosing cholangitis, which have also been described in quiescent Crohn's disease. Few new drugs for the treatment of extraintestinal manifestations of Crohn's disease have been developed in the past and only the role of infliximab has increased in Crohn's disease-related extraintestinal manifestations. Drugs specifically aimed at this treatment, stemming from a few randomized controlled studies or case series, are sulfasalazine, 5-ASA, corticosteroids, azathioprine or 6-mercaptopurine, methotrexate, infliximab, dapsone and cyclosporine or tacrolimus.

Patient use of the Internet for health care information in Switzerland

STUDY AIMS

The aim of this study was to examine for the first time the frequency of Internet use for medical purposes by patients in Switzerland.

METHODS

In 2001 over a period of one month, 1604 patients at 8 medical practices in Switzerland completed a self-administered questionnaire on their access to the Internet and any search for medical information using this media. The attending physician supplied the patient's diagnosis and information on the severity of the disorder motivating the visit using a separate questionnaire.

RESULTS

46% of the patients included in the study had a personal computer, 33% had an Internet connection and 10% used the Internet to find medical information. Age was inversely associated with the probability of having an Internet access, whereas educational level and command of the English language were factors directly associated with this. Among those patients with access to the Internet, young adults (25 to 44 years) and those with knowledge of the English language searched for medical information significantly more frequently. Furthermore, patients attending urban medical practices and those with a more severe level of disease more often sought health care information on the Internet.

CONCLUSIONS

The proportion of patients in Switzerland who search for medical information on the Internet is similar to the rates observed in European English-speaking countries. The Internet allows patients to actively search for information concerning their own health problems but is not currently the most common source of information used by patients. Since health professionals generate, directly or indirectly, most of the medical information published on the Internet, additional research is needed to better understand patients' needs and expectations concerning medical information using this media.

Use of and irradiation from plain lumbar spine radiography in Switzerland

PRINCIPLES

Plain lumbar spine radiographic examination (LSRE) is frequently used in medical practice and delivers a high dose of ionising radiation. The objectives of the study were to determine the annual frequency of LSRE in Switzerland and its distribution according to practitioners' and patients' characteristics, as well as the related population dose of ionising radiation.

METHODS

Data were extrapolated from a nationwide questionnaire survey on radiation exposure resulting from medical imaging in 1998, involving physicians and other healthcare providers performing radiological examinations in Switzerland.

RESULTS

An estimated number of 273,000 LSRE are performed annually in Switzerland (39 LSRE per 1000 inhabitants per year). The collective dose to the population due to LSRE was 1130 Sv (0.16 mSv per person per year). 50-60% of these procedures were performed to confirm or rule out a diagnosis, the majority (85%) in the context of an illness.

CONCLUSIONS

LSRE is the third most frequent radiographic procedure performed and delivers the highest population dose of ionising radiation of any radiodiagnostic procedure. Efforts to reduce the frequency and the radiation dose of this procedure must be kept up, technically by optimising the equipment and radioprotection measures, and clinically by implementing evidence-based approaches to appropriate indications for this imaging technique.

Use of and irradiation from plain lumbar spine radiography in Switzerland

PRINCIPLES

Plain lumbar spine radiographic examination (LSRE) is frequently used in medical practice and delivers a high dose of ionising radiation. The objectives of the study were to determine the annual frequency of LSRE in Switzerland and its distribution according to practitioners' and patients' characteristics, as well as the related population dose of ionising radiation.

METHODS

Data were extrapolated from a nationwide questionnaire survey on radiation exposure resulting from medical imaging in 1998, involving physicians and other healthcare providers performing radiological examinations in Switzerland.

RESULTS

An estimated number of 273,000 LSRE are performed annually in Switzerland (39 LSRE per 1000 inhabitants per year). The collective dose to the population due to LSRE was 1130 Sv (0.16 mSv per person per year). 50-60% of these procedures were performed to confirm or rule out a diagnosis, the majority (85%) in the context of an illness.

CONCLUSIONS

LSRE is the third most frequent radiographic procedure performed and delivers the highest population dose of ionising radiation of any radiodiagnostic procedure. Efforts to reduce the frequency and the radiation dose of this procedure must be kept up, technically by optimising the equipment and radioprotection measures, and clinically by implementing evidence-based approaches to appropriate indications for this imaging technique.

