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Wrap-Up An FCER Workshop to Establish Evidence-Based Chiropractic Practices
December 3-4, 2004 Do you have an evidence-based practice? If asked by a medical colleague about the treatment a patient received, can you access the latest research supporting your choice? Do you recognize that operating an evidence-based practice ensures that the patient is receiving the most appropriate treatment and also reduces risk of patient injury? When questioned by insurers and other third-party payors, are you able to justify your treatment methods with published research? Do you see how this would speed reimbursement? In an effort to create evidence-based chiropractic practices, in December 2004 the Foundation for Chiropractic Education and Research (FCER) held a series of four workshops—Translating Evidence Into Practice—to teach the practicing chiropractor to:
Also speaking were keynote presenters Reed Phillips, D.C., Ph.D., discussing the integration of research into chiropractic education; and George McClelland, D.C., discussing his use of research to influence chiropractic healthcare legislation. Here is a summary of the workshop from Dr. Anthony Rosner. SUMMARY OF WORKSHOP
Friday, December 3, 2004
This presentation presents the definition and description of evidence-based practice. The benefits of evidence are discussed, including various types of evidence to be considered. Practical solutions to obstacles will be provided to individual doctors for surmounting these barriers. Common barriers to consensus statements of best practice based upon evidence will be emphasized. Differentiation between rigidly enforced standards of quality and guidelines which are meant to be recomendations are included as well. Courses of action for overcoming common barriers concludes this presentation.
WORKSHOP A:
Quality improvement has become a major force in business and increasingly in healthcare. The Institute of Medicine defines health care quality as the extent to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. However, improving health care quality can require redesign of many traditional delivery models with particular attention to the effectiveness of meaningful and relevant patient outcomes. Effective quality improvement strategies in health settings require explicit observation and measurement of processes and outcomes, aligning well with incorporation of evidence-based decision making in clinical settings. A brief overview of quality improvement effort in chiropractic settings is presented, including application of the Institute for Healthcare Improvement methodology in a multidisciplinary tertiary spine care center and a chiropractic teaching clinic. In addition, a report of a large-scale community-based pilot study to improve the use of occupational health best practices in Washington state is presented. Workers compensation population pose a unique situation for quality improvement methods and offer a unique opportunity for study. It is a highly regulated environment, involves substantive musculoskeletal injury, may have significant economic yield where quality improvement [QI] can reduce disability. Of particular relevance to chiropractic, 20-40% of workers with low back injury seek chiropractic care when the benefit is offered. Occupational health care can play a central role in QI, and chiropractic services may have a pivotal role in occupational health delivery.
A comparison of chiropractic and medical management of spinal conditions requires some quantitative assessment of the costs of the two treatment modalities. There is a lot of literature attempting to do this, but regrettably the comparisons are often invalid, suspect or faulty in some respects. There are, however, very good studies. Such comparisons are important for purposes of private and public insurance coverage of chiropractic and related third party payment systems, such as worker's compensation systems. This presentation will offer an account of what a good cost of care comparison should look like. What unit of analysis [visits, patients, episode of illness, etc] should e used. How should costs be defined and aggregated, keeping in mind the quite different treatment patterns that patients of chiropractors and medical doctors are subjected to? What exactly is cost-effectiveness, and when might other cost-based comparisons be meaningful in the absence of cost-effectiveness results? What is the meaning and relevance of direct versus indirect costs? Studies hardly ever consider iatrogenic complications of chiropractic and medical care, but should they?
The key questions that we must answer to be accountable to patients, payers, and policy makers are: what benefits does chiropractic care have for various conditions and what are the costs to patients and society for that care? Ultimately, these questions can be answered when data is collected in the practice setting. This presentation will cover two broad areas: the challenges of participation in practice-based research and the benefits to the profession. I will answer questions such as the following: what is required of doctors, patients, and office staff? What are the challenges facing the researchers who work with field doctors? I will then present data from a six-year study on the relative effectiveness and cost-effectiveness of D.C. and M.D. care for acute and chronic low back pain.
WORKSHOP B:
There is a growing emphasis on evidence-based practice coupled with an increase in the volume of biomedical literature. An article in the Journal of the American Medical Association estimated that 6,000 to 7,000 scientific articles are published daily. This poses a significant challenge to the practitioner to stay informed. Fortunately there are some helpful resources to assist in combating the problem of information proliferation. Online biomedical indexes provide a key resource to getting the information that doctors and health professionals need when they need it. The primary goal of this presentation is to provide the practicing chiropractor with the skills to locate and retrieve information effectively. The content includes the identification of important database resources for the chiropractor, along with skills to use these resources. Participants will be provided with an understanding of the indexing process used by the National Library of Medicine and other database providers. This will include a brief description of the use of MeSH headings, subheadings, check tags, Boolean arguments, and other critical search information.
