Transcript Evidence-Based Health Care in Chiropractic Practice

Evidence-Based Health Care in
Chiropractic Practice:
A Clinicians Perspective
American Public Health Association
133rd Annual Meeting
Richard Branson, DC
Fairview Health Systems
“For Every Man There Exists a
Bait Which He Cannot
Resist
Swallowing”
Friedrich Nietzche 1844-1900
German Philosopher
Evidence-Based Medicine
EBM
How Can We Make
EBM the Bait That
Cannot be Resisted?
EBM
Evidence-Based Medicine?
• We Need New Health Care Knowledge to
Inform Our Decisions and Actions Related
to Patient Care.
• “By Denying Our Uncertainty and Curiosity
We Risk Becoming Dangerously Out of
Date and Immune to Self-Improvement and
Advances in Medicine.”
T.H. White
The Media and The Public
• “They” Already Believe That Medical Practice
is More “Scientific” Than Chiropractic Practice.
• “Chiropractic Has Been Marginalized and Does
Not Have the Wiggle Room for Practicing Poor
Evidence-Based Chiropractic Since We Are
Trying to Up-Grade Our Reputation, Not Just
Keep It.”
Leach RA. Evidence-based Chiropractic: Critical Thinking in the Private Practice Setting. JACA 2005;Jan/Feb:37-46.
Unsubstantiated Claims in
Chiropractic
Jerry Grod, DC
Institute for Evidenced-Based Chiropractic
Nine of Nine (100%) National and State Chiropractic
Organizations Publish and Distribute Patient Materials
With Claims not Currently Justified by Scientific
Evidence or are Intrinsically Untestable.
Examples of Unsubstantiated or Untestable Statements:
1. “Chiropractic care…is an effective alternative to drugs
and surgery for many conditions”.
2. “80% of all headache suffers obtain substantial relief from
chiropractors.”
3. “an uncorrected subluxation may lead to a deformity of
the spinal column.”
Grod JP, Sikorski D, Keating JC. Unsubstantiated claims in patient brochures from the largest state, provinical and National Chiropractic Associations and
Research Agencies. J Manip Physiol Ther. 2001;24:514-9
Unsubstantiated Claims
• How Can We Expect Providers to Use EBM
When Our National and State Organizations
are Making Unscientific and/or Untestable
Claims?
Provider Examples of
Unsubstantiated Claims
Donald E. Harte, DC
World Chiropractic Alliance
San Francisco Chronicle OPEN FORUM - Alternative to the sting of a failed flu vaccine
Tuesday, January 27, 2004
•
•
“Chiropractic allows a better-running, healthier nervous system. Ample literature supports the
successes of chiropractic with infectious disease.”
“The Great Flu Pandemic of 1918 was the greatest plague of modern times. It is estimated to have
killed between 25 million and 40 million people worldwide, about half a million in this country.
History shows us that those under chiropractic care during the flu pandemic had a far better
chance of survival.”
Provider Examples of
Unsubstantiated Claims
Willow Glen resident Lida Lopez Credits
Fisher's Treatments With Helping Her to
Conceive.
By Christine Frey August 5, 1998
According to her chiropractor, Paul Fisher,
Lopez had severe scoliosis. Her unaligned
spinal cord compressed the nerves which led to
her ovaries, blocking the brain's signals to
ovulate. By straightening her spinal cord, Fisher
says he released the pressure on the nerves;
the brain's signals could then flow through her
body.
Unsubstantiated Claims
Web Site
“If nerve impulses are obstructed to vital organs and
glands, they begin to function improperly, and may
produce a state of "disease". An adjustment, in
physiologic terms, removes the blockage of nerve
impulses caused by subluxation or other stresses to
allow the body to function naturally.”
Federal Trade Commission
Questions Chiropractic Claims
•
•
Concerned About the Claims Made in
Patient Brochures by Chiropractors.
Examples:
1.
"Chiropractic care is significantly more effective than commonly used medications
such as Ritalin in treating children”
2.
“Chiropractic care showed that they had "increased resistance to the common
childhood diseases," specifically measles mumps, German measles and chicken
pox.”
Response by Dr. Triano:
•
“While the conclusions espoused, perhaps, are attractive and popular to the DC, the
experts can and will refute them with ease.”
•
“members of the general public are likely to receive another negative image of the
profession based on accusations of using unsubstantiated claims.”
Dynamic Chiropractic September 21, 1998, Volume 16, Issue 20
Jerry Grod, DC
Institute for Evidenced-Based Chiropractic
What Evidence Do
Chiropractors Use?
