Are clinical practice guidelines for low back pain interventions of high quality and updated? A systematic review using the AGREE II instrument

Abstract

Background Clinical practice guidelines (CPGs) provide recommendations for practice, but the proliferation of CPGs issued by multiple organisations in recent years has raised concern about their quality. The aim of this study was to systematically appraise CPGs quality for low back pain (LBP) interventions and to explore inter-rater reliability (IRR) between quality appraisers. The time between systematic review search and publication of CPGs was recorded. Methods Electronic databases (PubMed, Embase, PEDro, TRIP), guideline organisation databases, websites, and grey literature were searched from January 2016 to January 2020 to identify GPCs on rehabilitative, pharmacological or surgical intervention for LBP management. Four independent reviewers used the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool to evaluate CPGs quality and record the year the CPGs were published and the year the search strategies were conducted. Results A total of 21 CPGs met the inclusion criteria and were appraised. Seven (33%) were broad in scope and involved surgery, rehabilitation or pharmacological intervention. The score for each AGREE II item was: Editorial Independence (median 67%, interquartile range [IQR] 31–84%), Scope and Purpose (median 64%, IQR 22–83%), Rigour of Development (median 50%, IQR 21–72%), Clarity and Presentation (median 50%, IQR 28–79%), Stakeholder Involvement (median 36%, IQR 10–74%), and Applicability (median 11%, IQR 0–46%). The IRR between the assessors was nearly perfect (interclass correlation 0.90; 95% confidence interval 0.88–0.91). The median time span was 2 years (range, 1–4), however, 38% of the CPGs did not report the coverage dates for systematic searches. Conclusions We found methodological limitations that affect CPGs quality. In our opinion, a universal database is needed in which guidelines can be registered and recommendations dynamically developed through a living systematic reviews approach to ensure that guidelines are based on updated evidence. Level of evidence 1 Trial registration REGISTRATION PROSPERO DETAILS: CRD42019127619.

Strategies to build and maintain competence in pain management: Insights from a SIAARTI survey on educational needs among Italian anesthesiologists

“…Therefore, fulfilling educational needs in pain management should be a lifelong process involving the anesthesiologists/pain therapists. Clear critical issues emerge from our results, being chronic pain, cancer pain, pediatric pain, MSK pain 32–36 and the risk of addiction, 37–39 in agreement with what has already been underlined by other studies and documents 20,28,40 . Although in Italy the average percapita/a year morphine equivalent dose (MED) is 144, which is far below the average of 693 MED a year in the USA and other European and non‐European countries (taking in consideration the six most common opioids), addiction, abuse, and misuse of prescription opioid analgesics remain a concern 22,41–44 .…”

“…The questionnaire comprised 72 questions addressing the following items: education, skills (both soft and hard skills), and technical expertise. The results were aggregated based on region of origin, year of specialization, and seniority [four groups of specialists: (31)(32)(33)(34)(35)(36)(37)(38)(39)(40), (41)(42)(43)(44)(45)(46)(47)(48)(49)(50), (51-60), over 61]. The data were analyzed and presented on a regional basis to highlight any interregional differences due to the organization of the Italian Health System, which provides for ample autonomy both in terms of budget and strategic choices of the regions.…”

More than one third of clinical practice guidelines on low back pain overlap in AGREE II appraisals. Research wasted?

“…The rating of all six domains was reported in 14 appraisals (82.4%) [ 17 , 25 – 35 , 37 , 40 ] and the rating of 23 item scores in two [ 36 , 39 ]. Overall assessment 1 (overall CPG quality) was reported in 11 appraisals (64.7%) [ 25 – 30 , 32 – 34 , 37 , 40 ] and overall assessment 2 (recommendation for use) in four (23.5%) [ 25 , 27 , 28 , 32 ]. A quality rating (not part of the AGREE II tool) was given in nine appraisals (53%) [ 17 , 26 , 28 , 29 , 33 , 34 , 36 , 37 , 39 ].…”

“…OF RATERS NO. OF CPG POPULATION INTERVENTION ACEVEDO 2016 [ 25 ] No 2000 - 2014 2 5 Chronic LBP Interventional management (surgical and non-surgical) ANDERSON 2021 [ 26 ] PROSPERO Inception - January 2020 2 10 Lumbar spinal stenosis Diagnosis, treatment, management CASTELLINI 2020 [ 27 ] PROSPERO January 2016 - January 2020 4 21 LBP Rehabilitation, pharmacological or surgical therapy CORP 2021 [ 28 ] Online repository January 2013 - May 2020 1-2 12 Adults with neck pain and LBP including whiplash-related disorders or symptoms of radiculopathy (e.g., radicular pain) Treatment deliverable via primary care or referral pathways to secondary care DONISELLI 2018 [ 29 ] No 2009 - March 2017 4 8 LBP Assessment and management ERNSTZEN 2017 [ 30 ] PROSPERO 2000 - May 2015 3 12 Adults with chronic MSK pain including LBP Evaluation, diagnosis, and management of chronic MSK pain FRANZ 2015 [ 31 ] No <...…”

“…We are aware that a CPG has a limited life span between systematic search strategy to answer the clinical questions and year of publication of the guideline itself [ 27 ]. The validity of recommendations more than three years old is often potentially questionable [ 103 ].…”