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

Surgical appropriateness nudges: Developing behavioral science nudges to integrate appropriateness criteria into the decision making of spine surgeons

BACKGROUND

Substantial variation exists in surgeon decision making. In response, multiple specialty societies have established criteria for the appropriate use of spine surgery. Yet few strategies exist to facilitate routine use of appropriateness criteria by surgeons. Behavioral science nudges are increasingly used to enhance decision making by clinicians. We sought to design "surgical appropriateness nudges" to support routine use of appropriateness criteria for degenerative lumbar scoliosis and spondylolisthesis.

METHODS

The work reflected Stage I of the NIH Stage Model for Behavioral Intervention Development and involved an iterative, multi-method approach, emphasizing qualitative methods. Study sites included two large referral centers for spine surgery. We recruited spine surgeons from both sites for two rounds of focus groups. To produce preliminary nudge prototypes, we examined sources of variation in surgeon decision making (Focus Group 1) and synthesized existing knowledge of appropriateness criteria, behavioral science nudge frameworks, electronic tools, and the surgical workflow. We refined nudge prototypes via feedback from content experts, site leaders, and spine surgeons (Focus Group 2). Concurrently, we collected data on surgical practices and outcomes at study sites. We pilot tested the refined nudge prototypes among spine surgeons, and surveyed them about nudge applicability, acceptability, and feasibility (scale 1-5, 5 = strongly agree).

RESULTS

Fifteen surgeons participated in focus groups, giving substantive input and feedback on nudge design. Refined nudge prototypes included: individualized surgeon score cards (frameworks: descriptive social norms/peer comparison/feedback), online calculators embedded in the EHR (decision aid/mapping), a multispecialty case conference (injunctive norms/social influence), and a preoperative check (reminders/ salience of information/ accountable justification). Two nudges (score cards, preop checks) incorporated data on surgeon practices and outcomes. Six surgeons pilot tested the refined nudges, and five completed the survey (83%). The overall mean score was 4.0 (standard deviation [SD] 0.5), with scores of 3.9 (SD 0.5) for applicability, 4.1 (SD 0.5) for acceptability, and 4.0 (SD 0.5), for feasibility. Conferences had the highest scores 4.3 (SD 0.6) and calculators the lowest 3.9 (SD 0.4).

CONCLUSIONS

Behavioral science nudges might be a promising strategy for facilitating incorporation of appropriateness criteria into the surgical workflow of spine surgeons. Future stages in intervention development will test whether these surgical appropriateness nudges can be implemented in practice and influence surgical decision making.

Evaluation of an advanced-practice physiotherapist in triaging patients with lumbar spine pain: surgeon-physiotherapist level of agreement and patient satisfaction

BACKGROUND

Surgery for lumbar spine pain is indicated for specific etiologies. Given the majority of individuals referred to spine surgeons are not surgical candidates, care delivery is inefficient, with consultations being of limited value for most. Using specially trained physiotherapists in triage is a human resource strategy that may optimize surgeons' time and the patient experience.

METHODS

An advanced-practice physiotherapist (APP) and a surgeon assessed consecutive patients with lumbar spine pain presenting at an academic health centre's spine surgery clinic. The second assessor was blinded to the outcome of the first. We used the κ statistic to evaluate surgeon-APP level of chance-corrected agreement concerning patients' need for a surgical consultation. To assess satisfaction with the APP, patients completed a modified version of the validated Visit-specific Questionnaire.

RESULTS

The sample included 102 participants (54 women) with a mean age of 54.3 ± 14.3 years and a mean Oswestry Disability Index score of 35.4 ± 16.6. The assessors' overall agreement was 86%. The κ coefficient for the need for a surgical consultation was 0.69 (95% confidence interval 0.54-0.84). The APP identified that 77% of patients did not require a surgical consultation. Twenty-one patients underwent surgery. Satisfaction scores for the APP were very high (mean score 92 out of 100).

CONCLUSION

In triaging patients with lumbar spine pain, the APP and surgeon had a high level of agreement. An APP performing triage at a surgical centre can effectively reduce wait lists by 70%, reserving surgical consultations for those patients in whom they are indicated.