Patient use of the Internet for health care information in Switzerland

STUDY AIMS

The aim of this study was to examine for the first time the frequency of Internet use for medical purposes by patients in Switzerland.

METHODS

In 2001 over a period of one month, 1604 patients at 8 medical practices in Switzerland completed a self-administered questionnaire on their access to the Internet and any search for medical information using this media. The attending physician supplied the patient's diagnosis and information on the severity of the disorder motivating the visit using a separate questionnaire.

RESULTS

46% of the patients included in the study had a personal computer, 33% had an Internet connection and 10% used the Internet to find medical information. Age was inversely associated with the probability of having an Internet access, whereas educational level and command of the English language were factors directly associated with this. Among those patients with access to the Internet, young adults (25 to 44 years) and those with knowledge of the English language searched for medical information significantly more frequently. Furthermore, patients attending urban medical practices and those with a more severe level of disease more often sought health care information on the Internet.

CONCLUSIONS

The proportion of patients in Switzerland who search for medical information on the Internet is similar to the rates observed in European English-speaking countries. The Internet allows patients to actively search for information concerning their own health problems but is not currently the most common source of information used by patients. Since health professionals generate, directly or indirectly, most of the medical information published on the Internet, additional research is needed to better understand patients' needs and expectations concerning medical information using this media.

Appropriateness of methadone maintenance treatment for opiate addiction: evaluation by an expert panel

With some 30,000 dependent persons, opiate addiction constitutes a major public health problem in Switzerland. The Swiss Federal Office of Public Health (FOPH) has long played a leading role in the prevention and treatment of opiate addiction and in research on effective means of containing the epidemic of opiate addiction and its consequences. Major milestones on that path have been the successive "Methadone reports" published by that Office and providing guidance on the care of opiate addiction with substitution treatment. In view of updating the recommendations for the appropriateness of substitution treatment for opiate addiction, in particular for the prescription of methadone, the FOPH commissioned a multi-component project involving the following elements. A survey of current attitudes and practices in Switzerland related to opiate substitution treatment Review of Swiss literature on methadone substitution treatment Review of international literature on methadone substitution treatment National Methadone Substitution Conference Multidisciplinary expert panel to evaluate the appropriateness of substitution treatment. The present report documents the process and summarises the results of the latter element above. The RAND appropriateness method (RAM) was used to distil from literature-based evidence and systematically formulated expert opinion, areas where consensus exist on the appropriateness (or inappropriateness) of methadone maintenance treatment (MMT) and areas where disagreement or uncertainty persist and which should be further pursued. The major areas which were addressed by this report are Initial assessment of candidates for MMT Appropriate settings for initiation of MMT (general and special cases) Appropriateness of methadone supportive therapy Co-treatments and accompanying measures Dosage schedules and pharmacokinetic testing Withdrawal from MMT Miscellaneous questions Appropriateness of other (non-methadone) substitution treatment Summary statements for each of the above categories are derived from the panel meeting and presented in the report. In the "first round", agreement was observed for 31% of the 553 theoretical scenarios evaluated. The "second round" rating, following discussion of divergent ratings, resulted in a much higher agreement among panellists, reaching 53% of the 537 scenarios. Frank disagreement was encountered for 7% of all scenarios. Overall 49% of the clinical situations (scenarios) presented were considered appropriate. The areas where at least 50% of the situations were considered appropriate were "initial assessment of candidates for MMT", the "appropriate settings for initiation of MMT", the "appropriate settings for methadone supportive treatment" and "Appropriateness of other (non-methadone) substitution treatment". The area where there was the least consensus on appropriateness concerned "appropriateness of withdrawal from MMT" (6%). The report discusses the implications and limitations of the panel results and provides recommendations for the dissemination, application, and future use of the criteria for the appropriateness of MMT. The RAND Appropriateness Method proved to be an accepted and appreciated method to assess the appropriateness of methadone maintenance treatment for opiate addicts. In the next step, the results of the expert panel process must now be combined with those of the Swiss and international literature reviews and the survey of current attitudes and practices in Switzerland, to be synthesized into formal practice guidelines. Such guidelines should be disseminated to all concerned, promoted, used and rigorously evaluated for compliance and outcome.

