No Recommendation Is (at Least Presently) the Best Recommendation: An Updating Quality Appraisal of Recommendations on Screening for Scoliosis
Abstract
:1. Introduction
1.1. Rationale
1.2. Objectives
2. Materials and Methods
2.1. Study Conduct and Reporting
2.2. Steps of the Study
2.3. Eligibility Criteria
2.3.1. Guidelines and Recommendation Statements
2.3.2. Review Reports
2.4. Identification of Relevant Publications
2.5. Appraisals and Quality Assessments
2.5.1. Guidelines and Recommendation Statements
2.5.2. Evidence Syntheses
3. Results
3.1. Updating Search Results
3.2. Quality of Guideline Development
3.3. Strengths of Recommendations and Levels of Evidence
3.4. Methodological Quality of Evidence Reviews
4. Discussion
4.1. Quality of Evidence Analyses
4.1.1. Strength of Recommendations and Levels of Evidence
4.1.2. Appraisals of Review Studies
4.2. Expert Evidence versus Expert Opinion
4.3. The Value of Scholarly Narrative Reviews
4.4. New Understanding and Terminology of Screening
4.5. When No Recommendation Is the Best Recommendation
4.6. Compelling Need for Further, People-Centred Research
5. Conclusions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Appendix A
Standard | Definition |
---|---|
1. | Establishing transparency |
2. | Management of conflicts of interest |
3. | Guideline development group composition: multidisciplinary group, methodologist involvement, patient and public perspectives |
4. | Clinical practice guideline—systematic review intersection/use of systematic review evidence |
5. | Evidence foundations for and rating strength of recommendations |
6. | Specific and unambiguous articulation of recommendations |
7. | External review |
8. | Updating |
Appendix B
Levels of Evidence: | ||
---|---|---|
Level | Definition | Type of Study/Source of Evidence—Screening Studies |
I | Good quality patient-oriented evidence | Systematic review/meta-analysis of randomised controlled trials with consistent findings High-quality individual randomised controlled study All-or-none study |
II | Limited quality patient-oriented evidence | Systematic review/meta-analysis of lower quality clinical trials or of studies with inconsistent findings Lower quality clinical trial Cohort study Case-control study |
III | Other evidence | Consensus guidelines Extrapolations from bench research Usual practice Opinion Disease-oriented evidence Case series |
Strengths of Recommendations: | ||
A | Recommendation based on consistent and good-quality patient-oriented evidence | |
B | Recommendation based on inconsistent or limited quality patient-oriented evidence | |
C | Recommendation based on consensus, usual practice, opinion1, disease-oriented evidence, or case series | |
Explanations: | ||
| ||
Consistent: |
| |
Inconsistent: |
| |
Coherent: | Differences in conclusions are explainable | |
| ||
Patient-oriented evidence: | Measures outcomes that matter to patients, e.g., morbidity, mortality, symptom improvement, cost reduction, quality of life | |
Disease-oriented evidence: | Measures intermediate, physiologic, or surrogate endpoints that may or may not reflect improvements in patient outcomes, e.g., blood pressure, blood chemistry, physiologic function, pathologic findings |
Appendix C
AMSTAR 2 Items: | ||
Questions: | ||
1. Did the research questions and inclusion criteria for the review include the components of PICO?; 2. Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol?; 3. Did the review authors explain their selection of the study designs for inclusion in the review?; 4. Did the review authors use a comprehensive literature search strategy?; 5. Did the review authors perform study selection in duplicate?; 6. Did the review authors perform data extraction in duplicate?; 7. Did the review authors provide a list of excluded studies and justify the exclusions? 8. Did the review authors describe the included studies in adequate detail?; 9. Did the review authors use a satisfactory technique for assessing the risk of bias (RoB) in individual studies that were included in the review?; 10. Did the review authors report on the sources of funding for the studies included in the review?; 11. If meta-analysis was performed did the review authors use appropriate methods for statistical combination of results?; 12. If meta-analysis was performed, did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis?; 13. Did the review authors account for RoB in individual studies when interpreting/discussing the results of the review?; 14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review? 15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review? 16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review? | ||
Possible Answers: | ||
Yes/No: for questions 1, 3, 5, 6, 10, 13, 4, 16; Yes/Partial Yes/No: for questions 2, 4, 7, 8; Yes/No/Includes only nonrandomised studies of interventions or Yes/No/Includes only randomised controlled trials: for question 9; Yes/No/No meta-analysis conducted: for questions 11, 12, 15 | ||
Rating Overall Confidence in the Results of a Review: | ||
Confidence | Rating | Interpretation of a Review |
