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PubMed2005

Who's calling the shots? Pediatricians' adherence to the 2001-2003 pneumococcal conjugate vaccine-shortage recommendations.

BACKGROUND: A national shortage of heptavalent pneumococcal conjugate vaccine (PCV7) occurred from September 2001 through May 2003. In December 2001 and January 2002, the Advisory Committee on Immunization Practices and the American Academy of Pediatrics (AAP) issued PCV7-shortage recommendations, emphasizing that all health care providers decrease the number of doses for healthy children so that more children could receive some PCV7. OBJECTIVES: We assessed (1) how the PCV7 shortage affected pediatricians, (2) whether children in the public and private sectors were vaccinated differently during the shortage, (3) pediatricians' knowledge of and adherence to the Advisory Committee on Immunization Practices/AAP recommendations, (4) and what factors were associated with nonadherence to the recommendations. METHODS: We conducted a cross-sectional mail survey of 2500 US physician-members of the AAP from November 2002 through March 2003; physicians providing childhood immunizations were eligible. We asked about PCV7-shortage experience, assessed recommendation adherence through clinical scenarios, and modeled potential factors associated with reported nonadherence to the recommendation to defer the fourth PCV7 dose. RESULTS: Of 2478 surveys sent to valid addresses, 1412 (57%) completed surveys were received; 946 (67%) of these were from eligible pediatricians. Overall, 79% experienced a PCV7 shortage, 94% reported being aware of the recommendations, and 42% reported barriers to recommendation adherence. Ninety-four percent reported vaccinating 6-month-old infants with private or public insurance in the same manner. As recommended, 91% reported fully vaccinating high-risk patients. Contrary to recommendations, 49% reported sometimes or always administering the fourth PCV7 dose to healthy children 12 to 15 months old; their reasons included recurrent otitis media, childcare attendance, and parental desire. Controlling for other characteristics, pediatricians who had no PCV7 shortage in their practices were significantly more likely to report administering the fourth dose than pediatricians who had a shortage (odds ratio [OR]: 3.67; 95% confidence interval [CI]: 2.40-5.63). Other factors associated with nonadherence were being in solo private practice (OR: 2.18; 95% CI: 1.26-3.77) or being male (OR: 1.51; 95% CI: 1.08-2.12). Among pediatricians deferring PCV7, 36% reported having no system to track children for whom PCV7 was deferred. CONCLUSIONS: Many pediatricians, both with and without a PCV7 shortage, administered more PCV7 doses than recommended. Pediatricians without a shortage were less likely to limit use, which suggests that they might have focused on the perceived value of administering the full schedule to their patients in preference to broader public health goals. Providing more information to physicians on the effectiveness of a fewer-dose schedule and the risk of disease when vaccine is deferred and educating parents might increase adherence to recommendations and achieve more equitable coverage during vaccine shortages.

Cross-Sectional Studies↗
PubMed2005

Acute diarrhea's recommendations on oral rehydration therapy and feeding.

Oral rehydration therapy and feeding for patients with diarrhea recommended by physicians who had attended the short course "Practical Approach to Common GI Problems" were compared with The Royal College of Pediatricians of Thailand Expert Committee on Gastrointestinal System's (RCPedT) Recommendations. A questionnaire was sent to physicians who had attended the short course. Physicians recommended a variety of oral rehydration solutions (ORS) which were different from RCPedT's recommendations. 42.6% of physicians recommended WHO/ORS, 54.1% recommended commercial ORS and 3.3% recommended any form of ORS. The other form of ORS, 59.0% of physicians recommended was carbonated drinks (nonphysiologic ORS) and 40.9% recommended home mixing of ORS. 55.7% of respondents recommended ORT for mild or moderate dehydration and 29.5% for mild or no dehydration only 14.8% of the physicians followed the guidelines. Although RCPedT WHO and American Academy of Pediatrics (AAP) Committee on Nutrition stated that vomiting was not a contraindication to successful use of ORT but vomiting was the most common reason (86.9%) given by respondents for failure of ORT and vomiting was the reason for starvation as well (11.5%). Early feeding of appropriate food 80.3% of respondents followed the guidelines but only 50.7% of respondents recommended breast feeding for children younger than 1 year old.

Acute Disease↗
PubMed1997

Prevention of bacterial endocarditis. Recommendations by the American Heart Association.