Long-Term Course to Lumbar Disc Resorption Patients and Predictive Factors Associated with Disc Resorption

The long-term course to lumbar intervertebral disc herniation (LDH) patients receiving integrative Korean medicine treatment and predictive factors associated with disc resorption were investigated. LDH patients who received integrative Korean medicine treatment from February 2012 to December 2015 and were registered in the "longitudinal project for LDH on MRI" were included. Disc resorption amount was measured 3-dimensionally with disc degeneration and modic change levels on baseline and follow-up MRIs. Patient characteristics, Korean medicine use, pain, symptom recurrence, and satisfaction were assessed through medical records and phone surveys. Of 505 participants, 19 did not show disc resorption, while 486 did. A total of 220 displayed resorption rates of ≥50%. LDH volume at baseline was 1399.82 ± 594.96 mm³, and that on follow-up MRI was 734.37 ± 303.33 mm³, indicating a 47.5% decrease (p < 0.0001). Predictive factors for disc resorption were disc extrusion, Komori migration classification, and LDH amount. Approximately 68.4% did not experience symptom recurrence over the 51.86 ± 19.07-month follow-up, and 90.3% were satisfied with Korean medicine treatment. The majority of LDH patients who improved after integrative Korean medicine treatment showed disc resorption within 1 year with favorable long-term outcomes. Predictive factors for disc resorption should be duly considered for informed decision-making. This trial is registered with ClinicalTrials.gov NCT02841163.

Individualized functional restoration as an adjunct to advice for lumbar disc herniation with associated radiculopathy. A preplanned subgroup analysis of a randomized controlled trial

BACKGROUND CONTEXT

Physical therapy is commonly sought by people with lumbar disc herniation and associated radiculopathy. It is unclear whether physical therapy is effective for this population.

PURPOSE

To determine the effectiveness of physical therapist-delivered individualized functional restoration as an adjunct to guideline-based advice in people with lumbar disc herniation and associated radiculopathy.

STUDY DESIGN

This is a preplanned subgroup analysis of a multicenter parallel group randomized controlled trial.

PATIENT SAMPLE

The study included 54 participants with clinical features of radiculopathy (6-week to 6-month duration) and imaging showing a lumbar disc herniation.

OUTCOME MEASURES

Primary outcomes were activity limitation (Oswestry Disability Index) and separate 0-10 numerical pain rating scales for leg pain and back pain. Measures were taken at baseline and at 5, 10, 26, and 52 weeks.

METHODS

The participants were randomly allocated to receive either individualized functional restoration incorporating advice (10 sessions) or guideline-based advice alone (2 sessions) over a 10-week period. Treatment was administered by 11 physical therapists at private clinics in Melbourne, Australia.

RESULTS

Between-group differences for activity limitation favored the addition of individualized functional restoration to advice alone at 10 weeks (7.7, 95% confidence interval [CI] 0.3-15.1) and 52 weeks (8.2, 95% CI 0.7-15.6), as well as back pain at 10 weeks (1.4, 95% CI 0.2-2.7). There were no significant differences between groups for leg pain at any follow-up. Several secondary outcomes also favored individualized functional restoration over advice.

CONCLUSIONS

In participants with lumbar disc herniation and associated radiculopathy, an individualized functional restoration program incorporating advice led to greater reduction in activity limitation at 10- and 52-week follow-ups compared with guideline-based advice alone. Although back pain was significantly reduced at 10 weeks with individualized functional restoration, this effect was not maintained at later timepoints, and there were no significant effects on leg pain, relative to guideline-based advice.

Influence of Clinical and Economical Factors on the Expert Rating of Appropriateness of Preoperative Use of Recombinant Erythropoietin in Elective Orthopedic Surgery Patients

To evaluate the relative impact of clinical factors and health care environment resources on the expert ratings of appropriateness of preoperative erythropoietin in elective orthopedic surgery, the authors analyzed 6905 individual votes on 496 clinical scenarios from 14 experts, applying a multivariate logistic model. Sixty-six percent of the indications were appropriate when resource constraints (RC) were not considered and 53% when they were, resulting in a drop in the median vote of 2 points on a 9-point scale (P < 0.05). Initial hemoglobin level, expected perioperative blood loss, and RC were by far the most significant contributors to the model (P < 0.01), but other factors (i.e., clinical specialty of the expert, prior history of transfusion reactions, patient age, cardiovascular disease, anemia of chronic disease) also contributed significantly (P< 0.01). For assessing appropriateness of care, this study confirms the need for detailed clinical scenarios and a multidisciplinary panel carefully selected to reflect those involved in the interventions under consideration.

