Healthcare Review & Consulting, Inc

1. Healthcare Review & Consulting, Inc

2. What is health? • Optimal physiological, mental , social well being? • Lack of Disease? • Being Subluxation Free? Everyone may define it differently, so how are we to measure it or know how to monitor the patient or when to discharge a patient?

3. The Subluxation (Multiple definitions) • Misalignment • Altered joint function • Altered pathological changes in nerve, muscle, ligamentous, and vascular structures • Alterations of structural, functional and pathological changes that may effect neural integrity, and influence organ function and general overall health. How do we measure it?

4. The Problem! • Healthcare has outgrown the ability of government, employers, individuals ability to support the costs • The move in health care to cut costs, allegedly by improving quality. • The desire to improve quality by asserting evidence based practice

5. The Problem! • Much in health care lacks strong evidence (85% of current health care practices remain scientifically invalid- Gunn AANA J ’98) • Lack of understanding by the practitioner of application, dose, frequency of care.

6. The Problem! • Lack of knowledge of latest literature • Inability to keep up with the literature • Inability to understand and integrate literature • Lack of interest

7. The Problem! • Philosophy • Complications of Healthcare system • Ignorance of appropriate clinical decisions • Apathy • Intentional Fraud

8. Patient Outcomes(Changes in Evidence presented by the Patient) • Clinical Symptoms • Effects on ADL, Work & Recreational Activities • Physiological and Anatomical Measurable Changes (Physical exam, imaging, Dx test) • Progressive resolution of diagnoses

9. Documentation • Improvement, efficacy and changes must be noted in the clinical file • Clinical Decision Making process in response to the changes documented. • Clinical Decision Making must be in concert with the evidence based literature.

10. What is Evidence Based Medicine? • “The conscientious, explicit and judicious use of current best evidence in clinical decision making” • “Integrating individual clinical expertise with the best available external clinical evidence from the research” -Sackett, BMJ, 1996;312

11. What is Evidence Based Medicine? • “Good Doctors use both individual clinical expertise and the best available external evidence, neither alone is enough” • “Without clinical expertise, practice risks become tyrannized by evidence”

12. What is Evidence Based Medicine? • “Even excellent external evidence may be inapplicable to or inappropriate for an individual patient” • “Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients” -Sackett, BMJ, 1996;312

13. What isn’t Evidence Based Medicine? • Cook-book approach to patient care • Does not replace clinical expertise which must decide whether the external evidence applies to the individual patient. • Cost cutting healthcare, it may lower the cost, but may also raise it as it applies the most efficacious interventions -Sackett, BMJ, 1996;312

14. What is the Evidence? • Randomized Controlled Studies • Randomized uncontrolled studies • Observational Cohort Studies • Meta-analysis of the literature

15. What is the Evidence? • Case Series • Case Studies • Consensus of expert opinions • Federal, State, Professional and community standards • Published Best Practices and Practice Parameters

16. What is an Evidence Based Review? • Knowledge of the literature base • Assessment of the documentation • Integration of the documented clinical judgment with the evidence • Respect for the appropriate clinical decision making process of the physician at the time care was rendered.

17. What is an Evidence Based Review?Documentation, Documentation, Documentation! • Must assess the clinical expertise and decision making through the available documentation • Documentation must conform with State Regulations and Professional Standards • If it wasn’t written down, then it wasn’t done!

18. What is a Best Practice? Best practices are those strategies, activities, techniques or use of resources that have evidence of success in providing significant improvement in quality, performance, safety, time of reaction, cost and or other measurable factors which impact on a target group (our patients) • Research • Clinical Decision Making • Patient Values

19. What is a Best Practice? • Best practices are using clinical reasoning to guide the practice, making judgments about the relevance of particular research and clinical evidence for a specific patient and setting • What is the best information to use to make decisions for a particular patient and setting? -Higgs AACN Clinical Issues 2001;12;482-90

20. “Recommendations” Guidelines Best Practice Cohort RCT Case Series RCT Clinical judgement & experience Guidelines vs Best Practice Treatment options: A = 80%, B = 25% C = 5%, D = 0%

21. Utilization of Best Practices • Instead of defining best practice narrowly by the strength of the current empirical evidence used to guide clinical decisions, • …Defined broadly by what is the best information to use to make decisions for a given patient in a particular setting. Credible and accountable clinical decisions rely on a number of forms of knowledge and evidence. -Higgs:

22. Utilization of Best Practices • The average healthcare clinician does not have the tools to evaluate research • The clinician must rely upon Best Practice (& experts) and integrate the information into practice appropriately. • Reviewing physician must do the same!

23. How do we utilize Best Practices in performing Reviews? • Chiropractic Best Practices to be disseminated by end of 2005 • Knowledge of current literature • Knowledge of past guidelines • Assessment of clinical reasoning of Dr.