OBJECTIVE: To update recommendations issued by the American Heart Association last published in 1990 for the prevention of bacterial endocarditis in individuals at risk for this disease. PARTICIPANTS: An ad hoc writing group appointed by the American Heart Association for their expertise in endocarditis and treatment with liaison members representing the American Dental Association, the Infectious Diseases Society of America, the American Academy of Pediatrics, and the American Society for Gastrointestinal Endoscopy. EVIDENCE: The recommendations in this article reflect analyses of relevant literature regarding procedure-related endocarditis, in vitro susceptibility data of pathogens causing endocarditis, results of prophylactic studies in animal models of endocarditis, and retrospective analyses of human endocarditis cases in terms of antibiotic prophylaxis usage patterns and apparent prophylaxis failures. MEDLINE database searches from 1936 through 1996 were done using the root words endocarditis, bacteremia, and antibiotic prophylaxis. Recommendations in this document fall into evidence level III of the US Preventive Services Task Force categories of evidence. CONSENSUS PROCESS: The recommendations were formulated by the writing group after specific therapeutic regimens were discussed. The consensus statement was subsequently reviewed by outside experts not affiliated with the writing group and by the Science Advisory and Coordinating Committee of the American Heart Association. These guidelines are meant to aid practitioners but are not intended as the standard of care or as a substitute for clinical judgment. CONCLUSIONS: Major changes in the updated recommendations include the following: (1) emphasis that most cases of endocarditis are not attributable to an invasive procedure; (2) cardiac conditions are stratified into high-, moderate-, and negligible-risk categories based on potential outcome if endocarditis develops; (3) procedures that may cause bacteremia and for which prophylaxis is recommended are more clearly specified; (4) an algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse; (5) for oral or dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended, erythromycin is no longer recommended for penicillin-allergic individuals, but clindamycin and other alternatives are offered; and (6) for gastrointestinal or genitourinary procedures, the prophylactic regimens have been simplified. These changes were instituted to more clearly define when prophylaxis is or is not recommended, improve practitioner and patient compliance, reduce cost and potential gastrointestinal adverse effects, and approach more uniform worldwide recommendations.

Antibiotic Prophylaxis↗
PubMed2003

Older age predicts a decline in adjuvant chemotherapy recommendations for patients with breast carcinoma: evidence from a tertiary care cohort of chemotherapy-eligible patients.

BACKGROUND: The appropriate use of adjuvant chemotherapy for elderly women with breast carcinoma remains controversial. Efficacy data in women age >/= 70 years are scarce, resulting in a lack of clear guidelines for patients in this age group. Although several studies have demonstrated decreasing use of chemotherapy with age, none specifically examined its use in an elderly cohort of patients who were deemed eligible for such therapy based on consensus guidelines, simultaneously examining the impact of comorbidity and previous history of malignant disease on these recommendations. METHODS: The authors examined adjuvant chemotherapy use among chemotherapy-eligible patients age > or = 50 years who were evaluated in a tertiary care cancer center. Associations between patient age and 1) physician recommendation for adjuvant chemotherapy, 2) recommended treatment regimen, and 3) patient acceptance of the treatment plan recommended were examined, adjusting for the impact of aggressive tumor characteristics, medical comorbidity, previous history of malignant disease, and features of the treatment setting. RESULTS: Of the 208 chemotherapy-eligible patients who were studied, 74% overall were recommended chemotherapy. Chemotherapy was recommended to 92% of women age 50-59 years compared with 77% of women age 60-69 years and 23% of women age > or = 70 years. Increasing age was associated strongly with a decreasing likelihood of receiving a recommendation in favor of chemotherapy. After adjusting for estrogen receptor status, previous history of malignant disease, comorbidity score, and prognostic group, the odds of receiving a recommendation in favor of chemotherapy fell by 22% per year or 91% per 10-year interval, and the rate of decline did not change significantly at age > or = 70 years. We found no age-related differences in either the drug regimens recommended or patient acceptance rates for adjuvant therapy. CONCLUSIONS: Age was associated strongly and independently with physician recommendation for adjuvant chemotherapy among a group of older women who were eligible specifically for such therapy. Medical comorbidity and a history of previous malignant disease did not alter this correlation significantly, although the latter was a significant predictor of chemotherapy use. Further studies clearly are needed to determine the underlying reasons for this strong age effect and to explore strategies that will optimize the utilization of this potentially curative therapy in the elderly.

