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Summary: Background: Effectiveness of implementing interventions to optimise guideline-recommended medical prescription in low back pain is not well established. Methods: A systematic review and random-effects meta-analyses for dichotomous outcomes with a Paule-Mandel estimator. Five databases and reference lists were searched from inception to 4th August 2021. Randomised controlled/clinical trials in adults with low back pain to optimise medication prescription were included. Cochrane Risk of Bias 2 tool and GRADE were implemented. The review was registered prospectively with PROSPERO (CRD42020219767). Findings: Of 3352 unique records identified in the search, seven studies were included and five were eligible for meta-analysis (N=11339 participants). Six of seven studies incorporated clinician education, three studies included audit/feedback components and one study implemented changes in medical records systems. Via meta-analysis, we estimated a non-significant odds-ratio of 0·94 (95% CI (0·77; 1.16), I² = 0%; n=5 studies, GRADE: low) in favour of the intervention group. The main finding was robust to sensitivity analyses. Interpretation: There is low quality evidence that existing interventions to optimise medication prescription or usage in back pain had no impact. Peer-to-peer education alone does not appear to lead to behaviour change. Organisational and policy interventions may be more effective. Funding: This work was supported by internal institutional funding only.

Summary Background In emergency nutritional relief programmes, therapeutic feeding centres are the accepted intervention for the treatment of severely malnourished people. These centres often cannot treat all the people requiring care. Consequently, coverage of therapeutic feeding centre programmes can be low, reducing their effectiveness. We aimed to assess the effectiveness of outpatient treatment for severe malnutrition in an emergency relief programme. Methods We did a retrospective cohort study in an outpatient therapeutic feeding programme in Ethiopia from September, 2000, to January, 2001. We assessed clinical records for 170 children aged 6–120 months. The children had either marasmus, kwashiorkor, or marasmic kwashiorkor. Outcomes were mortality, default from programme, discharge from programme, rate of weight gain, and length of stay in programme. Findings 144 (85%) patients recovered, seven (4%) died, 11 (6%) were transferred, and eight (5%) defaulted. Median time to discharge was 42 days (IQR 28–56), days to death 14 (7–26), and days to default 14 (7–28). Median rate of weight gain was 3·16 g kg −1 day −1 (1·86–5·60). In patients who recovered, median rates of weight gain were 4·80 g kg −1 day −1 (2·95–8·07) for marasmic patients, 4·03 g kg −1 day −1 (2·68–4·29) for marasmic kwashiorkor patients, and 2·70 g kg −1 day −1 (0·00–4·76) for kwashiorkor patients. Interpretation Outpatient treatment exceeded internationally accepted minimum standards for recovery, default, and mortality rates. Time spent in the programme and rates of weight gain did not meet these standards. Outpatient care could provide a complementary treatment strategy to therapeutic feeding centres. Further research should compare the effectiveness of outpatient and centre-based treatment of severe malnutrition in emergency nutritional interventions.

Patrick Kolsteren and colleagues assertion that there is little evidence to support the scale-up of community-based therapeutic care is incorrect and disregards published studies on the topic and the recent experience of many humanitarian agencies and national ministries of health in Africa. Kolsteren and colleagues base their assertion largely on one article in a supplement to Food and Nutrition Bulletin which described three small trials in Malawi. They do not cite an article in the same supplement that presents data from 23 511 unselected cases of severe acute malnutrition treated in 21 community-based therapeutic care programmes implemented in Malawi Ethiopia and Sudan between 2001 and 2005. These programmes achieved recovery mortality and default rates of 79.4% 4.1% and 11.0% respectively. 76% of cases were treated solely as outpatients. These results far exceed international standards with mortality rates four to five times lower than the average in hospitals where severe acute malnutrition is treated exclusively on an inpatient basis. Furthermore evidence is now building that community-based therapeutic care can be effectively managed by national ministries of health with limited external support. This is in contrast to the repeated failure of many developing countries to implement the more resource-intensive 1998 WHO inpatient protocols. This integrated model has also enabled far higher numbers of patients to be treated than was previously possible using the exclusive inpatient approach. For example in Niger in 2005 Medecins Sans Frontieres treated 60 000 cases of severe acute malnutrition and achieved mortality rates of about 5% and cure rates of more than 80%. 70% of these children were treated exclusively as outpatients. (excerpt)