Is there more than one approach to evaluating the variability of surgeons' performance?

INTRODUCTION: To demonstrate that the variability found to be significant between surgeons' performances within a small group does not necessarily mean that this significance applies to the entire field of that specific type of surgery. It is common for inferences and recommendations for an entire field to be based on the variability within a small group of surgeons. The variability between groups usually remains unknown. METHODS: An analysis of variance was used to assess the statistical significance of the variability among surgeons' performances of a specific type of surgery within the studied sample. The intraclass correlation coefficient was used to investigate how large a segment of this variability can be explained by a surgeon-related factor for the entire surgeon population of a specific field. The topic was illustrated using data obtained from a group of seven surgeons who operated on the penetrating rotator cuff tears of 742 patients. RESULTS: There were statistically significant differences between seven surgeons in the improvement of pain and the range of shoulder joint motion. However, only a small (≤2%) and statistically non-significant part of this variability could be explained by a difference between surgeons when the results were interpolated across the entire population of shoulder surgeons. DISCUSSION AND CONCLUSION: Variability in performance within a group of surgeons performing a specific type of surgery cannot be generalized to include the performance of all surgeons doing the same type of surgery without additional statistical analyses.

Lumbar fusion compared with conservative treatment in patients with chronic low back pain: a meta-analysis.

We assess the effect of lumbar fusion (LF) in reducing disability among patients with chronic low back pain (CLBP) compared with conservative treatment and to weigh the clinical significance of this effect. We conducted a random-effect meta-analysis on the basis of a systematic review with research quality grading according to Grading of Recommendations Assessment, Development and Evaluation (GRADE). The studies included were retrieved from MEDLINE and Cochrane CENTRAL databases from 1990 till January 2013. Randomized or nonrandomized controlled studies were included if the study participants had a history of CLBP because of degenerative spinal diseases and had been treated with LF. A study was included if it compared LF with conservative treatment. The outcome measure was a change in the Oswestry Disability Index (ODI) score during a follow-up. The meta-analysis included data on 666 patients (402 cases) who participated in four randomized-controlled trials. The ODI score reduced in the LF and the control groups. The mean reduction in the ODI score in the follow-up of 1.5 years was -2.91 (95% confidence interval -6.66 to 0.84) in favor of LF. The difference between groups was statistically and clinically insignificant. Test for heterogeneity indicated that study imputation would favor LF but the imputed result would still be clinically insignificant with an estimated corrected reduction of ODI score of -5.51 (95% confidence interval -5.78 to -5.24). There is strong evidence that LF is not more effective than conservative treatment in reducing perceived disability because of CLBP among patients with degenerative spinal diseases. It is unlikely that further research on the subject would considerably affect this conclusion.

Return to work after traumatic brain injury: Systematic review.

OBJECTIVE: To evaluate the evidence on pre- and post-injury predictors of vocational outcome after traumatic brain injury (TBI). LITERATURE SELECTION AND CRITICAL ANALYSIS: The search was conducted on PubMed and Central databases since 1990. A clinical question was formulated according to the PICO framework. Clinical relevance of the selected studies was evaluated following the GRADE framework. MAIN OUTCOMES AND RESULTS: The main outcome measures were employment status and return to work after TBI. Methodological quality of most of the relevant 12 controlled and 68 uncontrolled studies included in the review was estimated as very low. There was weak evidence that age, educational level, pre- and post-injury occupational status, severity of TBI, functional status, level of depression and anxiety, gender and race may be predictive for the vocational outcome after TBI. CONCLUSIONS AND IMPLICATIONS FOR FURTHER RESEARCH: No strong evidence was found that vocational outcomes after TBI could be predicted or improved. There is a need for both experimental and observational well-conducted studies on this important subject. Researchers are strongly encouraged to use unified and standardized terms and scales in further studies. The authors suggest the International Classification of Functioning, Disability and Health (ICF) as the best tool available for this purpose.

Selecting an optimal abbreviated ICF set for clinical practice among rehabilitants with subacute stroke: retrospective analysis of patient records.

To evaluate the adequacy of abbreviated versions of International Classification of Functioning, Disability and Health (ICF) (the WHO ICF Checklist and the ICF Comprehensive Core Set for Stroke) with respect to the specific clinical needs of a stroke rehabilitation unit before their implementation at a practical level. Common descriptions of functional limitations were identified from patient records of 10 subsequent subacute stroke patients referred to an inpatient multiprofessional rehabilitation unit of a university hospital. These descriptions were then converted into ICF categories, and the list was compared with the ICF Checklist of the WHO and the ICF Comprehensive and Brief Core Sets for Stroke developed by the ICF Research Branch. From the study population (50% women), 71 different, second-level ICF categories were identified, averaging 36.4 categories/patient (SD 5.8, range 28-46). Except for one category, all of the categories identified were also found in the ICF Comprehensive Core Set for Stroke. Of the categories identified, 49 (69%) were found in the WHO ICF Checklist. All except one category included in the ICF Brief Core Set for Stroke were also in our list. The Comprehensive Core Set for Stroke was found to be a good potential starting point for the practical implementation of the ICF in a stroke rehabilitation unit.