Age Factors↗
PubMed1995

Adherence to screening mammography recommendations in a university general medicine clinic.

OBJECTIVE: To determine factors predicting adherence to a health care provider's screening mammography recommendation in a general internal medicine practice. DESIGN: Prospective observational study. SETTING: An urban academic general internal medicine practice. PATIENTS: Three hundred forty-nine asymptomatic women, aged 50 years and older, without prior history of breast cancer, who received a health care provider's recommendation for screening mammography. MEASUREMENT: Independent variables were: patient age, race, insurance type, educational level, and duration of affiliation with the practice; visit type; and health care provider gender and level of training. Dependent variables were acceptance of the recommendation and adherence, defined as undergoing mammography within three months of the recommendation. RESULTS: Overall, 193 (55%) of the women underwent the recommended mammography. Two hundred ninety-eight (85%) initially agreed to the recommendation, and of these, 190 (64%) completed mammography within three months. By univariate analysis, acceptance of the recommendation decreased significantly with increasing age (p < 0.01), and by race (African-Americans 89% vs whites 82%, p = 0.05). Only age remained independently predictive of acceptance in a multiple variable analysis. Among women who accepted the recommendation, adherence varied significantly according to race (white 70% vs nonwhite 59%, p = 0.05), insurance type [Medicare as only insurance 45%, Medicaid 66%, non-health maintenance organization (non-HMO) private 62%, HMO 73%, p = 0.03], and health care provider training (attending physicians 73%, residents 58%, nurse practitioners 47%, p = 0.02). In a logistic regression analysis, insurance type and health care provider training remained independently predictive of adherence. CONCLUSION: Acceptance of screening mammography recommendations decreases with age. Among the women who agreed to the recommendation for screening mammography, insurance type and health care provider level of training best predicted adherence.

Age Factors↗
PubMed2006

[Recommendations for the management of ankylosing spodylitis after ASAS/EULAR. Evaluation in the German language area].

AIM: Our aim was to adapt and implement the evidence based recommendations for the management of ankylosing spodylitis (AS) of the "Assessments in AS" (ASAS) International Working Group together with the European League Against Rheumatism (EULAR) within the framework of a competence network (CN) in rheumatology in the German language area. METHODS: The ASAS/EULAR project calculated the effective size (ES), rate ratio, number of patients requiring treatment (number needed to treat, NNT) and the incremental cost-effectiveness ratio (ICER). The strength of the recommendations was determined through the evidence level found in the literature, the risk-benefit trade-off and the clinical experience of the experts. The recommendations were recently published in English. All of the centers taking part in the study area Spondyloarthritis (SpA) CN, as well as an additional 35 experts, were sent the English manuscript. All 35 participants were asked to evaluate the ten main management recommendations on a scale from 0 to 10. RESULTS: The recommendations encompass the use of drugs such as non-steroid anti-inflammatories (NSAR), which, along with conventional NSAR include coxibs and the parallel application of gastroprotectives, so called disease-modifying anti-rheumatic drugs, biologicals, simple analgesics, local and systematic glucocorticoids, non-drug therapies (such as patient training, medical training therapy and physiotherapy), in addition to surgical treatment methods. Moreover, three general recommendations were formulated and a therapy scheme created, taking into consideration the various clinical manifestations. The strength of the ASAS/EULAR recommendations was generally high. There was a marked consensus between the German speaking experts and the international proposal: a mean of 9.13 with relatively low variation between the recommendations. SUMMARY: Ten key recommendations for the treatment of AS were developed. These were strengthened by a systematic search of the literature and by expert consensus. The large group of German speaking experts were largely in agreement with the proposal. This can be seen as a starting point for the dissemination and implementation of the recommendations.

Analgesics↗
PubMed2005

Non-antibiotic treatment recommendations: delivery formats and implications for parent resistance.