Use of the World Wide Web to implement clinical practice guidelines: a feasibility study

BACKGROUND

Important efforts have been invested in the past few years in the development of quality clinical guidelines. However, the means for the effective dissemination of guidelines to practicing physicians have not been determined. Several studies have examined the possibilities offered by the World Wide Web (the Web), but studies examining the implementation of clinical guidelines in actual practice are clearly lacking.

OBJECTIVE

This study assessed the potential of the Web to implement clinical practice guidelines in actual clinical settings. It also documents the obstacles perceived by the physicians in their use of guidelines on the Internet to determine the role that the Web can play in the implementation of guidelines in practice.

METHODS

Two guidelines were developed using a standardized panel method and made available via the Web. One concerned indications for low-back surgery and the other dealt with indications for upper and lower digestive endoscopies. To identify obstacles to their use in clinical practice, 20 physicians were asked to consult the guidelines during consultations with patients. Answers were collected using 3 different questionnaires.

RESULTS

Questionnaires were completed for consultations involving 213 patients. Less than 50% of the physicians have direct access to the Internet in their examination room. For 75%, the use of the guidelines was easy and the time required to consult them acceptable (3.4 minutes on average, or 12% of the time spent with the patient). The fear that use of such guidelines might interfere with the physician-patient relationship was mentioned as a reason for not consulting the guidelines for 27 consultations. Taking into account their experience with the Web, 75% of the physicians considered that the Web has a great or very-great potential for the dissemination of guidelines and 78% indicated that they would use such guidelines if they became generally available for clinical questions that concerned them. Only 3 physicians had consulted guidelines on the Web prior to this study.

CONCLUSIONS

The acceptance of use of clinical practice guidelines via the Web is high. The main limits to further use of such Web-based guidelines seem to be the lack of a computer connection in the physician's office or examining room and the fear that use of such guidelines might interfere with the physician-patient relationship. Though most participants appreciate the considerable potential of the Web for disseminating guidelines, only a small handful regularly use guidelines available on the Web. There are still numerous obstacles to the regular use of guidelines in clinical practice, some related to the physicians, others to the guidelines themselves.

Development of appropriateness criteria for colonoscopy: comparison between a standardized expert panel and an evidence-based medicine approach

OBJECTIVES

To assess the degree of agreement between appropriateness criteria for the use of colonoscopy developed by a standardized expert panel method and evidence from published studies.

DESIGN

Descriptive, agreement study.

SETTING

Multidisciplinary panel; primary care practice in Switzerland.

PARTICIPANTS

Nine national experts; 577 primary care patients referred for colonoscopy, 154 published papers.

INTERVENTIONS

Evaluation of the appropriateness of 402 possible clinical indications for colonoscopy, based on a comprehensive review of the literature.

MAIN OUTCOMES MEASURES

Proportion of agreement (weighted kappa), between panel- and literature-based appropriateness categories (appropriate, uncertain, inappropriate) for theoretical and actual indications encountered.

RESULTS

Nineteen of 402 indications rated by the panel could be based on the evidence retrieved from eight randomized clinical trials. A 68% agreement (kappa = 0.52) was found between panel- and study-based criteria. The addition of an uncontrolled trial and seven observational studies yielded a 71% agreement (kappa = 0.63). Agreement was similar when examining 577 actual cases: 69% agreement, kappa = 0.47. Agreement between panel-based indications and published evidence was not influenced by the perceived comprehensiveness and the apparent quality of the published reports.

CONCLUSIONS

Evidence for the appropriateness of most indications for colonoscopy could not be derived directly from the published literature. Agreement between appropriateness criteria developed by an expert panel and evidence from published studies was moderate to good, where available. New approaches should be sought in order to systematically integrate complementary evidence obtained from clinical trials and expert panels into practice guidelines.

Chiropractor's use of radiography in Switzerland

OBJECTIVE

In this article, we investigate the use of diagnostic radiology by chiropractors in Switzerland, with the aim of determining their contribution to the annual radiation collective dose.

METHODS

We approached 138 chiropractors possessing radiologic equipment and asked them to provide, among other information, the frequency of radiographic examinations. The dose associated with each type of radiographic examination was established separately. The collective dose was determined by convolution of frequency and dosimetric information.

