Methods used to develop clinical guidelines in France. The example of common lumbosciatic syndrome.

A number of Regulatory Medical References, or criteria for quality health care, have been worked out in France by a committee of physicians' union and national health insurance agency representatives, based on clinical guidelines developed using predefined methods. For each guideline, the level of evidence was evaluated, and when this level was inadequate a strong professional consensus was sought. For common lumbosciatic syndrome, the ANDEM (Agence Nationale pour le Développment de l'Evaluation Médicale, or national agency for the development of medical evaluation) worked with a multidisciplinary study group (specialists and nonspecialists, physicians from teaching hospitals, regional hospitals and private practices, primary care practitioners and specialists) whose members were from different areas of France. A computerized and manual literature search was conducted. The project director and the study group chairperson reviewed each document using predefined criteria to evaluate the methodology and level of scientific evidence. When this level was inadequate, a strong consensus expressing an opinion accepted by the medical profession was looked for. Bold type was used to indicate data resting on very high levels of evidence. The committee of physicians' union and national health insurance agency representatives used these documents to select a number of situations for which "regulatory medical references" would be useful. Each reference was written as one or a few sentences starting by "It is inappropriate to...". The study group found that subjectivity and pragmatism significantly influence the selection of diagnostic and therapeutic strategies for common lumbosciatic syndrome. The review and discussion of the high-quality literature on this condition led the study group members to modify their opinions and facilitated the development of a consensus. The group noted the paucity of scientific data on the natural history of common lumbosciatic syndrome and on the value of drug therapy and other commonly used therapeutic modalities.