This study draws on a database of 570 community-based acute pediatric encounters in the USA and uses conversation analysis as a methodology to identify two formats physicians use to recommend non-antibiotic treatment in acute pediatric care (using a subset of 309 cases): recommendations for particular treatment (e.g., "I'm gonna give her some cough medicine.") and recommendations against particular treatment (e.g., "She doesn't need any antibiotics."). The findings are that the presentation of a specific affirmative recommendation for treatment is less likely to engender parent resistance to a non-antibiotic treatment recommendation than a recommendation against particular treatment even if the physician later offers a recommendation for particular treatment. It is suggested that physicians who provide a specific positive treatment recommendation followed by a negative recommendation are most likely to attain parent alignment and acceptance when recommending a non-antibiotic treatment for a viral upper respiratory illness.

Anti-Bacterial Agents↗
PubMed2003

Guideline chaos: conflicting recommendations for preoperative cardiac assessment.

The American College of Cardiology/American Heart Association (ACC/AHA) and the American College of Physicians (ACP) have disseminated guidelines to assess preoperative cardiac risks before noncardiac surgery. The objectives of this study were to determine if these guidelines differ in preoperative recommendations for a group of patients, and whether these recommendations differ from actual provider recommendations. In this retrospective cohort study, patient characteristics and physician recommendations were abstracted from electronic medical records of consecutive patients attending a Veteran Affairs medical preoperative evaluation clinic from January 1 to April 1, 1998. Patient characteristics were used to determine what preoperative cardiac testing should have been ordered if each guideline was followed. Possible recommendations included operation without testing (OWT), noninvasive stress testing (NST), cardiac catheterization (CC), or cancel or delay surgery (OTHER). Recommendations were compared using statistical tests for agreement. Of the 138 patients identified, most underwent moderate-risk surgeries. Recommendations for preoperative testing were discordant between guidelines for 17% of patients (kappa = 0.38). Guidelines never agreed on the need for NST. Extreme differences in recommendations (i.e., one recommends OWT, the other CC) occurred in 9 patients (7%). Physicians ordered NST more often (n = 27) than either guideline. In this subgroup of patients where providers ordered a NST, the 2 guidelines significantly differed (kappa = 0.26). When applied to real patients being evaluated for surgery, ACC/AHA and ACP guidelines significantly differed in recommendations for preoperative cardiac testing. Results have implications for implementation, management, and practitioner adherence to published guidelines.

Adult↗
PubMed2000

Effect of physician specialty on treatment recommendation to patients with coronary artery disease.

OBJECTIVE: To assess the influence of physician specialty and the way in which patient data are presented in the treatment recommended for patients with coronary artery disease. METHODS: In a prospective study, 3,628 patients with significant coronary artery disease who had been referred to 1 of 10 heart centers in the Netherlands as possible candidates for either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft surgery (CABG) were recruited. Within each center, the recommended treatment is determined by a team consisting of cardiologists only, cardiovascular surgeons only, or cardiologists and cardiovascular surgeons (i.e., composite teams). The main outcome measures are the proportions of patients for whom PTCA, CABG, or noninvasive (medical) therapy was recommended. RESULTS: Composite teams made 71% of recommendations, surgeon-only teams, 12%, and cardiologist-only teams, 17%. Cardiologist-only teams primarily recommended patients to PTCA, surgeon-only teams to CABG, while combined teams made more evenly distributed recommendations (p < .001). Although the patients discussed by the three types of teams were clinically different, the recommendation patterns remained significant after adjusting for these differences (p < .001). For patients with recent myocardial infarction, direct presentation of the case to the team by the referring cardiologist reduced the likelihood that CABG would be recommended. CONCLUSIONS: The treatment recommended to patients with coronary artery disease is affected by the composition of the team providing the recommendation. These findings have important implications for clinical decision making for patients with cardiovascular disease.

Adult↗
PubMed2006

Recommendations in health technology assessments worldwide.

OBJECTIVES: The objective of this study is to analyze statistically the possible determinants and implications of including or not including recommendations in health technology assessments (HTAs). METHODS: A sample of 433 HTAs published by eleven leading institutions or agencies in nine countries was reviewed and analyzed statistically by multiple logistic regression. RESULTS: The extent of policy and research recommendations in HTAs varies greatly from country to country. The content and scope of HTAs have some impact on recommendations. Extensive assessment of economic and organizational aspects increases the likelihood of including policy recommendations. Extensive assessment of technological and patient aspects increases the likelihood of including research recommendations, whereas extensive focus on economic aspects is negatively related to research recommendations. The most striking result is that the use of external partners for assessment increases the likelihood of including research recommendations in HTAs but not policy recommendations. CONCLUSIONS: HTA commissioners, agencies, institutions, and funding authorities need to be aware of the consequences of the choices they make in advance of assessing health technologies. Outsourcing HTA to external partners suggests a greater likelihood of being told that "more research is needed." The scope and content of HTAs has an impact on the type of recommendations, and country-specific preferences are strong predictors of recommendations in HTAs.