24. How do we utilize Best Practices in performing Reviews? Take into account: • The Grading of Recommendations (% chance of success) • Specific patient presentation • Risk Stratification

25. How do we utilize Best Practices in performing Reviews? Take into Account: • The Level of the evidence • Good evidence from relevant studies: RCT, Meta-analysis, • Fair evidence from relevant studies: RCT w/different results or single RCT with clinically significant conclusion, or Cohort study • Limited evidence from studies or reviews, uncertainty about conclusions, relevant cohort, case control, case series or outcomes research • Expert Opinion, consensus report, position statement from a national body • Insufficient or non-relevant evidence

26. How do we utilize Best Practices in performing Reviews? • Assessment of documentation of: • Subjective complaints • Objective findings • Diagnosis • Type of treatment • Frequency, duration of treatment • Complicating factors

27. How do we utilize Best Practices in performing Reviews? • Common Complicating/Risk Factors (for common soft tissue & joint injuries) • Age • Gender • Severity of Symptoms • Prior Surgery • Prior recent injury (<6mo) • Poor Body Mechanics • Falling as mechanism of injury • Neuro signs

28. How do we utilize Best Practices in performing Reviews? • Complicating/Risk Factors • Biomechanical • Prolonged static posture • Poor Spinal motor control • Sustained trunk load • Frequent bending, twisting, lifting, pushing, pulling

29. How do we utilize Best Practices in performing Reviews? • Complicating/Risk Factors • Psychosocial • Chronicity • Attorney Retention • Employment Satisfaction • Expectations for recovery • Participation in social welfare or disability program

30. How do we utilize Best Practices in performing Reviews? • Complicating/Risk Factors • Physiological • DJD, articular inflammatory dz, boney dz • Spinal stenosis, or physiol. narrow canal • Osteoporosis, bone weakening disorders • Scoliosis • Neurological signs or symptoms

31. Benchmarking of Care • A comparison of recovery rate to population data on natural course or usual treatment hx • Benchmarking ignores the complexity of case and complicating/risk factors of indvdl • Benchmarking ignores differences between symptomatic episodes and underlying dz

32. Assessment (structure=>process=>outcome) vs Benchmarking of Care • Appropriate care administered? • Complexity of case documented? • Intervention of factors outside provider control? • Patient compliance?

33. Assessment vs Benchmarking of Care • Is there documentation of the process? • Dr responding to the re-evaluations with appropriate changes in case management? • Changes in treatment plan, dx testing? • Progressing from passive to active care?

34. Assessment vs Benchmarking of Care • Is there documentation of the process? • Is the process of care reasonable? • Is the treatment efficacious? • Is progress (physiol., functional, symptomatic, diagnostic) noted in the re-examinations?

35. How do you apply the literature? • Organized, Published Best Practices • Synthesizing of the literature to the particular patient circumstance • Documenting the patient uniqueness • Use it to manage the care process vs allowing the management of costs by other parties.

36. How do you apply the literature? • Documenting complicating factors • Awareness of different patient populations • Use it as a guide to treatment planning for the greatest likelihood of benefit for majority • Closely observe progress for pt’s with significant number of risk factors, and respond!

37. Does the literature apply to all cases? • Most literature applies to select pop grps • + Physiological Changes + pt outcomes • POEM’s=Patient Oriented Evidence that Matters

38. Does the literature apply to all cases? • Was Study Design methodologically sound? • Was analysis of data performed correctly • Was the study results interpreted correctly? • How was the quality, validity, sensitivity, specificity of the study? • Is there systematic bias or inferential error?

39. Does the literature apply to all cases?(How can a clinician evaluate this?) • Reliability on Best Practice • Demonstration of Clinical Reasoning • Documentation of Process • Regular re-evaluations of patient, monitoring • Look @ all outcome measures and compare to EBM, taking into account the particular patient situation, risk factors and benchmarks for majority pop.

40. Record Review: What to look at!History • Is there doc. of mode of onset? • If MVA, is there a description of accident? • Is causal relationship plausible? • If work related, is there description of mode of onset? • Was there any immediate or emergency care?

41. Record Review: What to look at!History • Is there concurance of injuries @ ER with complaints at doctor’s office? • Was there a gap in time prior to seeking care? If so, why?

42. Record Review: What to look at!History • Does subjective complaints correlate to the mode of injury? • Is there a review of systems? • Is there sufficient HPI to substantiate code level?

43. Record Review: What to look at!Examination • Are there sufficient body areas/organ systems to substantiate coding level? • Are there descriptors with +Ortho tests to indicate true positives vs false positives? • Is there a loss of ROM? • Do the findings substantiate/concur with subj?

44. Record Review: What to look at!Diagnosis • Dx concur with Hx, subj. complaints & Exam findings? • Simple or complicated DX? • Multiple tissues types or body areas or anatomical/physiological structures injured?

45. Record Review: What to look at!Prognosis • Prognosis documented? • Pt @ MMI? • Has pt been discharged?

46. Record Review: What to look at!Treatment Plan • Is there a written treatment plan? • Is there duplication of types of care? • Are all tx modalities applied appropriately? • Is the dose/duration of treatment substantiated as per EBM & clinical reasoning?

47. Record Review: What to look at!Treatment Plan • Has the treatment plan been updated as per re-examinations and progress or lack thereof? • If patient progressing, is there decrease dosage of care? • If patient progressing, is there transition to active care?

48. Record Review: What to look at!Documentation • Daily notes? Legible? • Notes organized in standard format? • Computer generated or computer organized?

49. Record Review: What to look at!Documentation • Documentation of progress &/or efficacy? • Regular Re-exams? • Substantiation of Care Rendered? • Passive modalities discontinued after acute phase?

50. Independent Chiropractic Examination Introduction: • Obtain the date, place and mode of onset of the incident and any previous care. • Review any past accidents or injuries and the importance to the incident under examination. • Any previous similar complaints? • Has the injuries affected the patients ADL, or work activities? Any loss of time from work? If so how long?