RESULTS

The number of chiropractic radiographic examinations performed in Switzerland in 1998 was 60,000, mainly spinal and pelvic examinations. The associated annual collective dose was found to be 144 Sv (an annual effective dose of 20 microSv per capita). The chiropractic contribution to the total dose due to conventional radiography in Switzerland is about 6%.

CONCLUSIONS

Considering the number of chiropractors in Switzerland (less than 200), their contribution to the collective dose is relatively high. This is due to the high effective dose associated with the main types of examinations performed (eg, lumbar spine). It is therefore necessary to develop and apply guidelines for the use of this type of radiographic examination, as well as quality control programs, in order to optimize the radiographic technique and hence reduce the doses.

Dosimetric aspects of a national survey of diagnostic and interventional radiology in Switzerland

The effective dose delivered to the patient was determined, by modeling, for 257 types of examinations covering the different modalities of diagnostic and interventional radiology. The basic operational dosimetric quantities considered were obtained from the parameters of the examinations on the basis of dosimetric models. These models required a precise characterization of each examination. The operational dosimetric quantities were converted into doses to organs and effective doses using appropriate conversion factors. The determination of the collective effective dose to the Swiss population requires a number of corrections to account for the variability of several parameters: sensitivity of the detection system, age, gender, and build of the patient. The use of various dosimetric models is illustrated in this paper for a limited number of examination types covering the different radiological modalities, for which the established typical effective doses are given. With regard to individual doses, the study indicated that the average effective doses per type of examination can be classified into three levels: (a) the weakly irradiating examinations (less than 0.1 mSv), which represent 78% of the examinations and 4% of the collective dose, (b) the moderately irradiating examinations (between 0.1 mSv and 10 mSv), which represent 21% of the examinations and 72% of the collective dose, (c) the strongly irradiating examinations (more than 10 mSv), which represent 1% of the examinations and 24% of the collective dose.

Nation-wide survey on radiation doses in diagnostic and interventional radiology in Switzerland in 1998

A nation-wide survey on radiation doses in diagnostic and interventional radiology was conducted in Switzerland in 1998 aiming at establishing their collective radiological impact on the Swiss population. The study consisted on the one hand of surveying the frequency of more than 250 types of examinations, covering conventional radiology, mammography, fluoroscopy, angiography, interventional radiology, CT, bone densitometry, conventional tomography and dental radiology. On the other hand, for each type of examination the associated patient dose was established by modeling. The results of this study show that about 9.5 million diagnostic and interventional examinations are performed annually in Switzerland (1.34 per caput) and that the associated annual collective dose is of the order of 7100 person.Sv (1.0 mSv per caput). Switzerland is similar to other European countries in terms of the frequency of examinations and the collective dose.

Relationship between severity of lumbar disc disease and disability scores in sciatica patients

OBJECTIVE

To study the association between the clinical examination and the radiological assessment of lumbar disc disease in patients with sciatica.

METHODS

The study included 394 consecutive sciatica patients. The patients' disabilities were evaluated by a visual analog pain scale, the Prolo functional-economic rating scale, the modified Roland-Morris disability questionnaire, and the health-related quality of life short form (SF-36) questionnaire. Radiological imaging findings were independently classified according to the Modic criteria into five groups of increasing severity of disc disease. Stepwise multivariate logistic regression was used to determine which scores were significant independent predictors of a severe disc disease (extrusion or sequestration).

RESULTS

Of these patients, 9.6% had no disc disease, 3.3% had a bulging, 11.4% had a protrusion, 68.5% had an extrusion, and 7.1% had a disc sequestration. Statistically significant positive linear associations with the severity of disc disease were found for the leg pain scale, the Roland-Morris and Prolo disability scales, and the SF-36 scores related to physical functioning, physical role, and bodily pain (all P < 0.005). A poor (<5) Prolo score (odds ratio, 2.91; 95% confidence interval, 1.74-4.87), a higher leg pain score (odds ratio, 1.16 per centimeter increase; 95% confidence interval, 1.07-1.27), and a lower low back pain score (odds ratio, 0.90 per centimeter decrease; 95% confidence interval, 0.82-0.98) were retained in the multivariate logistic model as independent predictors of severe disc disease.

CONCLUSION

The positive correlation between disability status and imaging findings validates both assessment methods. Routine use of disability scores brings a useful contribution to the assessment of sciatica patients.

