Posts Tagged ‘Maintenance’

GUIDELINES FOR CLINICAL GUIDELINES?

Sunday, November 2nd, 2008

There seems to be a progressively increasing number of practice guidelines appearing on the horizon for Chiropractors. If enough of these are generated could it get to the point that depending on whom a Chiropractor is dealing with, they will need to behave and practice in a chameleon-like fashion – what’s good for one patient, may be very different to what is good for another – depending on which guideline oversees that person’s situation?

Some of these guidelines appear to be less like best practice guidelines and more like agenda-based guidelines.

Most recently the Chiropractors Registration Board of Victoria has crossed over a boundary not previously entered into, and that is into the arena of clinical practice guidelines (http://www.chiroreg.vic.gov.au/comment.php). This is being justified on the basis that they act to protect the public against unethical chiropractice – but once reviewed against the standard of everyday chiropractic one might ask who will protect the chiropractor from the public and other third parties?

And if many established and widespread chiropractic practices such as X-raying for biomechanical assessment, use of physiological assessments such as surface EMG, adjusting children and newborns, caring for people with non-musculoskeletal conditions, maintenance and even wellness adjustments are guidelined as fringe, questionable and even unacceptable behaviours, then will future chiropractic practice resemble the service that so many chiropractors have offered to their communities for over 100 years?

Most of these guidelines are presented under the umbrella of “evidence-based practice”: Evidence-based clinical practice is defined as “The conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients… (it) is not restricted to randomized trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions.” (Sackett DL. Editorial. Evidence Based Medicine. Spine 1998.)

However it appears that some guideline developers twist the definition of “best” – disqualifying research and publication, or evidence, which isn’t the “best” – that is, if it isn’t a randomised, placebo-controlled, longitudinal, multi-centred, independently peer reviewed, published in a journal which the expert panel subscribes to, then it ain’t “best” and therefore it doesn’t exist…

In fact “best evidence” means the best level of evidence that we can find and what it tells us… If we don’t have the gold standard evidence, then do we have silver, bronze and even minor placing evidence to review and interpret? It is no secret that not only is chiropractic not very amenable to controlled study for a plethora of reasons, but the bulk of our evidence exists in the realm of longitudinal outcome studies, case series, and case studies. If this is the “best evidence” what does it tell us – there can be no denying that they tell us that a massive diversity of health complaints present in chiropractors’ offices, and that positive changes seem to happen?

We can’t say that if 100 “Syndrome A” sufferers present to chiropractic offices tomorrow, what percentage of these people will receive some degree of improvement let alone a complete resolution. But based on the evidence wouldn’t it be fair to say that if a “Syndrome A” sufferer presents to your office tomorrow, that it would be rational to initiate a course of treatment with clear goals and terms for review? How does that seem inferior or unacceptable to any other health care profession’s plan of action? Even after the gold standard research measures that 45% of patients receive an average of 35% improvement, what can we guarantee Mrs Jones on Monday morning? A course of care with clear goals and terms for review…

“Well it might mean that they aren’t receiving necessary medical intervention and maybe they have some terminal condition and detection will be delayed by this unproven approach!” Welcome to the life of a health care consumer trying to deal with a “primary care practitioner” – maybe the medications that the MD would prescribe as an “alternative” to our care would be ineffective or even damaging; may mask or delay the identification of other pathology; and maybe it could take months and even years to get a correct diagnosis in the medical system anyway? Sound familiar?

The chiropractic profession is not alone in the struggle to produce relevant and applicable guidelines which guide best practice, as opposed to restricting practice. “The National Health and Medical Research Council (NHMRC – an Australian Government body) has statutory responsibilities to raise the standard of individual and public health throughout Australia and to foster the development of consistent health standards. As part of this role, the NHMRC encourages the development of evidence-based guidelines by expert bodies.” (NHMRC standards and procedures for externally developed guidelines, updated September 2007)

Is a health care profession’s registration board an example of such an “expert body”? A quick read of the profiles of members of the board suggests that there is not much representation of the chiropractic profession’s academic and scientific community. So has the board received significant funding to employ the services of such experts? Who would know – no names or qualifications of any contributors or peer review panel members are listed in any of the guidelines. The guideline which covers the issue of paediatric care is an exception: It gives thanks to a Medical Paediatrician and an American Chiropractor who also holds Medical Degree, who is a self proclaimed “Quackbuster” who deals with healthcare consumer protection, and is therefore about quackery, health fraud, chiropractic, and other forms of so-Called “Alternative” Medicine (“sCAM”): Is this our desired expert body?