Optimal duration of conservative management prior to surgery for cervical and lumbar radiculopathy: a literature review

Study Design Literature review. Objective Since the 1970s, spine surgeons have commonly required 6 weeks of failed conservative treatment prior to considering surgical intervention for various spinal pathologies. It is unclear, however, if this standard has been validated in the literature. The authors review the natural history, outcomes, and cost-effectiveness studies relating to the current standard of 6 weeks of nonoperative care prior to surgery for patients with spinal pathologies. Methods A systematic Medline search from 1953 to 2013 was performed to identify natural history, outcomes, and cost-effectiveness studies relating to the optimal period of conservative management prior to surgical intervention for both cervical and lumbar radiculopathy. Demographic information, operative indications, and clinical outcomes are reviewed for each study. Results A total of 5,719 studies were identified; of these, 13 studies were selected for inclusion. Natural history studies demonstrated that 88% of patients with cervical radiculopathy and 70% of patients with lumbar radiculopathy showed improvement within 4 weeks following onset of symptoms. Outcomes and cost-effectiveness studies supported surgical intervention within 8 weeks of symptom onset for both cervical and lumbar radiculopathy. Conclusions There are limited studies supporting any optimal duration of conservative treatment prior to surgery for cervical and lumbar radiculopathy. Therefore, evidence-based conclusions cannot be made. Based on the available literature, we suggest that an optimal timing for surgery following cervical radiculopathy is within 8 weeks of onset of symptoms. A shorter period of 4 weeks may be appropriate based on natural history studies. Additionally, we found that optimal timing for surgery following lumbar radiculopathy is between 4 and 8 weeks. A prospective study is needed to explicitly identify the optimal duration of conservative therapy prior to surgery so that costs may be reduced and patient outcomes improved.

Development of appropriateness criteria for the surgical treatment of symptomatic lumbar degenerative spondylolisthesis (LDS)

PURPOSE

Spine surgery rates are increasing worldwide. Treatment failures are often attributed to poor patient selection and inappropriate treatment, but for many spinal disorders there is little consensus on the precise indications for surgery. With an aging population, more patients with lumbar degenerative spondylolisthesis (LDS) will present for surgery. The aim of this study was to develop criteria for the appropriateness of surgery in symptomatic LDS.

METHODS

A systematic review was carried out to summarize the current level of evidence for the treatment of LDS. Clinical scenarios were generated comprising combinations of signs and symptoms in LDS and other relevant variables. Based on the systematic review and their own clinical experience, twelve multidisciplinary international experts rated each scenario on a 9-point scale (1 highly inappropriate, 9 highly appropriate) with respect to performing decompression only, fusion, and instrumented fusion. Surgery for each theoretical scenario was classified as appropriate, inappropriate, or uncertain based on the median ratings and disagreement in the ratings.

RESULTS

744 hypothetical scenarios were generated; overall, surgery (of some type) was rated appropriate in 27%, uncertain in 41% and inappropriate in 31%. Frank panel disagreement was low (7% scenarios). Face validity was shown by the logical relationship between each variable's subcategories and the appropriateness ratings, e.g., no/mild disability had a mean appropriateness rating of 2.3 ± 1.5, whereas the rating for moderate disability was 5.0 ± 1.6 and for severe disability, 6.6 ± 1.6. Similarly, the average rating for no/minimal neurological abnormality was 2.3 ± 1.5, increasing to 4.3 ± 2.4 for moderate and 5.9 ± 1.7 for severe abnormality. The three variables most likely (p < 0.0001) to be components of scenarios rated "appropriate" were: severe disability, no yellow flags, and severe neurological deficit.

