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 1844-1900German Philosopher

Evidence-Based MedicineEBM

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• “By Denying Our Uncertainty and Curiosity We Risk Becoming Dangerously Out of Date and Immune to Self-Improvement and Advances in Medicine.”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

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

Jerry Grod, DCInstitute for Evidenced-Based Chiropractic

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

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.”

Donald E. Harte, DC

World Chiropractic Alliance

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 ClaimsWeb 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

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

Jerry Grod, DCInstitute for Evidenced-Based Chiropractic

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.

Provider’s Are to Busy With Their Professional and Personal Lives to Keep Up On the Increasing Volumes

of Information. 0 years 5 years 10 years 15 years 20 years

Experience

Kno

wle

dge

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

Core Decision

PatientPreference

Clinical Evidence

ClinicalExperience

ClinicalPresentation

The Chiropractic OathIn 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

Making Evidence Suitable for

Health Care Providers

1. Generate Research

2. Integration and Dispersion of Science: Guidelines and Reviews

3. Step-Down to a Level That Can be Understood.

4. Suitable for Use by Providers.

1. Generate Research

2. Disperse Research

3. Step-down/Simplify Research 4. End User

Electrical Power Analogy

EBM

The Research-to-Practice Pipeline

GuidelinesRCT reviews

RCT’sReviews of Observational Studies

Observational StudiesPhysiologic Studies

Clinical Observations

Wea

k

Stro

ng

Aware•Peers•Associations•Patients•Publications•Payers

Accepted•Marketing•R-O-I•Peers•Experts

Applicable•Cookbook•Clinical Variation•Patient preferences

AbleHow 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.

Adhered to•Habits•Money•Fear•Culture

Patient Provider

•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)

Glasziou P, Haynes B. The paths from research to improved health outcomes. EBM 2005; 10:5-7.

Step 1Aware

Self Directed LearningPeers National and State

Associations

PatientsHealth Plans

Publications

Step 2Accepted

" 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.

• Marketing

• Return-On-Investment - “Will I Profit?”

• Experts and Peers - Influence the Use of Information and Products.

Step 3Applicable

Evidence Does Not Make DecisionsClinical 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 4Able

• 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 5Acted 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 7The 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?”50.00%

26.00%

35.00%31.00% 30.00%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

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?”

26%

25%

30%

29%

22.00%

23.00%

24.00%

25.00%

26.00%

27.00%

28.00%

29.00%

30.00%

2000 2001 2002 2003 2004

Yes

2000 no data2001 n=389 (64%)2002 n=418 (64%)2003 n=477 (70%)2004 n=503 (70%)

No Data

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 Information1. Provide Free Access to Research Resources.

1. Ovid, CINDAHL - http://www.ovid.com2. Cochrane Library - www.cochrane.org3. Full Text Journal Articles and Reviews.4. BioMail - www. Biomail.org

2. Create and Provide a Free Journal of Evidence-Based 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

• 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.

JEBC

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 TimeHappy Holidays

TylerAnnMarie

Mariah

Bailey