“It is now widely recognised that guidelines should be based, where possible, on the systematic identification and synthesis of the best available scientific evidence. The NHMRC requirements for developing clinical practice guidelines are rigorous so as to ensure that this standard is upheld. As such, guidelines with NHMRC approval are recognised in Australia and internationally as representing best practice in health and medical knowledge and practice.”

I’ll leave it to the educated reader to review the current proposed guidelines based on the following information:

Key principles for developing guidelines:

The nine key principles are:

1. The guideline development and evaluation process should focus on outcomes: This statement shouldn’t be glossed over as it seems that some of the worst examples of guidelines are more interested in practice than outcomes.

2. The guidelines should be based on the best available evidence and include a statement concerning the strength of recommendations. Evidence can be graded according to its level, quality, relevance and strength; (Ideally, recommendations would be based on the highest level of evidence. However, it has been acknowledged that the levels of evidence used by the NHMRC for intervention studies are restrictive for guideline developers, especially where the areas of study do not lend themselves to randomised controlled trials. It is proposed that this issue will be addressed when the toolkit publications are reviewed.)

It is tradition when presenting scientific evidence, to cite the source of your evidence. The proposed guidelines of the Registration Board list no references, and request for such evidence is refused on the grounds of “intellectual property”. Does this mean that there is no evidence? Is it only some “expert’s” opinion? Or are there too many pages of citations to fit in the publication? Who would know?

3. The method used to synthesise the available evidence should be the strongest applicable;

4. The process of guideline development should be multidisciplinary and include consumers early in the development process. Involving a range of generalist and specialist clinicians, allied health professionals and experts in methodology and consumers has the potential to improve quality and continuity of care and assists in ensuring that the guidelines will be adopted;

The board’s approach is to implement this step as late as possible, input only being sort after the guidelines have been drafted; and if past guidelines are representative, additional input will only lead to minor amendments at best.

That’s also why it is best to employ a medical paediatrician and an overseas chiropractor to produce a guideline on chiropractic care for children in Victoria. Perhaps the Australian chiropractic paediatric specialists that abound and the university academia that are responsible for the undergraduate paediatric curriculum were out to lunch when the document was written?

5. Guidelines should be flexible and adaptable to varying local conditions;

6. Guidelines should consider resources and should incorporate an economic appraisal, which may assist in choosing between alternative treatments;

7. Guidelines are developed for dissemination and implementation with regard to their target audiences. Their dissemination should ensure that practitioners and consumers become aware of them and use them;

In the case of the guidelines being discussed here you can download them from the web-site – otherwise you can get someone else to download them from the web-site for you.

8. The implementation and impact of the guidelines should be evaluated; and

9. Guidelines should be updated regularly.

I look forward to the dissemination of the steps and process for implementation of steps 3 and 5 to 9 with our newest guidelines – don’t hold your breath.

So, if the Registration Board’s attempt to offer guidelines is severely flawed where can we turn?

Guidelines have been produced which would more likely live up to the standards of the NHRMC. The Council on Chiropractic Practice Clinical Practice Guideline (“CCP”) is currently undergoing its’ second revision. Following publication of the CCP Guidelines the document was submitted to the National Guideline Clearinghouse for consideration for inclusion. The NGC is sponsored by the U.S. Agency for Health Care Research and Quality and is in partnership with the American Medical Association and the American Association of Health Plans.

Its mission is as follows: “The NGC mission is to provide physicians, nurses, and other health professionals, health care providers, health plans, integrated delivery systems, purchasers and others an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines and to further their dissemination, implementation and use.” In other words the US equivalency of the NHRMC.

The AHRQ contracts with ECRI, a nonprofit health services research agency, to perform the technical work for the NGC. ECRI is an international nonprofit health services research agency and a Collaborating Center of the World Health Organization.

In November of 1998, following review by ECRI, the CCP Guidelines were accepted for inclusion within the National Guideline Clearinghouse.

The CCP has developed practice guidelines for vertebral subluxation with the active participation of field doctors, consultants, seminar leaders, and technique experts. In addition, the Council has utilized the services of interdisciplinary experts in the Agency for Health Care Policy and Research (AHCPR), guidelines development, research design, literature review, law, clinical assessment, chiropractic education, and clinical chiropractic.

The Council additionally included consumer representatives at every stage of the process and had individuals participating from several major chiropractic political and research organizations, chiropractic colleges and several other major peer groups. The participants in the guidelines development process undertaken by the CCP and their areas of expertise are clearly disclosed.

The Guidelines offer ratings of practices based on the following system:

Established: Accepted as appropriate for use in chiropractic practice for the indications and applications stated.