1. Private, Personal Experience or the Collective
Experience of the Profession.
2. Evidence of Chiropractic Theory From the Basic
Sciences.
3. Fallacious Reasoning and Dogma.
–
–
“Chiropractic Works Because it has Never Been
Disproved.”
“It Just Makes Sense That Everyone Would be Better
Off Without Nerve Interference.”
Grod JP, Sikorski D, Keating JC. Unsubstantiated claims in patient brochures from the largest state, provinical and National Chiropractic Associations and Research Agencies. J
Manip Physiol Ther. 2001;24:514-9
Empty Chiropractic
• To Practice Chiropractic in the Absence of
Best Practice and Use of EBM is to Practice
in a Vacuum.
• “Until the Average Doctor of Chiropractic
Advocates the Use of Evidenced-Based
Chiropractic the Best Interests of Our
Patients and Society Will Not Be Well
Served.”
Leach RA. JACA Jan/Feb 2005; 37-46.
Traditional Sources of
Information
1. Training - Half of What is Taught When
We Were Students is Outdated in 10 years.
Sydney Burwell, MD Dean at Harvard Medical School.
2. Textbooks - Often Old and Outdated for
Causal Factors, Diagnosis, Prognosis and
Treatment.
Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-Based Medicine: How to Practice and
Teach EBM, 3rd ed. Edinburgh, Churchill Livingstone, 2005.
Traditional Sources of
Information
3. Experts - Often Inaccurate and Inadequate at
Producing Significant Change Independent of
Other Methods.
“There are as many opinions as there are experts.”
Franklin D. Roosevelt
“An expert is somebody who is more than 50 miles from home, has no
responsibility for implementing the advise he gives and shows
slides.”
Edwin Meese III
Former US Attorney General
Thomson O'Brien MA, Oxman AD, Haynes RB, Davis DA, Freemantle N, Harvey EL. Local opinion leaders:
effects on professional practice and health care outcomes. The Cochrane Database of Systematic
Reviews 1999, Issue 1. Art. No.: CD000125. DOI:10.1002/14651858.CD000125.
Traditional Sources of
Information
4. Didactic Meetings - Ineffective at Changing
Behavior.
Thomson O'Brien MA, Freemantle N, Oxman AD,Wolf F, Davis DA,Herrin J. Continuing education meetings and
workshops: effects on professional practice and health care outcomes. The Cochrane Database of
Systematic Reviews 2001, Issue 1. Art. No.: CD003030.
DOI: 10.1002/14651858.CD003030.
5. Professional Journals - Overwhelming. To Find
One Article of Quality and Relevance You Need
to Read 86-107 Articles.
Haynes DL, Devereaux PJ, Guyatt GH. Clinical expertise in the era of evidence-based medicine and patient choice
(editorial). ACP J Club 2002;136:A11-13.
The Paradox
Our Clinical Experience
Increases Over Time But
Our Knowledge of New
Treatment and Diagnostic
Approaches Decreases
Over Time.
0 years
5 years
10 years
Experience
15 years
20 years
Provider’s Are to Busy With
Their Professional and
Personal Lives to Keep Up
On the Increasing Volumes
of Information.
Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM,
3rd ed. Edinburgh, Churchill Livingstone, 2005
National Chiropractic Support for
EBM
Resolution Passed by
The American Chiropractic Association
September 2004
• “The ACA is Aware of Over-Utilization and Questionable
Utilization of Care That Occurs in the Health Care Delivery
System.”
• “The ACA Supports Evidenced-Based Medicine and Best
Practices That are Predicated by an Objective Review of the
Most Current and Valid Evidence Available in the Literature
and Other Sources.”
Evidence-Based Medicine
Patient
Preference
Clinical
Evidence
Core Decision
Clinical
Presentation
Clinical
Experience
The Chiropractic Oath
In accordance with the law of nature, that law which God has prescribed to all men; and in
consequence of my dedication to getting the sick well by the application of that law, I promise
and swear to keep, to the best of my ability and judgement, the following oath:
I will observe and practice every acknowledged rule of professional conduct in relation with my
profession, my patient, my colleague, and myself.
I will keep an open mind regarding the progress of my profession, provided that these
progressions shall be confined within the boundaries of the chiropractic science, philosophy,
and art.
I will serve my patient to the best of my ability, violating neither his confidences nor his dignity,
and in my association with patients I shall not violate that which is moral and right.
I shall regard and refer to my fellow chiropractor with honor, giving credit where it is due.
I shall improve my knowledge and skill, firm in my resolution to justify the responsibility
which the degree of Doctor of Chiropractor symbolizes and imposes.
