Article type
Year
Abstract
Introduction: The Dutch College of General Practitioners (NHG) have already published over 50 treatment standards. At the start of the tennis elbow standard, no informative systematic reviews were available. Therefore, to synthesize the best evidence, the available RCTs were summarized in a systematic manner. It was the first time systematic reviews were specially conducted to support a NHG standard.
Methods: A comprehensive search was performed. All RCTs were assessed for methodological quality by two assessors independently, using a standardized criteria list (maximum score = 100). Treatment results were dichotomized in success or failure. Statistical pooling was performed according to a pre-set analysis plan using Cochrane Collaboration RevMan (fixed-effects model).
Results: No RCTs were available on important topics like patient education, analgesics and surgical intervention. Twelve RCTs dealing with corticosteroid injections and 20 with physiotherapy were assessed in 2 separate systematic reviews. The methodological quality of the RCTs in both reviews was moderate (median scores of 40 and 50, respectively). The RCTs on physiotherapy (mainly laser, ultrasound and massage) did not indicate effectiveness of this approach. The RCTs on corticosteroid injections, however, indicated short-term effectiveness (2-6 weeks): pooled OR = 0.15 (95% CI: 0.10-0.23), X2 (df= 5) = 13.3, indicating statistical heterogeneity. At the longer-term follow-up, no difference could be detected. The methodologically better studies indicated more favourable results than the methodologically worse. Optimal corticosteroid substance, dosage, injection interval and injection volume could not be extracted from the various RCTs.
Discussion: Impact and dissemination: The systematic reviews played a crucial role in the decision-making process of the standard-setting committee. It was concluded that corticosteroid injections are indicated for patients with severe tennis elbow complaints. Although often prescribed in the Netherlands, it was recommended not to refer for physiotherapy for this indication. The final version of the standard, and a detailed questionnaire concerning its content, is now sent to selected national experts and a random sample of 50 general practitioners. The degree of acceptation of the guidelines, as evaluated in this commentary phase, will be presented at the Colloquium. Systematic reviews are a prerequisite for treatment standards. When recent, well-conducted reviews are not available, the performance of such reviews covering the most relevant topics should precede the standard-setting process.
Methods: A comprehensive search was performed. All RCTs were assessed for methodological quality by two assessors independently, using a standardized criteria list (maximum score = 100). Treatment results were dichotomized in success or failure. Statistical pooling was performed according to a pre-set analysis plan using Cochrane Collaboration RevMan (fixed-effects model).
Results: No RCTs were available on important topics like patient education, analgesics and surgical intervention. Twelve RCTs dealing with corticosteroid injections and 20 with physiotherapy were assessed in 2 separate systematic reviews. The methodological quality of the RCTs in both reviews was moderate (median scores of 40 and 50, respectively). The RCTs on physiotherapy (mainly laser, ultrasound and massage) did not indicate effectiveness of this approach. The RCTs on corticosteroid injections, however, indicated short-term effectiveness (2-6 weeks): pooled OR = 0.15 (95% CI: 0.10-0.23), X2 (df= 5) = 13.3, indicating statistical heterogeneity. At the longer-term follow-up, no difference could be detected. The methodologically better studies indicated more favourable results than the methodologically worse. Optimal corticosteroid substance, dosage, injection interval and injection volume could not be extracted from the various RCTs.
Discussion: Impact and dissemination: The systematic reviews played a crucial role in the decision-making process of the standard-setting committee. It was concluded that corticosteroid injections are indicated for patients with severe tennis elbow complaints. Although often prescribed in the Netherlands, it was recommended not to refer for physiotherapy for this indication. The final version of the standard, and a detailed questionnaire concerning its content, is now sent to selected national experts and a random sample of 50 general practitioners. The degree of acceptation of the guidelines, as evaluated in this commentary phase, will be presented at the Colloquium. Systematic reviews are a prerequisite for treatment standards. When recent, well-conducted reviews are not available, the performance of such reviews covering the most relevant topics should precede the standard-setting process.