A Critical Appraisal of 2007 American College of Occupational and Environmental Medicine (ACOEM) Practice Guidelines for Interventional Pain Management: An Independent Review Utilizing AGREE, AMA, IOM, and Other Criteria

Background: Today, with the growing interest of the medical community and others in practice guidelines, there is greater emphasis on formal procedures and methods for arriving at a widely scrutinized and endorsed consensus than ever before. Conflicts in terminology and technique are notable for the confusion that guidelines create and for what they reflect about differences in values, experiences, and interests among different parties. While public and private development activities continue to multiply, the means for coordinating these efforts to resolve inconsistencies, fill in gaps, track applications and results, and assess the soundness of particular guidelines continue to be limited. In this era of widespread guideline development by private organizations, the American College of Occupational and Environment Medicine (ACOEM) has developed guidelines that evaluate areas of clinical practice well beyond the scope of occupational medicine and yet fail to properly involve physicians expert in these, especially those in the field of interventional pain management. As the field of guidelines suffers from imperfect and incomplete scientific knowledge as well as imperfect and uneven means of applying that knowledge without a single or correct way to develop guidelines, ACOEM guidelines have been alleged to hinder patient care, reduce access to interventional pain management procedures, and transfer patients into a system of disability, Medicare, and Medicaid. Objective: To critically appraise occupational medicine practice guidelines for interventional pain management by an independent review utilizing the Appraisal of Guidelines for Research and Evaluation (AGREE), American Medical Association (AMA), Institute of Medicine (IOM), and other commonly utilized criteria. Methods: Revised chapters of ACOEM guidelines, low back pain and chronic pain, developed in 2007 and 2008 are evaluated, utilizing AGREE, AMA, IOM instruments, and Shaneyfelt et al’s criteria, were independently reviewed by 4 appraisers. Results: Critical appraisal utilizing the AGREE instrument found that both chapters scored less than 10% in 3 of the 6 domains, less than 20% in one domain, over 30% in one domain, and over 70% in one domain. Global assessment also scored below 30% with a recommendation from AGREE, “not recommended or suitable for use in practice.” Based on AMA key attributes, both chapters of ACOEM guidelines met only one of the 6 key attributes, only 3 of the 8 attributes were met by IOM criteria, and based on the criteria described by Shaneyfelt et al, overall only 28% of criteria were met. Conclusion: Both the low back pain and chronic pain chapters of the ACOEM guidelines may not be ideal for clinical use based on the assessment by the AGREE instrument, AMA attributes, and criteria established by Shaneyfelt et al. They also scored low on IOM criteria (37.5%). These guidelines may not be applicable for clinical use. Key words: Evidence-based medicine, systematic reviews, guideline development, AHCPR, AHRQ, IOM, AMA, AGREE, workers’ compensation, guidelines, ACOEM, ASIPP, interventional pain management, interventional techniques, chronic pain guidelines, low back pain guidelines