To all this, I pledge myself, knowing these ideals are prescribed by the dictates of reason alone.
Knowledge Translation
Electrical Power Analogy
1.
2.
1. Generate Research
2. Disperse Research
3.
4.
Making Evidence Suitable for
Health Care Providers
Generate Research
Integration and Dispersion of
Science: Guidelines and
Reviews
Step-Down to a Level That
Can be Understood.
Suitable for Use by Providers.
EBM
3. Step-down/Simplify Research
4. End User
The Research-to-Practice Pipeline
•New research is entered into practice.
•Leakage occurs at all seven stages.
•If 80% knowledge transfer occurs at each step
there is a 21% patient usage (0.87 = 0.21)
Guidelines
RCT reviews
RCT’s
Reviews of Observational Studies
Observational Studies
Physiologic Studies
Clinical Observations
Aware
•Peers
•Associations
•Patients
•Publications
•Payers
Provider
Accepted
•Marketing
•R-O-I
•Peers
•Experts
Applicable
•Cookbook
•Clinical
Variation
•Patient
preferences
Patient
Able
How do we
apply the
science?
• Access
•Knowledge
•Training
Acted on
•Forget
•Neglect
•Habits
Helped by
reminders
Agreed
•Made aware
•Accept it
•Undertake it
Involves
values and
beliefs.
Glasziou P, Haynes B. The paths from research to improved health outcomes. EBM 2005; 10:5-7.
Adhered to
•Habits
•Money
•Fear
•Culture
Step 1
Aware
Self Directed Learning
Peers
Publications
Patients
National and State
Associations
Health Plans
• Marketing
Step 2
Accepted
" I have been using the ArthroStim® for 7 months, and I absolutely LOVE it! It provides an
alternative to a manual adjustment, is great for extremities, offers marketing opportunities
as not all chiropractors use it yet, creates internal referral, and best of all it gets RESULTS."
Dr. A. G.
• Return-On-Investment - “Will I Profit?”
• Experts and Peers - Influence the Use of Information and Products.
Step 3
Applicable
Evidence Does Not Make Decisions
Clinical Variation - Each Patient is Different.
1. Is My Patient Different From Those in the Study?
2. Is the Treatment Feasible for My Clinic Setting?
3. What are the Potential Benefits and Harms of the
Treatment?
4. What are the Patients Values, Beliefs and
Expectations?
5. Are There any Alternative Treatments?
Step 4
Able
• Training - Is Proper Training Needed to Use
and Interpret New Tests or Treatment?
• Access - Is New Equipment Needed? Is the
Treatment Within the Scope of Practice?
Acupuncture
Step 5
Acted On
• Forget - Simply Don’t Remember
• Neglect - Choose Not to Use. Laziness.
• Change of Habits - Reminders are Helpful.
Step 6
The Patients View - Agreed
• Involves Values, Beliefs and Personal
Goals.
• Provider Must Educate the Patient of New
Information.
• The Patient Must Understand This New
Information.
• They Must Agree With and Believe It.
Step 7
The Patients View - Adherence
Habits Such as Staying Compliant With Exercise.
Money - Can the Patient Afford the Treatment?
Fear - Are They Afraid of the Test or Treatment?
Culture - Can You Use the Treatment? Religious Beliefs,
Cultural Beliefs. Minority Patients.
Barriers To an Evidence-Based
Medicine Practice
Time
Skills &
Applicability
Uncertainty
Tradition &
Habits
Lack of Time
• The Average Clinician Spends 30 Minutes a
Week on General Reading and Study.
Sackett DL. Using evidence-based medicine to help physicians keep up-to-date. Serials 1997;9:178-81.
• We Need to Read 19 Articles a Day to Keep
Abreast in A Specialty.
Davidoff F, Haynes B, Sackett D, et al. Evidence-based medicine: a new journal to help doctors identify the information
they need. BMJ. 1995;1085-8.
Poor Evidence-Based Medicine
Skills
• 1991 Graduate of WSCC.
– Critical Thinking Skills Were Not Taught.
– No Training on What Evidence-Based Resources Were
Available.
• Limited Training in Research and Statistics.
– Study Design, Statistics and Technical Jargon is
Difficult to Impossible to Understand.
• Limited Courses Available for CE Credit to
Practicing Chiropractic Providers.
Applicability to Real-Time Practice
• Studies are Difficult to Apply.
– Is the Test or Treatment Available, Affordable, Accurate,
and Worth the Risk?
– Are the Patient’s in the Studies Similar to My Own?