Health Policy↗
PubMed2004

Over-the-counter topical antipruritic agents are commonly recommended by office-based physicians: an analysis of US practice patterns.

BACKGROUND: Pruritus is one of the most common complaints among patients who visit physicians. Over-the-counter topical antipruritic medications are widely recommended by physicians and are self-administered by patients for the treatment of pruritus. However, there are few scientific controlled studies evaluating the effect of these drugs on pruritus. OBJECTIVES: To assess the role of physician-recommended over-the-counter medications for the treatment of pruritus. METHODS: Records were analyzed for office-based physician visits in which over-the-counter antipruritic topical medications were recommended in the National Ambulatory Medical Care Survey between the years 1995 and 2000. RESULTS: The largest proportion of over-the-counter antipruritic agent recommendations were during visits to dermatologists, accounting for 41% of all such recommendations. Other physicians that recommended such agents included family physicians and pediatricians, accounting respectively for 26% and 21% of the recommendations. The most commonly recommended over-the-counter medications included hydrocortisone preparations (72%) and diphenhydramine (15%). Over-the-counter medications were more frequently recommended in the pediatric age group. CONCLUSION: This study demonstrates that over-the-counter medications are frequently recommended for the treatment of pruritus.

Adolescent↗
PubMed2006

n-3 fatty acid dietary recommendations and food sources to achieve essentiality and cardiovascular benefits.

Dietary recommendations have been made for n-3 fatty acids, including alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA) to achieve nutrient adequacy and to prevent and treat cardiovascular disease. These recommendations are based on a large body of evidence from epidemiologic and controlled clinical studies. The n-3 fatty acid recommendation to achieve nutritional adequacy, defined as the amount necessary to prevent deficiency symptoms, is 0.6-1.2% of energy for ALA; up to 10% of this can be provided by EPA or DHA. To achieve recommended ALA intakes, food sources including flaxseed and flaxseed oil, walnuts and walnut oil, and canola oil are recommended. The evidence base supports a dietary recommendation of approximately 500 mg/d of EPA and DHA for cardiovascular disease risk reduction. For treatment of existing cardiovascular disease, 1 g/d is recommended. These recommendations have been embraced by many health agencies worldwide. A dietary strategy for achieving the 500-mg/d recommendation is to consume 2 fish meals per week (preferably fatty fish). Foods enriched with EPA and DHA or fish oil supplements are a suitable alternate to achieve recommended intakes and may be necessary to achieve intakes of 1 g/d.

Cardiovascular Diseases↗
PubMed1997

Determinants of patient adherence to consultative comprehensive geriatric assessment recommendations.

BACKGROUND: In consultative models of Comprehensive Geriatric Assessment (CGA), lack of implementation of CGA recommendations is well documented and appears to be a potential explanation for negative findings. The purpose of this study is to identify patient determinants of adherence to recommendations received from a community-based CGA consultative model program. METHODS: Subjects (N = 139) received self-care and/or physician-initiated CGA recommendations and were interviewed three months later to determine adherence with the most important recommendation, and health belief, communication, and social support factors associated with adherence. Independent variables were organized into the Andersen Behavioral Model for analysis. RESULTS: At the bivariate level, one predisposing factor (intention) and six enabling factors (low difficulty level, high support, high utility, high self-efficacy, agreement on the importance of the recommendation and good specific communication about the recommendation) were significant determinants of adherence. Two functional health measures and seriousness of the target condition of the recommendation were significant need factors. In the final logistic regression model, one predisposing variable (intention), one enabling variable (utility), and one need factor (high functional status), and two interaction terms significantly predicted adherence. CONCLUSION: CGA recommendations that are seen as worthwhile, not too much trouble, and able to be accomplished are the most likely to be initiated. Older adults with relatively higher functional levels are also more likely to follow through with CGA recommendations even though their needs may be lower. We found the Andersen Behavioral Model useful in the analysis of factors associated with adherence behavior to consultative CGA recommendations.