high | no or one non-critical weakness | it provides an accurate and comprehensive summary of the results of the available studies that address the question of interest |
moderate | more than one critical weakness | it has more than one weakness but no critical flaws; may provide an accurate summary of the results of the available studies that were included |
low | one critical flaw with or without non-critical weaknesses | it has a critical flaw and may not provide an accurate and comprehensive summary of the available studies that address the question of interest |
critically low | more than one critical flaw with or without non-critical weaknesses | it has more than one critical flaw and should not be relied on to provide an accurate and comprehensive summary of the available studies |
Appendix D
Question | Steps to Follow When Searching for Likely Best Evidence/Levels of Evidence | ||||
---|---|---|---|---|---|
Step 1/Level 1 | Step 2/Level 2 | Step 3/Level 3 | Step 4/Level 4 | Step 5/Level 5 | |
Is this (early detection) test worthwhile? (screening) | systematic review of randomised trials | randomised trial | non-randomised controlled cohort/follow-up study | case-series, case-control or historically controlled studies | mechanistic reasoning |
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Guidelines: | |||
---|---|---|---|
Institution, Year | Standard of Development | Recommendation | |
SRS/AAOS/POSNA/AAP, 2015 [17] | opinion-based; narrative addressing new evidence; | screening recommended (but readers encouraged “to reach their own decisions”) | |
SOSORT, 2018 [18] | consensus-based; Delphi method; a panel of experts and scoliosis conservative treatment practitioners | screening recommended | |
US PSTF, 2018 [19] | systematically developed; screening program criteria-based | statement of no recommendation 1 | |
UK NSC, 2016, 2021 [20] | systematically developed; screening program criteria-based | recommendation not to screen | |
Evidence Reviews: | |||
Authors, Year | Purpose | Type of Study | Conclusions |
Bazian Ltd., 2015 [48] | UK NSC recommendation formulation | systematic review of RCTs and observational studies | “(…) there is an agreed screening test to detect AIS but there is no single agreed cut-off; (…) follow-up testing using X-rays (…) may cause harm to people who would not need any treatment; (…) [it is difficult to determine] how accurate the screening test is to identify those people who need treatment; (…) it is not clear whether there is any added benefit from giving treatments for AIS following detection at screen compared with after clinical detection (…)” |
Dunn et al., 2018 [3] | US PSTF recommendation formulation | systematic review of RCTs and observational studies | “(…) no direct evidence for a benefit of universal AIS screening of adolescents on long-term health outcomes; (…) the majority of persons identified through screening will never require treatment; Theoretical harms of universal screening have been proposed, but high-quality evidence is lacking; direct evidence on the association between magnitude of curve at skeletal maturity and adult quality of life outcomes is lacking (…)” |
Standards, IOM [28] 1 | SRS/AAOS/ POSNA/AAP, 2015 [17] | SOSORT, 2018 [18] | US PSTF, 2018 [19] | UK NSC, 2016, 2021 [20] |
---|---|---|---|---|
1. | CA | CA | Y | Y |
2. | N | Y | Y | Y |
3. | N | N | Y | Y |
4. | N | N | Y | Y |
5. | N | CA | Y | Y |
6. | Y | Y | Y | Y |
7. | N | N | Y | N |
8. | Y | Y | Y | Y |
Publication: | SORT Qualification 1: | |
---|---|---|
Institution, Year | Level of Evidence | Strength of Recommendation |
SRS/AAOS/POSNA/AAP, 2015 [17] | III | C |
SOSORT, 2018 [18] | III | C |
US PSTF, 2018 [19] | II | B |
UK NSC, 2016, 2021 [20] | II | B |
Systematic Review | AMSTAR 2 | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Questions 1: | Overall Confidence 1 | ||||||||||||||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | ||
answers 1: | |||||||||||||||||
Dunn et al., 2018 [3] | Y | Y | Y | Y | Y | Y | Y | Y | Y | N | NA | NA | Y | Y | NA | Y | High |
Bazian Ltd., 2015 [48] | Y | N | Y | PY | CA | CA | N | PY | N | N | NA | NA | N | N | NA | N | Moderate |
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Płaszewski, M. No Recommendation Is (at Least Presently) the Best Recommendation: An Updating Quality Appraisal of Recommendations on Screening for Scoliosis. Int. J. Environ. Res. Public Health 2022, 19, 6659. https://doi.org/10.3390/ijerph19116659
Płaszewski M. No Recommendation Is (at Least Presently) the Best Recommendation: An Updating Quality Appraisal of Recommendations on Screening for Scoliosis. International Journal of Environmental Research and Public Health. 2022; 19(11):6659. https://doi.org/10.3390/ijerph19116659
Chicago/Turabian StylePłaszewski, Maciej. 2022. "No Recommendation Is (at Least Presently) the Best Recommendation: An Updating Quality Appraisal of Recommendations on Screening for Scoliosis" International Journal of Environmental Research and Public Health 19, no. 11: 6659. https://doi.org/10.3390/ijerph19116659