On January 9, 1995, Eric J. Muehlbauer, executive director for the North American Spine Society (NASS), whose members are mostly surgeons, sent out a memorandum regarding the release of the clinical practice guideline from the Agency for Health Care Policy and Research (AHCPR), Acute Low Back Problems in Adults.
Included in the memorandum was a "detailed analysis of the low back pain guidelines." The analysis was actually in the form of a "Response Letter on AHCPR Methodology," which began with the comment that "selection bias has been guaranteed to such a high degree that this has become a political, and not a scientific document."
The response letter criticized:
- reliance on randomized control trials
- the criteria for choosing assessment articles
- clinical "tinkering" based on questionable methodology
- unsubstantiated personal opinion in chapter 3
For NASS to come out against the strict reliance on controlled trials seems odd given their history of demanding hard science as viable evidence of efficacy.
NASS concluded:
"We, the North American Spine Society, feel that this document should not be published in its present form. Instead, a new consensus should be sought, with appointed input from all relevant medical specialties dealing with LBP (low back pain) issues, and with AHCPR staff that is responsive to the criticisms of the methodology raised in this letter."
It should be noted that the AHCPR panel members were selected from nominees of all medical and chiropractic societies. NASS does not appear to want to have chiropractic represented.
The front page of the 1995 summer edition of the NASS News proclaimed, "AHCPR Guidelines Disputed." The article said that patients should not have treatment selected or denied based on the guidelines; that the guidelines relied upon limited scientific information; that the consensus method does not necessarily identify the best forms of treatment or diagnosis; and that clinical judgments made by the AHCPR panel should be balanced with those of relevant medical societies.
With all of this opposition so clearly and adamantly stated, NASS just released four consensus statements of their own (see Spine, 1995; 20(16):1829-1833).
- open disc surgery as a treatment for disc herniation
- lumbar MRI
- radiography for low back pain
- epidural steroids for lumbar radicular pain
The most recent issue of The Back Letter (Nov. 2, 95) made a comparison of these four consensus statements to the applicable portions of the AHCPR guidelines. With the exception of the statement on the use of epidural steroids (which many find indefensible), the NASS consensus statements generally agree with the conclusions of the AHCPR low back panel.
Looking at the events of the past year in context only leaves many wondering about NASS' original reaction to the guidelines. Perhaps the NASS experience typifies the evolution most groups undergo as they wrestle with practice guidelines. Could it be that rage, denial, review and grudging acceptance are all part of the guidelines experience for most health care providers?