Aged↗
PubMed2003

Frequency and predictive value of a mammographic recommendation for short-interval follow-up.

BACKGROUND: A recommendation for short-interval follow-up of "probably benign finding" is associated with up to 11% of screening mammograms, but its predictive value for breast cancer is unclear. We examined the predictive values (i.e., the percentage of women with a diagnosis of breast cancer 2 years after a short-interval follow-up recommendation) and likelihood ratios (derived from the pretest and post-test odds of breast cancer in the Women's Health Initiative sample) for breast cancer that are associated with a recommendation for short-interval follow-up among postmenopausal women. METHODS: We performed a longitudinal analysis of a prospective cohort of 68 126 postmenopausal women (aged 50-79 years) who were participating in clinical trials as part of the Women's Health Initiative at 40 centers across the United States. Eligible participants had screening mammograms at baseline and at least 2 years of follow-up that included a repeat mammography. Outcomes measured were breast cancer events at 1 and 2 years after baseline and the results of subsequent mammograms. All P values were two-sided. RESULTS: A total of 2927 (5%) of the 58 408 eligible women had baseline mammograms that included recommendations for short-interval follow-up. The incidence of breast cancer for women with a short-interval follow-up recommendation was 1.0% at 2 years after the baseline mammogram compared with breast cancer incidences of 0.6% and 0.5% for women whose baseline mammograms were described as "benign" and "negative," respectively. Across the 40 participating centers, the prevalence of short-interval follow-up recommendations among baseline mammograms varied from 1.2% to 9.8% (P<.001), even when the analysis was adjusted for key variables in regression models. Centers reporting higher frequencies of such recommendations did not have lower positive predictive values for breast cancer than centers reporting lower frequencies. The likelihood ratio for breast cancer after a recommendation for short-interval follow-up on a subsequent mammogram was 2.20 (95% confidence interval = 1.65 to 2.86). CONCLUSION: Having a mammographic recommendation for short-interval follow-up was associated with a low positive predictive value for breast cancer among postmenopausal women during a 2-year follow-up. This result suggests that the current criteria for this recommendation-repeat mammography within 6 months-should be reconsidered.

Aged↗
PubMed2001

Ageism in medical students' treatment recommendations: the example of breast-conserving procedures.

PURPOSE: Age bias may play a role in physicians' discussions of equivalent therapeutic options with patients, especially in respect to breast-conservation therapy. This study investigated bias based on age (ageism) among physicians-in-training in their treatment recommendations for breast-conserving procedures. METHOD: Second-year medical students responded to a questionnaire concerning recommendations they would make for breast conservation or mastectomies with or without breast reconstruction for eight patients with similar-stage breast cancer. The patients differed by age (older were > or =59 years, younger < or =31 years), race, and marital status. A total of 116 students made 1,146 recommendations. Percentages of the students' recommendations for breast-conservation therapy (BCT) were calculated for the two patient age groups and for the recommendations for breast reconstruction after the patient had already chosen modified radical mastectomy (MRM). Chi-square tests were used for statistical analysis. RESULTS: The students recommended BCT for a significantly higher percentage of younger patients than older patients (86% versus 66%; p<.001). They recommended MRM to 34% of older patients versus 14% of younger patients (p<.001). Furthermore, the students recommended breast reconstruction after MRM to a significantly higher percentage of younger patients than older patients (95% versus 65%; p<.001). CONCLUSIONS: Medical students' recommendations of breast conservation and breast reconstruction showed age bias. Educational efforts should be instituted during the medical school to decrease ageism in students' treatment recommendations.

Adult↗
PubMed1997

Classics from the spine literature revisited: a randomized trial of 2 versus 7 days of recommended bed rest for acute low back pain.