[Refugees, migrants, language barrier: opinion of physicians on translation aids]

When the patient and caregiver do not share a common language, an interpreter is not always the best solution, and in any case, one cannot be present for every visit, especially in the case of an emergency. According to a questionnaire that was sent to all of the physicians who are members of a health care network for asylum seekers in the Swiss canton of Vaud (n = 169), it appears that 45% of practitioners found a telephone translation service to be a practical solution, and 58% would like medical glossaries with phonetic pronunciation and visual illustrations made available. With a response rate of 91%, it is estimated that these two types of services would be used as often as qualified interpreters, if they were made available. Other translating aids are also proposed.

[Evaluating the appropriateness of low back pain care]

Physicians must insure that care provided--whether it be preventive, diagnostic, therapeutic of palliative--is appropriate. Confronted with the swift development of medical progress and the tremendous quantity and uneven quality of available information on appropriateness of care, it is important to determine optimal strategies for identifying necessary, relevant and valid information in this respect. Medical care is considered appropriate if the expected benefits to the patient outweigh the potential risks. The ideal source of information concerning appropriateness of care stems from rigorously conducted, randomized, controlled trials and from systematic reviews of the literature, such as those prepared by the Cochrane Collaboration. Concerning treatment of low back pain, recent years have witnessed several groups active in preparing such rigorous systematic reviews. Different sources of information on appropriateness of care for back pain are presented in this article. Unfortunately, many reviews underline the absence of evidence for the effectiveness of most treatments now used in the treatment of low back pain. On the other hand, absence of proof of effectiveness, and, as often in medicine, elements other than the quality of evidence must enter into the decision to use or not to use various treatments. But this should not keep us from pursuing rigorous clinic research to improve the scientific basis of care provided to our patients suffering from low back pain.

Helicobacter pylori eradication treatment does not benefit patients with nonulcer dyspepsia

OBJECTIVES

The aim of this study was to assess the still controversial role of treatment of Helicobacter pylori (H. pylori) infection in patients with nonulcer dyspepsia.

METHODS

We conducted a double-blind, randomized, placebo-controlled, multicenter trial comparing the efficacy of 7 days of eradication treatment (lansoprazole 15 mg b.i.d., amoxicillin I g b.i.d., and clarithromycin 500 mg b.i.d.) with a control treatment (lansoprazole 15 mg b.i.d. and placebo) in H. pylori-infected patients with nonulcer dyspepsia. 13C breath tests were performed at baseline and during follow-up. We assessed patient symptoms, health status (based on the SF-12 questionnaire), patient satisfaction, drug consumption, health care consultation behavior, and absenteeism related to dyspepsia over a 1-yr period.

RESULTS

A total of 74 patients randomized to eradication treatment and 70 patients randomized to placebo were compared. The rate of eradication of H. pylori infection was 75% in the active treatment group and 4% in the placebo group (p < 0.005). The symptom score improved to a similar extent in the group receiving active treatment (-4.0; 95% CI = -5.0 to -3.0) and placebo (-3.6; 95% CI = -4.5 to -2.7). Treatment response was not related to the severity or duration of initial symptoms or to the severity of gastritis on histology. Quality of life scores were comparable at 12 months. There was no significant difference in dyspepsia-related absenteeism or satisfaction with management of NUD. Patients receiving active treatment were more likely not to have had to use any dyspepsia treatment over the 12 months (60.8% vs 44.3%; p = 0.047).

CONCLUSIONS

This study did not demonstrate any substantial benefit of curing H. pylori infection in patients with nonulcer dyspepsia. The study adds further evidence that H. pylori is not the main pathogenetic or therapeutic target in these patients.

Overuse and underuse of colonoscopy in a European primary care setting

BACKGROUND

Efforts to decrease overuse of health care may result in underuse. Overuse and underuse of colonoscopy have never been simultaneously evaluated in the same patient population.

METHODS

In this prospective observational study, the appropriateness and necessity of referral for colonoscopy were evaluated by using explicit criteria developed by a standardized expert panel method. Inappropriate referrals constituted overuse. Patients with necessary colonoscopy indications who were not referred constituted underuse. Consecutive ambulatory patients with lower gastrointestinal (GI) symptoms from 22 general practices in Switzerland, a country with ready access to colonoscopy, were enrolled during a 4-week period. Follow-up data were obtained at 3 months for patients who did not undergo a necessary colonoscopy.