This presentation will discuss the concepts of validity and reliability, along with sensitivity and specificity. Several studies on the validity of manipulation will be presented and their relevance for the issues of validity discussed. The concept of reliability will focus on interrater reliability, and several studies examining this issue will be presented. The implications of the results of both validity and reliability studies will be discussed in terms of practice. Suggestions for what these issues mean for practice will be given.
To practice evidence-based health care, clinicians must understand basic statistical concepts and methods. Clinicians should recognize the strengths and weaknesses of common statistical treatments of research data. Direction and examples will be given to understand statistical concepts which are based upon the three following guidelines and statements that researchers should use to create their papers:
The CONSORT statement is the standard of reporting on randomized trials. The TREND statement is the new standard for reporting on nonrandomized trials. The Cochrane Reviewers' Handbook gives guidelines for reviewers of systematic reviews. By becoming familiar with the three guidelines that should be used to create papers, clinicians will be able to aptly assess the validity of those types of evidence. Clinicians should recognize the strengths and weaknesses of common statistical treatments of research data and offering guidance as to which methodologies are appropriate and may be applicable to a given situation. Below is a list of concepts to be acquainted with to assess the evidence. These concepts will be illustrated using the medical literature as well as from rehabilitation outcomes research.
Saturday, December 4, 2004
WORKSHOP C:
The move to "evidence-based practice" over the past decade or so has brought with it changes in the way clinical research is conducted and disseminated, and changes in the way clinicians are expected to use the evidence from that research. Integration of clinical research evidence into clinical practice remains the biggest challenge in evidence-based practice. Even today, the evidence is still lacking that shows that evidence-based practice either changes the way in which clinicians practice or improves care for patients. There may be many reasons for this, including a hesitancy by clinicians to adopt an evidence-based approach to their practice, a failing by researchers to provide evidence that his clinically relevant and meaningful, and a reluctance by educators to integrate evidence into clinical education and training. This workshop focuses on the clinician both as "research-user" and as "research-provider." Both roles are implicit in clinicians adopting an "evidence-based approach" to their practice. As "research-users," clinicians need the skills to articulate clinical scenarios that can be answered by the available evidence, to find and then appraise the evidence, and finally to apply the evidence in the clinical management of the individual patient. As "research-providers," clinicians need to undertake research in their own practices that is not only feasible, but also provides meaningful and relevant evidence to improve patient care, and then disseminate that evidence in a publishable format. This workshop will cover those skills that clinicians need as "research-users," including critical appraisal, risk statistics and confidence intervals, and primary and secondary sources of evidence. The workshop will also focus on the clinician as "research-provider" and the types of research that can be done in routine practice settings, including outcomes research in which patient outcomes are systematically recorded using valid and reliable instruments. There are many barriers to translating evidence into practice. This workshop aims to facilitate chiropractors in adopting an evidence-based approach and in facing the many challenges that are associated with making the change.
For those in clinical practice, opportunity exists to contribute to the evidence base providing information to the chiropractic profession, notably through the use of case reports derived from individual practice patient databases. However, knowledge of exactly how to bring that information to the attention of the chiropractic profession and the greater scientific community is not typically part of the training that chiropractors receive as they go through their chiropractic schooling, enter practice and continue into postgraduate studies. However, the information contained in their practices is of great value to the profession. This presentation will focus on obtaining the skills necessary to take chiropractic information and format it for possible future presentation, in order that the information from these cases can be conveyed to various audiences in the most efficient fashion. We will talk about gathering information, organizing it, writing it and publishing it.
The entire thrust of this presentation is to empower the chiropractic physician to articulate findings in research to other healthcare providers, prospective third party payors, the media, the public, and especially their own patients. In so doing, I will be offering an overview of the strengths and weaknesses of a body of research evidence published in the scientific literature, pointing out in seven case studies how randomized clinical trials and meta-analyses can go astray with personal biases while providing a false sense of security of internal validity at the expense of utility or even common sense. Essentially, poor information in the medical journals needs to be read critically because it may suffer from poor design--on top of being grossly distorted in the media. For these reasons, the practitioner needs to be able to become more critical in his or her approach to the literature as well as being able to articulate it--indeed, the very tools which this presentation seeks to hand over to the conference attendee. With regard to safety issues and vertebrobasilar artery accidents, in particular, a considerable body of flawed literature abounds which will be reviewed. Until adequate comparisons of patients with similar symptoms under medical care are made, attributing vertebrobasilar artery dissections to spinal manipulation is speculative and problematical. It will become apparent in these discussions, also, that with few exceptions there is no adequate sham or placebo procedure for spinal manipulation.
Misinformation, abuse and confusion surround the discussion of evidence-based care. What is it? How do you use it? Are guidelines, best practices, and standards of care the same? This presentation will explain the differences in these terms and give guidance as to how they can be applied to improve the quality of patient care and to support questions or appropriateness of treatment plans.
