Characteristics and quality of clinical practice guidelines addressing acupuncture interventions: a systematic survey of 133 guidelines and 433 acupuncture recommendations

Abstract

ObjectiveTo systematically summarise acupuncture-related Clinical Practice Guidelines (CPGs)’s clinical and methodological characteristics and critically appraise their methodology quality.DesignWe summarised the characteristics of the guidelines and recommendations and evaluated their methodological quality using the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument.Data sourcesNine databases were searched from 1 January 2010 to 20 September 2020.Eligibility criteria for selecting studiesWe included the latest version of acupuncture CPGs, which must have used at least one systematic review addressing the benefits and harms of alternative care options to inform acupuncture recommendations.Data extraction and synthesisReviewers, working in pairs, independently screened and extracted data. When there are statistical differences among types of CPGs, we reported the data by type in the text, but when not, we reported the overall data.ResultsOf the 133 eligible guidelines, musculoskeletal and connective tissue diseases proved the most commonly addressed therapeutic areas. According to the AGREE II instrument, the CPG was moderate quality in the domain of clarity of scope and purpose, clarity of presentation, the rigour of development, stakeholder involvement and low quality in editorial independence, and applicability. The study identified 433 acupuncture-related recommendations; 380 recommended the use of acupuncture, 28 recommended against the use of acupuncture and 25 considered acupuncture but did not make recommendations. Of the 303 recommendations that used Grading of Recommendations Assessment, Development and Evaluation to determine the strength of recommendations, 152 were weak recommendations, 131 were strong recommendations, of which 104 were supported by low or very low certainty evidence (discordant recommendations).ConclusionIn the past 10 years, a large number of CPGs addressing acupuncture interventions exist. Although these guidelines may be as or more rigorous than many others, considerable room for improvement remains.

Increasing the usefulness of acupuncture guideline recommendations

“…In acupuncture guidelines, as in some others, this is not always the case 10. Among acupuncture recommendations published in the past 10 years, less than 4% reported the severity of the underlying condition to which their recommendations apply, and less than 30% reported disease stage 7. For example, in 2019, the China Association of Chinese Medicine published a guideline for the diagnosis and treatment of knee osteoarthritis using traditional Chinese medicine 11.…”

“…For example, between 2010 and 2020, 133 guidelines included more than 430 acupuncture recommendations worldwide (fig 1). 7 Over 70% of these guidelines were produced by conventional medical organisations, with the remainder published by organisations focused on traditional and complementary medicine in China, South Korea, and Australia 7. Acupuncture was most commonly recommended for musculoskeletal and connective tissue disease; neurological disorders; obstetrics, gynaecology, and women’s health; oncology; and gastrointestinal disorders 5678…”

“…Failure to provide sufficient details regarding the interventions also limits clinicians’ ability to implement the recommended acupuncture treatment. Just 40% of guidelines from conventional medicine organisations specified the types of acupuncture (eg, manual, electro-acupuncture, acupressure) they were recommending, and only 5% specified the range of points selected 7. The American College of Chest Physicians guideline on complementary therapies and integrative medicine for lung cancer suggested using acupuncture or related techniques as an adjunct treatment for nausea and vomiting from chemotherapy or radiation therapy (moderate certainty evidence, conditional recommendation) 12.…”

“…Among guidelines that included acupuncture interventions in the past decade, 80% of the acupuncture specific guidelines reported outcomes to justify their recommendations. However, nearly half of the guidelines from conventional and complementary medicine do not report the outcomes evaluated 7. Moreover, failure to consider patients’ values and preferences further limited the usefulness of acupuncture recommendations.…”

“…In a randomised controlled trial that presented 500 clinicians with a clinical scenario for which sparse evidence was available, 80% of participants preferred receiving a recommendation 2324. However, 22% of the guidelines from conventional medicine organisations that included evidence on acupuncture with low or very low certainty refrained from making recommendations 7. For example, the 2021 US Department of Veterans Affairs guidelines on primary care management of headache mentioned acupuncture but did not make any relevant recommendation 25.…”