CONCLUSION

This is the first study to report criteria for determining candidacy for surgery in LDS developed by a multidisciplinary international panel using a validated method (RAM). The panel ratings followed logical clinical rationale, indicating good face validity. The work refines clinical classification and the phenotype of degenerative spondylolisthesis. The predictive validity of the criteria should be evaluated prospectively to examine whether patients treated "appropriately" have better clinical outcomes.

The appropriateness method has acceptable reliability and validity for assessing overuse and underuse of surgical procedures

OBJECTIVE

To summarize the findings of methodological studies on the RAND/University of California Los Angeles (RAND/UCLA) appropriateness method, which was developed to assess if variation in the use of surgical procedures is because of overuse and/or underuse.

STUDY DESIGN AND SETTING

A MEDLINE literature search was performed. Studies were included if they assessed the reliability or validity of the RAND/UCLA appropriateness method for a surgical procedure or the effect of altering panelist composition or eliminating in-person discussion between rating rounds. Information was abstracted on procedure, study design, and findings.

RESULTS

One thousand six hundred one titles were identified, and 37 met the inclusion criteria. The test-retest reliability is good to very good (kappa, 0.64-0.81) for total knee and hip joint replacement, coronary artery bypass grafting (CABG), and carotid endarterectomy (CEA). The interpanel reliability is moderate to very good (kappa, 0.52-0.83) for CABG and hysterectomy. Construct validity has been demonstrated by comparing the appropriateness method with guidelines and/or evidence-based approaches for endoscopy, colonoscopy, CABG, hysterectomy, and CEA. Predictive validity has been studied for cardiac revascularization, in which concordance with appropriateness classification is associated with better clinical outcomes.

CONCLUSION

Our findings support use of the appropriateness method to assess variation in the rates of the procedures studied by identifying overuse and underuse. Further methodological research should be conducted as appropriateness criteria are developed and implemented for a broader range of procedures.

Appraisal of WHO guidelines in maternal health using the AGREE II assessment tool

In 2007, the World Health Organization (WHO) received a criticism for a lack of transparency and systematic methods in the development of guidelines, which were at that time perceived as substantially driven by expert opinion. In this paper we assessed the quality of maternal and perinatal health guidelines developed since then. We used the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool to evaluate the quality of methodological rigour and transparency of four different WHO guidelines published between 2007 and 2011. Our findings showed high scores among the most recent guidelines on maternal and perinatal health suggesting higher quality. However, there is still potential for improvement, especially in including different stakeholder views, transparency of guidelines regarding the role of the funding body and presentation of the guideline document.

Lumbar muscle fatigue and subjective health measurements in patients with lumbar disc herniation 2 years after surgery

INTRODUCTION

In this prospective study the purpose was to evaluate patients with lumbar-disc herniation regarding changes in back-muscle fatigue and subjective health measurements 2 years after surgery.

METHODS

Endurance time, EMG median frequency and ratings of lumbar-muscle fatigue and pain were measured before surgery, 4 weeks after and 2 years after surgery in 26 patients (19 men and 7 women) with lumbar-disc herniation. A modified Sørensen test was performed with concurrent recordings of electromyography from the lumbar muscles at four recording sites. The questionnaires Oswestry disability index, Roland-Morris disability questionnaire, Self-efficacy scale, SF-36, Back beliefs questionnaire, Odom and a 6-grade physical activity scale were used.

RESULTS

Two years after surgery the patients had longer endurance times (increase from 178 s to 231 s, p < 0.001), a non-significant tendency for flatter L5 slopes (decrease from -0.20 to -0.16 Hz/s, p < 0.066), higher initial median frequency (L1 increase from 58 to 64 Hz p < 0.001, L5 increase from 76 to 84 Hz p = 0.001) and improved questionnaire scores. The questionnaires Oswestry, Roland-Morris and SF-36 physical functioning correlated with the endurance time 0.69-0.93 and with L5 slope 0.01-0.93 and the highest correlations were found in women.

CONCLUSION

Both EMG and endurance time measurements are needed for evaluating fatigue in lumbar-disc herniation.