Investigational: Further study is warranted. Evidence is equivocal, or insufficient to justify a rating of “established.”

Inappropriate: Insufficient favorable evidence exists to support the use of this procedure in chiropractic practice.

Categories of Evidence underpinning each rating are presented as:

E: Expert opinion based on clinical experience, basic science rationale, and/or individual case studies. Where appropriate, this category includes legal opinions.

L: Literature support in the form of reliability and validity studies, observational studies, “pre-post” studies, and/or multiple case studies. Where appropriate, this category includes case law.

C: Controlled studies including randomized and non-randomized clinical trials of acceptable quality.

To download the full version and updates of the CCP guidelines go to http://www.worldchiropracticalliance.org/

THE PERCEIVED VALUE VERSUS COST FORMULA

Monday, February 11th, 2008

Whether a person chooses to continue or discontinue chiropractic care depends upon how much the person values the care when compared with how much they feel it is costing them.

If the value appears greater than the cost the patient will continue care. If the cost appears to become more than the value they will discontinue treatment. The more we can increase the perceived value the less we need to worry about the cost!

VALUE INCREASERS:

1) Experiencing benefits from chiropractic care. Especially if those benefits are over and above the initial complaint or the benefits expected.

2) Increased education and understanding about chiropractic.

3) Third parties (family and friends) experiencing benefits: Another great reason to stimulate referrals quickly.

4) A “paradigm shift”: Changing people’s attitudes from “don’t fix it till it’s broke”, to one of maintenance, prevention and/or preferably wellness. That is “getting the BIG idea”!

COST INCREASERS:

1) Financial constraints: The amazing thing about this factor is that the more you can increase perceived value the less important this becomes. If you want it then you will find a way to pay. However cost is one of the main reasons people discontinue.

2) Time constraints: The old saying is that “time is money”. If it takes a person more than 20 minutes to drive to your practice; then they sit in your waiting room for 20 minutes; then it takes 15 minutes to get adjusted; then it takes 5 minutes to pay and reschedule – that’s 80 minutes out of their life. And then you tell them you want to see them 3 times a week? Big cost.

VALUE DECREASERS:

1) No or slow perceived response to treatment.

2) A reaction to an adjustment.

3) ‘Chiropractic consultants’: Rumor, opinion and hearsay can always affect the attitude of a new member of the chiropractic “family”.

4) Our attitude towards chiropractic: It ‘rubs off’ you know!

5) “The law of diminishing intent”: Ever made a new year’s resolution; then a few weeks later it just doesn’t seem that important any more? Day to day stresses and commitments and the distractions of “life” seem to get in the way. That is – the original commitment gradually becomes diluted to the point of becoming unimportant:

If we constantly feed, reinforce and nurture our goals and resolutions there is less chance of them fading and getting lost in this way. It is never safe to think that a patient has got “the big idea” now, and will hence have it forever – they need constant feeding, reinforcement and nurturing of their goals and resolutions.

TWO WAYS TO GET PEOPLE TO DO THINGS:

1) Control and manipulate: This is like trying to get a donkey to move by putting a carrot in front of its nose or hitting it from behind with a big stick. The problem with these techniques is that the reward or the punishments need to be continually increased to receive the same response over a long period of time.

In our health care setting this would take claiming bigger and bigger benefits to our patients as they feel better (the carrot), or convincing people that if they don’t continue to see us something terrible will happen to them (the stick). At some point in time the carrot and the stick will not be big enough!

2) Build relationships and teach by example: This is not about getting people to do what we want them to do: It is about showing people how they can get what they want – by following our example!

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YOUR ATTITUDE IS CONTAGIOUS!

Sunday, January 27th, 2008

The number and type of clients you see and draw to your practice are a SYMPTOM of your own attitude towards chiropractic!

1) If your attitude is that chiropractic is great for the relief of any number of aches and pains - then you will have a pain relief and crisis care practice.

No matter how many visits you try to extract from your customers, they will tend to use you only for the relief of aches and pains - you may have a PVA of 20, but this will be 20 visits of crisis care. And because you will see primarily pain relief occurring, you will justify your attitude. In other words, you will either not initiate larger state of wellbeing and general health changes, or even if they are occurring you will be oblivious; because you won’t even ask the questions that might detect that something else is going on. And your patient’s won’t think to mention any other changes that are happening in their lives, because you are the “Back Doctor”, and the other stuff has nothing to do with you.

2) If your attitude is that chiropractic is good for fixing back problems, or straightening abnormal spinal angles - then you will have a corrective care practice.