• Guidelines May not Target Correct Providers.
– Guidelines were Primarily for Medical Doctors.
• Multiple Factors Involved in Decisions.
– Is the Patient Willing to Partner in Carrying Out the Test or
Treatment?
– Will the Test or Treatment Help My Patient Reach Their
Goals?
Uncertain of the Benefits to My
Patients
• Patient Preferences of Treatment
• “I Don’t Believe the Research.”
• “My Patients are Different”
• Sicker, Older, Younger
• More Complicated
Habits and Resistance to Change
• Read the Literature
• Conferences and Training Related to New
Tests or Treatments.
• Limited Time to Incorporate Research.
• Limited Resources to Obtain the Research
(Costs, Internet, Ovid, etc…)
• “My Patients Get Well With the Treatment I
Use. What Is The Point?”
Do Chiropractors Use Research?
Survey of BCBS MN
Network Providers
“Do You Currently Use Guidelines or Clinical
Pathways?”
60.00%
50.00%
50.00%
40.00%
35.00%
31.00%
30.00%
26.00%
30.00%
20.00%
10.00%
0.00%
2000
2001
2002
2003
2004
Yes
2000 n=272 (57%)
2001 n=389 (64%)
2002 n=418 (64%)
2003 n=477 (70%)
2004 n=503 (70%)
Survey of BCBS MN
Network Providers
“Have Guidelines or Clinical Pathways
Improved the Way You Provide Care?”
30%
30.00%
29%
29.00%
28.00%
27.00%
26%
26.00%
Yes
25%
25.00%
24.00%
23.00%
No Data
22.00%
2000
2001
2002
2003
2004
2000 no data
2001 n=389 (64%)
2002 n=418 (64%)
2003 n=477 (70%)
2004 n=503 (70%)
and
Ideas
1. Provide Low Cost or Free Access to
Information.
2. Evidenced-Based Chiropractic Web Site.
3. Interactive Workshops.
4. Measure and Reward for Excellence.
5. Upgrade Continuing Education.
Free Access to Information
1. Provide Free Access to Research Resources.
1.
2.
3.
4.
Ovid, CINDAHL - http://www.ovid.com
Cochrane Library - www.cochrane.org
Full Text Journal Articles and Reviews.
BioMail - www. Biomail.org
2. Create and Provide a Free Journal of EvidenceBased Chiropractic.
•
•
•
“Step Down” Research.
Brief Summaries of Chiropractic Related Research.
History, Examination, Diagnosis, Treatments, New
Technology, Guidelines, Systematic Reviews, RCT’s.
Evidence-Based Chiropractic
Web Site
JEBC
• Sponsored by Major Players in Chiropractic National/State Associations, FCER, Insurance
Companies, Others?
• Collaboration by Major Players May Help
Acceptance by the Profession.
• Access to Free Material.
• Links to EBM Materials and Web Sites Related to
the Practice of Chiropractic.
Interactive Workshops
3. Provide Low-Cost or No-Cost Interactive
Workshops on EBM.
1. Offer Continuing Education Credits.
2. Collaborate with Insurance Companies.
Sponsor Workshops, Provide List of
Attendees.
3. National and State Association Collaboration
and Sponsorship.
Measure and Reward
4. Determine Methods to Measure Use of
EBM in Chiropractic.
– Reward Providers Who have High Utilization
of EBM and Documented Quality
Improvement.
– Partner with Employers and Insurers.
– Look at www.bridgestoexcellence.com as an
Example.
Upgrade Continuing Education
State Boards Could Create Strict Approval
Standards for Continuing Education Based
Upon Current EBM.
• NBCE Train and Supply State Boards with
Guidelines and Standards of CE Approval
Related to EBM.
• Restrict Approval to Courses That Are
Based On Substantiated Claims.
How Do We Create an
Epidemic of EBM Use?
“Ideas Can be Contagious Just Like a Virus
Is.”
1. Law of the Few - Connectors, Mavens and
Salesman.
2. The Stickiness Factor - Simple Message,
Easy to Remember.
3. The Principle of Context - Broken
Window Concept. The Environment.
Conclusions
1. EBHC Is In the Best Interest For All Parties.
2. Providers are the Closest Link to Patient and the
Use of Tests and Treatments.
3. Chiropractic, Like Other Professions, Needs to
Improve the Use of EBM.
4. Barriers, and Hopefully Solutions, Exist to the
Widespread Incorporation of EBM Into the
Chiropractic Profession.
Thank You for Your Time
Happy Holidays
AnnMarie
Mariah
Bailey
Tyler