• Daniel L Belavy, Scott D Tagliaferri, Paul Buntine, Tobias Saueressig, Katja Ehrenbrusthoff, Xiaolong Chen, Ashish Diwan, Clint T Miller, and Patrick J Owen.
• Division of Physiotherapy, Department of Applied Health Sciences, Hochschule Für Gesundheit (University of Applied Sciences), Gesundheitscampus 6-8, 44801, Bochum, Germany. daniel.belavy@hs-gesundheit.de.
• Eur Spine J. 2022 Nov 1; 31 (11): 285128652851-2865.

PurposeExamine the effectiveness of interventions to approach guideline-adherent surgical referrals for low back pain assessed via systematic review and meta-analysis.MethodsFive databases (10 September 2021), Google Scholar, reference lists of relevant systematic reviews were searched and forward and backward citation tracking of included studies were implemented. Randomised controlled/clinical trials in adults with low back pain of interventions to optimise surgery rates or referrals to surgery or secondary referral were included. Bias was assessed using the Cochrane ROB2 tool and evidence certainty via Grading of Recommendations Assessment, Development and Evaluation (GRADE). A random effects meta-analysis with a Paule Mandel estimator plus Hartung-Knapp-Sidik-Jonkman method was used to calculate the odds ratio and 95% confidence interval, respectively.ResultsOf 886 records, 6 studies were included (N = 258,329) participants; cluster sizes ranged from 4 to 54. Five studies were rated as low risk of bias and one as having some concerns. Two studies reporting spine surgery referral or rates could only be pooled via combination of p values and gave evidence for a reduction (p = 0.021, Fisher's method, risk of bias: low). This did not persist with sensitivity analysis (p = 0.053). For secondary referral, meta-analysis revealed a non-significant odds ratio of 1.07 (95% CI [0.55, 2.06], I2 = 73.0%, n = 4 studies, Grading of Recommendations Assessment, Development and Evaluation [GRADE] evidence certainty: very low).ConclusionFew RCTs exist for interventions to improve guideline-adherent spine surgery rates or referral. Clinician education in isolation may not be effective. Future RCTs should consider organisational and/or policy level interventions.Prospero RegistrationCRD42020215137.© 2022. The Author(s).

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