WORKSHOP D:
Healthy People 2010 is the cornerstone of evidence-based prevention and health promotion activities in the U.S. It is a call to action for our nation's health professionals to more effectively address the most pressing healthcare needs of all Americans. Chiropractic has, to date, lagged behind many other health professions in using the vast extant literature on prevention and health promotion on which Healthy People is based to consciously contribute to the national objectives derived from that literature. This session will provide chiropractic practitioners and faculty with a "crash course" on how they can contribute to the most relevant Healthy People goals and objectives. All attendees--whether they consider themselves spine specialists, primary care generalists, or wellness practitioners--will return to their offices on Monday equipped to take practical, appropriate, and evidence-based actions directed toward disease prevention and health promotion for chiropractic patients.
One important funding priority for research and community project grants is the inclusion of the "underserved" populations. While the Los Angeles area literally teems with diversity, many groups are still underserved in local chiropractic offices and research efforts. Including African Americans, Native Americans, Asians, Pacific Islanders, Hispanic, disabled persons, elderly, and the disadvantaged due to poverty, homelessness, etc. has been, historically, a challenge in chiropractic. This session will offer ways to broaden the diversity within our chiropractic efforts, enriching and strengthening the role of chiropractic in the health care of all people. Learning Objectives: By the end of this session the learner will:
Patient-centered chiropractic and integrative care describes the characteristics of both patient-centered and integrative care. Differentiation between the biomedical paradigm and a patient-centered alternative paradigm are presented. The two models of integration vs assimilation relative to the healthcare system are also described, as well as issues of patient satisfaction with chiropractic care. Core competencies in patient-centered integrative care are emphasized in relation to chiropractors serving as primary care physicians and spinal health specialists. The education of chiropractors as primary care practitioners is discussed, along with the role of chiropractors in the troubled healthcare system. Friday, December 3 Luncheon
This presentation will review the impact that the escalation in favorable research that impacts the practice of chiropractic and its political efforts has had over the past 25 years. It will address some of the legislative and administrative initiatives and successes that the American Chiropractic Association and affiliated chiropractic groups have had on Capitol Hill--as well s some of the battles that are still looming or may be anticipated in the future. Saturday, December 4 Luncheon
There are seven stages of development by which the use of new innovation in health care progresses. They are:
A discussion and examples of each stage will be presented. CLOSING SESSION
Despite the vast advances in chiropractic research that the past 30 years have witnessed, one could argue that practice patterns have changed very little--or if they have, they have responded to economic forces rather than documented scientific observations. The chiropractic profession is not alone in this regard, for such national governmental entities as the Agency for Health Quality and Research have noted that the abundance of medical research results, guidelines and best practices often becomes neglected rather than put into everyday practice. The problem has become significant enough for the AHRQ to offer grants for conferences held by any healthcare profession to address this problem, which simply stated has been the title of this entire workshop: Translating Evidence into Practice. The workshop leaders that we have heard have approached this problem from a wide variety of angles--including a review of the barriers between evidence and practice, the Quality Improvement process as exemplified by the Institute for Healthcare Improvement and other entities, building and participating in a practice-based research network, using the most efficient means to retrieve scientific and clinical information from the literature, understanding both the significances and differences between validity and reliability, finally getting a handle on the variety of statistical methods most commonly used in reporting information in the literature, establishing the clinician as both a user and provider of critical research information, effectively reporting clinical observations in the scientific literature, learning how to articulate this literature with a skeptical [some might say jaundiced] eye, finally being able to distinguish guidelines from best practices from standards of care, achieving the most effective methods from the literature to practice disease prevention and health promotion, reaching out to a broad and diverse population, and finally appreciating the new model of integrative care from a patient-centered perspective. Our lunchtime speakers were able to pepper our servings over the past two days with copious examples of political and legislative action that has resulted from the surge of research activity which we have witnessed over the past three decades. Furthermore, we have had a glimpse into what happens when our healthcare delivery system encounters an innovation--and the picture is not always so rosy. But most of all we have been able to bring you--the attendee--to the research table to begin a dialogue whose importance can never be underestimated. Our hope is to be able to integrate the research tools and evidence--however modest--into your practice so that it may advance into the 21st century and be neither left behind nor ridiculed. We hope to repeat this workshop some 12 months from now and be able to report some advances in your practices as a result of this meeting at that time. To that effect we have left you with a questionnaire which we hope reflects both your interest and the trouble that you took to come to Whittier these past two days. We will be seeking your responses 3, 6 and 9 months from now to see if there have been any changes--which in this type of inquiry will not be possible to systematically be attributable to this conference. You can be sure, however, that we will be looking for clues. We hope that your practice improves as a result of the process which we have initiated these past two days and greatly appreciate both your attendance and participation in this important period--not only in the chiropractic profession but in the healthcare delivery system in general.
Faculty The formal portion of the program comprises two days of intensive workshops in which specific areas in the research literature are presented and explored with the attendees in concrete and easily understood terms, such that there would be specific tools to carry away that could be incorporated into one's practice over time. The areas to be reviewed and speakers have been specifically chosen to provide maximum overlap with both elements of healthcare delivery and broad research interests. These will be enumerated following the introduction of each of the 16 speakers:
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