STUDY DESIGN: Review of a trial of bed rest for patients with acute low back pain. OBJECTIVES: To assess the validity and results of the study, and their applicability to and influence on current clinical practice and recommendations. SUMMARY OF BACKGROUND DATA: Although bed rest has been a cornerstone of treatment for acute low back pain, historically this recommendation was largely based on "expert opinion." In 1986, Deyo et al. published a randomized study of 2 versus 7 days of recommended bed rest for acute low back pain. Despite results from this and other studies, current clinical practice and treatment recommendations continue to overemphasize bed rest. METHODS: The study was reviewed using structured criteria adopted from the medical literature that focus on the validity of the study design, the results of the treatment, and the relevance of the findings to clinical practice. RESULTS: Two hundred and three patients were randomized to 2 versus 7 days of recommended bed rest. Groups were similar at baseline evaluation. Outcomes assessed at 3 and 12 weeks were similar between groups, except that patients receiving a recommendation for 2 days of bed rest had significantly fewer days of work absence than those recommended 7 days. Limitations of the study included poor compliance with recommended bed rest, especially in the 7-day group, a marginal sample size without information on relevant confidence intervals, and patient characteristics that may have affected the generalizability of these findings to others with acute low back pain. CONCLUSIONS: Despite limitations, this study provided strong evidence that less bed rest was associated with similar outcomes for acute low back pain along with quicker return to work. Results from this and other studies support a shift away from bed rest as a primary recommendation in the initial management of low back pain. In spite of this, bed rest recommendations for episodes of low back pain remain common. Additional efforts are needed to change clinical practice.

Absenteeism↗
PubMed2006

Evidence-based clinical guidelines: a new system to better determine true strength of recommendation.

RATIONALE, AIMS AND OBJECTIVES: Clinical practice guidelines often grade the 'strength' of their recommendations according to the robustness of the supporting research evidence. The existing methodology does not allow the strength of recommendation (SOR) to be upgraded for recommendations for which randomized controlled trials are impractical or unethical. The purpose of this study was to develop a new method of determining SOR, incorporating both research evidence and expert opinion. METHODS: A Delphi technique was employed to produce 10 recommendations for the role of exercise therapy in the management of osteoarthritis of the hip or knee. The SOR for each recommendation was determined by the traditional method, closely linked to the category of research evidence found on a systematic literature search, and on a visual analogue scale (VAS). Recommendations were grouped A-D according to the traditional SOR allocated and the mean VAS calculated. Difference across the groups was assessed by one-way ANOVA variance analysis. RESULTS: Mean VAS scores for the traditional SOR groups A-D and one proposition which was 'not recommended' showed significant linearity on one-way ANOVA. However, certain recommendations which, for practical reasons, could not assessed in randomized controlled trials and therefore could not be recommended strongly by the traditional methodology, were allocated a strong recommendation by VAS. CONCLUSIONS: This new system of grading strength of SOR is less constrained than the traditional methodology and offers the advantage of allowing SOR for procedures which cannot be assessed in RCTs for practical or ethical reasons to be upgraded according to expert opinion.

Analysis of Variance↗
PubMed2006

Breast cancer risk and provider recommendation for mammography among recently unscreened women in the United States.

BACKGROUND AND OBJECTIVE: Many women with increased breast cancer risk have not been screened recently. Provider recommendation for mammography is an important reason many women undergo screening. We examined the association between breast cancer risk and reported provider recommendation for mammography in recently unscreened women. DESIGN: Cross-sectional study using 2000 National Health Interview Survey. PARTICIPANTS: In all, 1673 women ages 40 to 75 years without cancer who saw a health care provider in the prior year and had no mammogram within 2 years. MEASUREMENTS AND ANALYSIS: We assessed breast cancer risk by Gail score and risk factors. We used multivariable logistic regression models in SUDAAN adjusted for age, race and illness burden, to examine the association between risk and reported recommendation for mammography within 1 year for all women and women ages 50 to 75 years. RESULTS: Of 1673 recently unscreened women, 29% reported a recommendation. Twelve percent of women had increased Gail risk and of these recently unscreened, high-risk women, 25% reported a recommendation. After adjustment, high-risk women were not more likely to report a recommendation than average-risk women. Results were similar for women 50 to 75 years old. No individual breast cancer factors other than age were associated with reporting a recommendation. CONCLUSIONS: Approximately 70% of recently unscreened women seen by a health care provider in the prior year reported no recommendation for mammography, regardless of breast cancer risk. This did not include women who received a recommendation and were screened. Increasing reported recommendation rates may represent an opportunity to increase screening participation among recently unscreened women, particularly for women with increased breast cancer risk.

Adult↗