Intervention usage for the management of low back pain in a chiropractic teaching clinic

Background Despite numerous low back pain (LBP) clinical practice guidelines, published studies suggest guideline nonconcordant care is still offered. However, there is limited literature evaluating the degree to which chiropractors, particularly students, follow clinical practice guidelines when managing LBP. The aim of this study was to evaluate the frequency of use of specific interventions for LBP by students at a chiropractic teaching clinic, mapping recommended, not recommend, and without recommendation interventions based on two clinical practice guidelines. Methods This was a retrospective chart review of patients presenting to the Canadian Memorial Chiropractic College teaching clinic with a new complaint of LBP from January to July 2019. Interventions provided under treatment plans for each patient were extracted. Interventions were classified as recommended, not recommended, or without recommendation according to two guidelines, the NICE and OPTIMa LBP guideline. Results 1000 patient files were identified with 377 files meeting the inclusion criteria. The most frequent interventions provided to patients were manipulation/mobilization (99%) and soft tissue therapy (91%). Exercise, localized percussion, and advice and/or education were included in just under half of the treatment plans. Patient files contained similar amounts of recommended (70%) and not recommended (80%) interventions according to the NICE guideline classification, with half the treatment plans including an intervention without recommendation. Under the OPTIMa acute guideline, patient files contained similar amounts of recommended and not recommended care, while more recommended care was provided than not recommended under the OPTIMa chronic guideline. Conclusions Despite chiropractic interns providing guideline concordant care for the majority of LBP patients, interventions classified as not recommended and without recommendation are still frequently offered. This study provides a starting point to understand the treatment interventions provided by chiropractic interns. Further research should be conducted to improve our understanding of the use of LBP guideline recommended care in the chiropractic profession. Trial registration Open Science Framework # g74e8.

The Impact of Clinical Practice Guidelines on Preoperative Antibiotic Administration for Carpal Tunnel Release

Background: In 2015, the American Association of Plastic Surgeons (AAPS) published a consensus statement against the routine use of preoperative antibiotic prophylaxis to prevent surgical site infection in clean hand surgery. The American Academy of Orthopaedic Surgeons (AAOS) similarly cited “insufficient evidence” in its Appropriate Use Criteria guidelines to support the use of antibiotics in carpal tunnel surgery. Nonetheless, its administration remains a common practice during clean hand surgery. We sought to evaluate the impact of the above guidelines on preoperative antibiotic administration. Methods: An institutional review board–approved retrospective chart review of consecutive patients with carpal tunnel syndrome treated with open carpal tunnel release (CTR) at our institution was performed in the 2 years before and after publication of AAPS/AAOS guidelines. Patient demographics and surgical outcomes were reviewed. Incidence of antibiotic administration, patient demographics, and surgeon factors were collected. Results: A total of 770 primary open CTR procedures were performed in the studied years. In 2013 and 2014, 83.9% of patients received preoperative antibiotics. In 2017 and 2018, 48.2% of patients received preoperative antibiotics. Of the variables analyzed, immunosuppression, history of diabetes, and poorly controlled diabetes (A1c > 7) were found to be statistically significant in its positive correlation to prophylactic preoperative antibiotic use. Diabetes was not associated with surgical site infections. Conclusion: Patients were more likely to receive preoperative antibiotics before the publication of the AAPS/AAOS clinical practice guidelines. Patients with diabetes regardless of their glycemic control are more likely to receive preoperative antibiotics.

Usefulness of Cochrane Reviews in Clinical Guideline Development—A Survey of 585 Recommendations

The Danish Health Authority develops clinical practice guidelines to support clinical decision-making based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system and prioritizes using Cochrane reviews. The objective of this study was to explore the usefulness of Cochrane reviews as a source of evidence in the development of clinical recommendations. Evidence-based recommendations in guidelines published by the Danish Health Authority between 2014 and 2021 were reviewed. For each recommendation, it was noted if and how Cochrane reviews were utilized. In total, 374 evidence-based recommendations and 211 expert consensus recommendations were published between 2014 and 2021. Of the 374 evidence-based recommendations, 106 included evidence from Cochrane reviews. In 28 recommendations, all critical and important outcomes included evidence from Cochrane reviews. In 36 recommendations, a minimum of all critical outcomes included evidence from Cochrane reviews, but not all important outcomes. In 33 recommendations, some but not all critical outcomes included evidence from Cochrane reviews. Finally, in nine recommendations, some of the important outcomes included evidence from Cochrane reviews. In almost one-third of the evidence-based recommendations, Cochrane reviews were used to inform clinical recommendations. This evaluation should inform future evaluations of Cochrane review uptake in clinical practice guidelines concerning outcomes important for clinical decision-making.