Appropriateness criteria for surgery improve clinical outcomes in patients with low back pain and/or sciatica

STUDY DESIGN

Prospective, controlled, observational outcome study using clinical, radiographic, and patient/physician-based questionnaire data, with patient outcomes at 12 months follow-up.

OBJECTIVE

To validate appropriateness criteria for low back surgery.

SUMMARY OF BACKGROUND DATA

Most surgical treatment failures are attributed to poor patient selection, but no widely accepted consensus exists on detailed indications for appropriate surgery.

METHODS

Appropriateness criteria for low back surgery have been developed by a multispecialty panel using the RAND appropriateness method. Based on panel criteria, a prospective study compared outcomes of patients appropriately and inappropriately treated at a single institution with 12 months follow-up assessment. Included were patients with low back pain and/or sciatica referred to the neurosurgical department. Information about symptoms, neurologic signs, the health-related quality of life (SF-36), disability status (Roland-Morris), and pain intensity (VAS) was assessed at baseline, at 6 months, and at 12 months follow-up. The appropriateness criteria were administered prospectively to each clinical situation and outside of the clinical setting, with the surgeon and patients blinded to the results of the panel decision. The patients were further stratified into 2 groups: appropriate treatment group (ATG) and inappropriate treatment group (ITG).

RESULTS

Overall, 398 patients completed all forms at 12 months. Treatment was considered appropriate for 365 participants and inappropriate for 33 participants. The mean improvement in the SF-36 physical component score at 12 months was significantly higher in the ATG (mean: 12.3 points) than in the ITG (mean: 6.8 points) (P = 0.01), as well as the mean improvement in the SF-36 mental component score (ATG mean: 5.0 points; ITG mean: -0.5 points) (P = 0.02). Improvement was also significantly higher in the ATG for the mean VAS back pain (ATG mean: 2.3 points; ITG mean: 0.8 points; P = 0.02) and Roland-Morris disability score (ATG mean: 7.7 points; ITG mean: 4.2 points; P = 0.004). The ATG also had a higher improvement in mean VAS for sciatica (4.0 points) than the ITG (2.8 points), but the difference was not significant (P = 0.08). The SF-36 General Health score declined in both groups after 12 months, however, the decline was worse in the ITG (mean decline: 8.2 points) than in the ATG (mean decline: 1.2 points) (P = 0.04). Overall, in comparison to ITG patients, ATG patients had significantly higher improvement at 12 months, both statistically and clinically.

CONCLUSION

In comparison to previously reported literature, our study is the first to assess the utility of appropriateness criteria for low back surgery at 1-year follow-up with multiple outcome dimensions. Our results confirm the hypothesis that application of appropriateness criteria can significantly improve patient outcomes.

Timing of surgery for sciatica: subgroup analysis alongside a randomized trial

Surgery speeds up recovery for sciatica. Prolonged conservative care with surgery for those patients with persistent sciatica however, yields similar results at 1 year. To investigate whether baseline variables modify the difference in recovery rates between these treatment strategies, baseline data of 283 patients enrolled in a randomized trial, comparing early surgery with prolonged conservative care, were used to analyse effect modification of the allotted treatment strategy. For predictors shown to modify the effect of the treatment strategy, repeated measurement analyses with the Roland Disability Questionnaire and visual analogue scale pain as continuous outcomes were performed for every level of that predictor. Presumed predictive variables did not have any interaction with treatment, while “sciatica provoked by sitting” showed to be a significant effect modifier (P = 0.07). In a Cox model we estimated a hazard ratio (HR, surgery versus conservative) of 2.2 (95% CI 1.7–3.0) in favour of surgery when sciatica was provoked by sitting, while the HR was 1.3 (95% CI 0.8–2.2) when this sign was absent. The interaction effect is marginally significant (interactions are usually tested at the 10% level) but the patterns generated by the repeated measurement analyses of all primary outcomes are completely consistent with the inferred pattern from the survival analysis. Classical signs did not show any contribution as decision support tools in deciding when to operate for sciatica, whereas treatment effects of early surgery are emphasized when sciatica is provoked by sitting and negligible when this symptom is absent.

Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial

OBJECTIVE

To determine whether the faster recovery after early surgery for sciatica compared with prolonged conservative care is attained at reasonable costs.

DESIGN

Cost utility analysis alongside a randomised controlled trial.

SETTING

Nine Dutch hospitals.

PARTICIPANTS

283 patients with sciatica for 6-12 weeks, caused by lumbar disc herniation.

INTERVENTIONS

Six months of prolonged conservative care compared with early surgery.

MAIN OUTCOME MEASURES

Quality adjusted life years (QALYs) at one year and societal costs, estimated from patient reported utilities (UK and US EuroQol, SF-6D, and visual analogue scale) and diaries on costs (healthcare, patient's costs, and productivity).

RESULTS

Compared with prolonged conservative care, early surgery provided faster recovery, with a gain in QALYs according to the UK EuroQol of 0.044 (95% confidence interval 0.005 to 0.083), the US EuroQol of 0.032 (0.005 to 0.059), the SF-6D of 0.024 (0.003 to 0.046), and the visual analogue scale of 0.032 (-0.003 to 0.066). From the healthcare perspective, early surgery resulted in higher costs (difference euro1819 (pound1449; $2832), 95% confidence interval euro842 to euro2790), with a cost utility ratio per QALY of euro41 000 (euro14,000 to euro430 000). From the societal perspective, savings on productivity costs led to a negligible total difference in cost (euro-12, euro-4029 to euro4006).

CONCLUSIONS

Faster recovery from sciatica makes early surgery likely to be cost effective compared with prolonged conservative care. The estimated difference in healthcare costs was acceptable and was compensated for by the difference in absenteeism from work. For a willingness to pay of euro40,000 or more per QALY, early surgery need not be withheld for economic reasons. Trial registration Current Controlled Trials ISRCTN 26872154.

Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial

OBJECTIVES

To evaluate the effects of early lumbar disc surgery compared with prolonged conservative care for patients with sciatica over two years of follow-up.

DESIGN

Randomised controlled trial.

SETTING

Nine Dutch hospitals.

PARTICIPANTS

283 patients with 6-12 weeks of sciatica.

INTERVENTIONS

Early surgery or an intended six months of continued conservative treatment, with delayed surgery if needed.

MAIN OUTCOME MEASURES

Scores from Roland disability questionnaire for sciatica, visual analogue scale for leg pain, and Likert self rating scale of global perceived recovery.

RESULTS

Of the 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiscectomy. Of the 142 patients assigned to conservative treatment, 62 (44%) eventually required surgery, seven doing so in the second year of follow-up. There was no significant overall difference between treatment arms in disability scores during the first two years (P=0.25). Improvement in leg pain was faster for patients randomised to early surgery, with a significant difference between "areas under the curves" over two years (P=0.05). This short term benefit of early surgery was no longer significant by six months and continued to narrow between six months and 24 months. Patient satisfaction decreased slightly between one and two years for both groups. At two years 20% of all patients reported an unsatisfactory outcome.

CONCLUSIONS

Early surgery achieved more rapid relief of sciatica than conservative care, but outcomes were similar by one year and these did not change during the second year.

TRIAL REGISTRY

ISRCT No 26872154.

A panel assessment of glaucoma management: modification of existing RAND-like methodology for consensus in ophthalmology. Part I: Methodology and design

PURPOSE

To examine ways to improve existing methodology to reach appropriate consensus in the treatment of primary open-angle glaucoma.

DESIGN

Evidence-based literature and accumulated expert opinion.

METHODS

A core nonvoting steering committee composed of four individuals created 148 statements. Another nonvoting individual with expertise in clinical epidemiology reviewed all evidence in support of or against each statement and summarized this information. After review of these summaries, 10 panelists voted on each of the statements both before and after a panel meeting where each question was discussed by the panel. The polling was conducted online using a customized software program for the process.

RESULTS

Consensus was reached on most statements both before and after the panel meeting. The proportion of questions where consensus agreement or disagreement was reached increased from 82 of 148 before the panel meeting to 110 of 148 after the meeting. Detailed information regarding the results of the polling are provided in the accompanying article.(1)

CONCLUSIONS

Refinements to existing descriptions of modified RAND-like appropriateness methodology was successful in allowing a group of ophthalmology panelists to reach consensus for or against most statements developed by nonpanelists. Future studies should be conducted to compare how robust and valid this methodology is as compared with other methods of determining optimal clinical care decision making.

