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

The impact of patient preferences and costs on the appropriateness of spinal manipulation and mobilization for chronic low back pain and chronic neck pain

BACKGROUND

Although the delivery of appropriate healthcare is an important goal, the definition of what constitutes appropriate care is not always agreed upon. The RAND/UCLA Appropriateness Method is one of the most well-known and used approaches to define care appropriateness from the clinical perspective-i.e., that the expected effectiveness of a treatment exceeds its expected risks. However, patient preferences (the patient perspective) and costs (the healthcare system perspective) are also important determinants of appropriateness and should be considered.

METHODS

We examined the impact of including information on patient preferences and cost on expert panel ratings of clinical appropriateness for spinal mobilization and manipulation for chronic low back pain and chronic neck pain.

RESULTS

The majority of panelists thought patient preferences were important to consider in determining appropriateness and that their inclusion could change ratings, and half thought the same about cost. However, few actually changed their appropriateness ratings based on the information presented on patient preferences regarding the use of these therapies and their costs. This could be because the panel received information on average patient preferences for spinal mobilization and manipulation whereas some panelists commented that appropriateness should be determined based on the preferences of individual patients. Also, because these therapies are not expensive, their ratings may not be cost sensitive. The panelists also generally agreed that preferences and costs would only impact their ratings if the therapies were considered clinically appropriate.

CONCLUSIONS

This study found that the information presented on patient preferences and costs for spinal mobilization and manipulation had little impact on the rated appropriateness of these therapies for chronic low back pain and chronic neck pain. Although it was generally agreed that patient preferences and costs were important to the appropriateness of M/M for CLBP and CNP, it seems that what would be most important were the preferences of the individual patient, not patients in general, and large cost differentials.

An experimental study of the influence of individual participant characteristics on formal consensus development

Objectives:The aim of this study was to examine the influence of participants' characteristics on the results produced by formal consensus methods.

Methods:The approach was an experimental study of 346 participants in 20 groups rating the appropriateness of four mental health interventions for the treatment of chronic fatigue syndrome, irritable bowel syndrome, and chronic back pain. There were four factors in the design: systematic literature review provided or not, decisions made under realistic or “ideal” resource assumptions, clinically mixed (general practitioners and mental health professionals) or homogenous group (general practitioners only), convened or mail-only group. A group's rating was defined as the median of participants' ratings. The influence of participants' characteristics (age, sex, and specialty) was examined using multilevel models.

Results:The largest differences were between the GPs and mental health professionals, both in their initial ratings of the different interventions, and in how much they altered their ratings between rounds. There were smaller but statistically significant (p<.05) differences between specialty and age groups in initial ratings for the treatment (by whatever means) of different conditions, and for certain conditions women increased their ratings more than men. Women rated intervention more favorably when assuming “ideal” rather than realistic levels of resources, but men did not.

Conclusions:Our findings support the practice of treating professional specialty as an important determinant of the results in consensus panels.

Developing clinical guidelines: a challenge to current methods

Current methods for producing clinical guidelines are cumbersome and not always reliable. Could a more streamlined approach improve coverage and make decisions more transparent?