RESULTS

Eight thousand seven hundred sixty patient visits were screened for inclusion; 651 patients (7.4%) had lower GI symptoms (mean age 56.4 years, 68% women). Of these, 78 (12%) were referred for colonoscopy. Indications for colonoscopy in 11 patients (14% of colonoscopy referrals or 1.7% of all patients with lower GI symptoms) were judged inappropriate. Among 573 patients not referred for the procedure, underuse ranged between 11% and 28% of all patients with lower GI symptoms, depending on the criteria used.

CONCLUSIONS

Applying criteria from an expert panel of nationally recognized experts indicates that underuse of referral for colonoscopy exceeds overuse in primary care in Switzerland. To improve quality of care, both overuse and underuse of important procedures must be addressed.

Is the diagnostic yield of upper GI endoscopy improved by the use of explicit panel-based appropriateness criteria?

BACKGROUND

Increasing the appropriateness of use of upper gastrointestinal (GI) endoscopy is important to improve quality of care while at the same time containing costs. This study explored whether detailed explicit appropriateness criteria significantly improve the diagnostic yield of upper GI endoscopy.

METHODS

Consecutive patients referred for upper GI endoscopy at 6 centers (1 university hospital, 2 district hospitals, 3 gastroenterology practices) were prospectively included over a 6-month period. After controlling for disease presentation and patient characteristics, the relationship between the appropriateness of upper GI endoscopy, as assessed by explicit Swiss criteria developed by the RAND/UCLA panel method, and the presence of relevant endoscopic lesions was analyzed.

RESULTS

A total of 2088 patients (60% outpatients, 57% men) were included. Analysis was restricted to the 1681 patients referred for diagnostic upper GI endoscopy. Forty-six percent of upper GI endoscopies were judged to be appropriate, 15% uncertain, and 39% inappropriate by the explicit criteria. No cancer was found in upper GI endoscopies judged to be inappropriate. Upper GI endoscopies judged appropriate or uncertain yielded significantly more relevant lesions (60%) than did those judged to be inappropriate (37%; odds ratio 2.6: 95% CI [2.2, 3.2]). In multivariate analyses, the diagnostic yield of upper GI endoscopy was significantly influenced by appropriateness, patient gender and age, treatment setting, and symptoms.

CONCLUSIONS

Upper GI endoscopies performed for appropriate indications resulted in detecting significantly more clinically relevant lesions than did those performed for inappropriate indications. In addition, no upper GI endoscopy that resulted in a diagnosis of cancer was judged to be inappropriate. The use of such criteria improves patient selection for upper GI endoscopy and can thus contribute to efforts aimed at enhancing the quality and efficiency of care. (Gastrointest Endosc 2000;52:333-41).

Appropriateness of surgery for sciatica: reliability of guidelines from expert panels

STUDY DESIGN

Reliability study of guidelines development.

OBJECTIVE

To compare criteria for low back surgery between two expert panels.

BACKGROUND

Reliability of expert panels for determining appropriateness of indications for surgical procedures has heretofore received little attention.

METHODS

Two multidisciplinary expert panels of similar composition were convened, in the United States and in Switzerland, to evaluate the appropriateness of 720 distinct clinical scenarios involving sciatica. Each indication was assigned to a category of appropriate, uncertain, and inappropriate. The appropriateness of the 720 theoretical scenarios were compared between the two panels, and both sets of criteria were applied to two series of actual cases.

RESULTS

Seventy-nine percent (n = 566) of the 720 theoretical indications were assigned to identical categories of appropriateness by both panels (kappa = 0.63; P < 0.001). Only 2 of the 720 scenarios elicited frank disagreement. The percentage of the 720 indications that were considered appropriate differed between the two panels (U.S.: 3%; Swiss: 11%, P < 0.001), as did the percentage of intrapanel agreement for indications (U.S.: 51%, Swiss: 64%, P < 0.001). When the same theoretical scenarios were matched with two series of actual cases (n = 181 and 149) agreement was moderate (kappa = 0.46) to fair (kappa = 0.30).

CONCLUSION

There was substantial agreement on the appropriateness of surgery for theoretical cases of sciatica between independent expert panels from two countries. A better understanding of discordant ratings, especially for actual cases, should precede attempts at transposing recommendations emanating from a panel in one country to another.