Use of evidence in WHO recommendations

BACKGROUND

WHO regulations, dating back to 1951, emphasise the role of expert opinion in the development of recommendations. However, the organisation's guidelines, approved in 2003, emphasise the use of systematic reviews for evidence of effects, processes that allow for the explicit incorporation of other types of information (including values), and evidence-informed dissemination and implementation strategies. We examined the use of evidence, particularly evidence of effects, in recommendations developed by WHO departments.

METHODS

We interviewed department directors (or their delegates) at WHO headquarters in Geneva, Switzerland, and reviewed a sample of the recommendation-containing reports that were discussed in the interviews (as well as related background documentation). Two individuals independently analysed the interviews and reviewed key features of the reports and background documentation.

FINDINGS

Systematic reviews and concise summaries of findings are rarely used for developing recommendations. Instead, processes usually rely heavily on experts in a particular specialty, rather than representatives of those who will have to live with the recommendations or on experts in particular methodological areas.

INTERPRETATION

Progress in the development, adaptation, dissemination, and implementation of recommendations for member states will need leadership, the resources necessary for WHO to undertake these processes in a transparent and defensible way, and close attention to the current and emerging research literature related to these processes.

Surgery versus prolonged conservative treatment for sciatica

BACKGROUND

Lumbar-disk surgery often is performed in patients who have sciatica that does not resolve within 6 weeks, but the optimal timing of surgery is not known.

METHODS

We randomly assigned 283 patients who had had severe sciatica for 6 to 12 weeks to early surgery or to prolonged conservative treatment with surgery if needed. The primary outcomes were the score on the Roland Disability Questionnaire, the score on the visual-analogue scale for leg pain, and the patient's report of perceived recovery during the first year after randomization. Repeated-measures analysis according to the intention-to-treat principle was used to estimate the outcome curves for both groups.

RESULTS

Of 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiskectomy after a mean of 2.2 weeks. Of 142 patients designated for conservative treatment, 55 (39%) were treated surgically after a mean of 18.7 weeks. There was no significant overall difference in disability scores during the first year (P=0.13). Relief of leg pain was faster for patients assigned to early surgery (P<0.001). Patients assigned to early surgery also reported a faster rate of perceived recovery (hazard ratio, 1.97; 95% confidence interval, 1.72 to 2.22; P<0.001). In both groups, however, the probability of perceived recovery after 1 year of follow-up was 95%.

CONCLUSIONS

The 1-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery if needed, but the rates of pain relief and of perceived recovery were faster for those assigned to early surgery. (Current Controlled Trials number, ISRCTN26872154 [controlled-trials.com].).

Improving the use of research evidence in guideline development: 3. Group composition and consultation process

Background

The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the third of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this.

Objective

In this review we address the composition of guideline development groups and consultation processes during guideline development.

Methods

We searched PubMed and three databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct systematic reviews ourselves. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments.

Key questions and answers

What should be the composition of a WHO-panel that is set up to develop recommendations?

The existing empirical evidence suggests that panel composition has an impact on the content of the recommendations that are made. There is limited research evidence to guide the exact composition of a panel. Based on logical arguments and the experience of other organisations we recommend the following:

• Groups that develop guidelines or recommendations should be broadly composed and include important stakeholders such as consumers, health professionals that work within the relevant area, and managers or policy makers.

• Groups should include or have access to individuals with the necessary technical skills, including information retrieval, systematic reviewing, health economics, group facilitation, project management, writing and editing.

• Groups should include or have access to content experts.

• To work well a group needs an effective leader, capable of guiding the group in terms of the task and process, and capable of facilitating collaboration and balanced contribution from all of the group members.

• Because many group members will not be familiar with the methods and processes that are used in developing recommendations, groups should be offered training and support to help ensure understanding and facilitate active participation.

What groups should be consulted when a panel is being set up?