You could have a huge practice, with people seeing you for a bunch of visits in a relatively short space of time. People will be convinced and even impressed by your level of professionalism, equipment and affluent appearance. But here’s the question: How many families are you seeing, how many of your clients have been seeing you for 5 and even 10 years, how dependent are you on the next bunch of new patients to refill the appointment book and balance sheet?

3) If your attitude is that regular chiropractic helps to prevent spinal problems from progressing to be serious, acute and painful - then you will have a maintenance practice.

How quickly do your patients get to four to six week intervals in their care? Often they get to monthly visits and you haven’t even reassessed them. A couple of times a week for a couple of weeks, then once a week for a couple more weeks, and then before you know what’s happened they are booked in, in 4-6 weeks. They may be out of pain, and they may have experienced some initial health improvements, but have YOU really made any signifiant physiological and functional changes to their global state of wellbeing? Will they live longer and better as a result of an adjustment every 30-60 days, while in between they undo all your good work?

4) If your attitude is that chiropractic is an integral part of a person’s health program, having an effect on their nervous system and releasing the work of the body’s innate intelligence - then you will have a broad scope health and wellness practice.

Their symptoms, state of disease, financial position are even totally irrelevant to your belief that a regular adjustment will do them good… It’s this simple - PEOPLE WHO GET ADJUSTED DO BETTER! And they usually feel and function better too. But you don’t take responsibility for your practice members’ state of health - You didn’t get them into the state they are currently in, and you can but assist them and even coach them towards a more optimal lifestyle… You understand that each adjustment is a positive healing step forwards, and you utilise all your clinical and technical skills to determine how many steps they take backwards in between adjustments to determine the optimal schedule for their care. And this attitude is contagious, because the type of new patient that appears at your door seems to intuitively understand this philosophy, and they seem to be surrounded by a family and peer group that wants to join them at your rooms on a regular basis.

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Practice Tip - WHAT DO YOUR PRACTICE MEMBERS REALLY THINK ABOUT YOUR CARE?

Friday, October 19th, 2007

The Million Dollar Question

Many of us now call ourselves “Wellness DCs” or “Healthy Lifestyle Doctors” or some other impressive sounding title - I guess we are trying to differentiate our services from the other “garden variety” DCs? But these titles often are a reflection of us, and not a true reflection of how our customers really see us, or how they themselves behave. Maybe we exercise regularly, get adjusted every 1-2 weeks, keep a positive outlook, eat organic etc. But then we have 80% of our practice on monthly schedules, and have no discernable influence on their other healthy habits?

I suffered a daunting revelation when I upgraded my technique and scheduling systems to a more “wellness” driven focus. You see I used to spend ~15 minutes with each client, and they loved my soft-tissue techniques, and often complimented me on my ability to find the sore spots and to provide instantaneous relief from their musculoskeletal aches and pains. Not that there is anything wrong with this - but my mission is to improve the health and wellness of everyone that I can influence - not to be the natural alternative to Nurofen and Panadeine. And when I changed my technique to a neurological model, many left the practice before they could possibly experience the extra health benefits - why? “Because I didn’t rub their shoulders”!

So, what do YOUR clients really think of YOU? Here is the million dollar question to ask your practice members that will inform you of the truth…

“If you could come and have an adjustment whenever you wanted to, and it didn’t cost you anything, how often would you come?”

1) If the answer is, “Oh I’d come every single week, and sometimes even more”: Congratulations - you probably are truly a wellness DC - your clients truly comprehend the global benefits of an adjustment. They probably perceive the reduction in tension and stress, the improved sleep patterns, the maximised immunity, and the increases in energy after each adjustment.

2) “Oh, I’d come every 4-6 weeks”: Maybe you should replace the title “Wellness” with “Maintenance” DC. Your clients have probably discovered that if they go longer than 4-6 weeks, that their aches and pains start to increase in severity and regularity. Your periodical adjustments offer them effective and lasting pain relief.

3) “Oh, I’d come a 2-3 times a year”: I actually don’t quite understand this concept - maybe it’s because they get their car serviced twice a year, and go to the dentist twice a year, and floss their teeth twice a year, and make love twice a year? I’m not sure of what possible benefit two adjustments per year could have - maybe I underestimate the power of an adjustment?

4) “Oh, I’d come in whenever I had a problem”: Whoops, if you get a lot of this answer, then it is time to change your title to “garden variety DC”.

To take this question to the next level: If your practice members answer that they would like to come more often than they actually do - the next question to ask is - “What do we need to do to help you come as often as you would really like to?” - now its time to work out a strategy, schedule, fee, that makes their dream a reality…

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