We did not identify methodological research that addressed this question, but based on logical arguments and the experience of other organisations we recommend that as many relevant stakeholder groups as practical should be consulted to identify suitable candidates with an appropriate mix of perspectives, technical skills and expertise, as well as to obtain a balanced representation with respect to regions and gender.

What methods should WHO use to ensure appropriate consultations?

We did not find any references that addressed issues related to this question. Based on logical arguments and the experience of other organisations we believe that consultations may be desirable at several stages in the process of developing guidelines or recommendations, including:

• Identifying and setting priorities for guidelines and recommendations

• Commenting on the scope of the guidelines or recommendations

• Commenting on the evidence that is used to inform guidelines or recommendations

• Commenting on drafts of the guidelines or recommendations

• Commenting on plans for disseminating and supporting the adaptation and implementation of the guidelines or recommendations.

• Key stakeholder organisations should be contacted directly whenever possible.

• Consultation processes should be transparent and should encourage feedback from interested parties.

Use, appropriateness, and diagnostic yield of screening colonoscopy: an international observational study (EPAGE)

BACKGROUND

Screening for colorectal cancer (CRC) has been shown to decrease mortality.

OBJECTIVE

To examine determinants associated with having (1) a screening colonoscopy, (2) an appropriate indication for screening, and (3) a significant diagnosis at screening.

DESIGN

Prospective observational study.

SETTING

Twenty-one endoscopy centers from 11 countries.

PATIENTS

Asymptomatic patients who underwent a colonoscopy for the purpose of detecting CRC and who did not have a history of polyps or CRC, a lesion observed at a recent barium enema or sigmoidoscopy, or a recent positive fecal occult blood test.

INTERVENTION

Screening colonoscopy.

MAIN OUTCOME MEASUREMENTS

Appropriateness according to the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) criteria and significant diagnoses (cancer, adenomatous polyps, new diagnoses of inflammatory bowel disease, angiodysplasia).

RESULTS

Of 5069 colonoscopies, 561 (11%) were performed for screening purposes. Patients were more likely to have a screening colonoscopy if they were aged 45 to 54 years (odds ratio [OR] 2.53, 95% confidence interval [CI] 1.60-3.99). Screening colonoscopies were appropriate, uncertain, and inappropriate in 26%, 60%, and 14% of cases, respectively. Eighty-one significant diagnoses were made, including 4 cancers. Significant diagnoses were more often made for uncertain/appropriate indications (OR 3.20, 95% CI 1.12-9.17) than for inappropriate indications.

LIMITATIONS

Although data completeness was asked of all centers, it is possible that not all consecutive patients were included. Participating centers were a convenience sample and thus may not be representative.

CONCLUSIONS

About 1 of 10 colonoscopies were performed for screening, preferentially in middle-aged individuals. A higher diagnostic yield in uncertain/appropriate indications suggests that the use of appropriateness criteria may enhance the efficient use of colonoscopy for screening.

An experimental study of determinants of the extent of disagreement within clinical guideline development groups

OBJECTIVE

To assess the effect of design features and clinical and social cues on the extent of disagreement among participants in a formal consensus development process.

METHODS

Factorial design involving 16 groups consisting of 135 general practitioners (GPs) and 42 mental health professionals from England. The groups rated the appropriateness of four mental health interventions for three conditions (chronic back pain, irritable bowel syndrome, and chronic fatigue syndrome) in the context of various clinical and social cues. The groups differed in three design features: provision of a systematic literature review (versus not provided), group composition (mixed versus GP only), and assumptions about the healthcare resources available (realistic versus idealistic). Disagreement was measured using the mean absolute deviation from a group's median rating for a scenario.

RESULTS

None of the design features significantly affected the extent of disagreement within groups (all p>0.3). Disagreement did differ between treatments (closer consensus for cognitive behavioural therapy and behavioural therapy than for brief psychodynamic intervention therapy and antidepressants) and cues (closer consensus for depressed patients and patients willing to try any treatment).

CONCLUSION

In terms of the extent of disagreement in the groups in this study, formal consensus development was a robust technique in that the results were not dependent on the way it was conducted.

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.