Evidence-based chiropractic and documentation

Evidence-based chiropractic and documentation

Good clinical documentation • A record of a patient’s subjective complaints, objective findings, assessment, and plan for case management • Should represent the thought processes involved in patient care • Provides evidence of the patient’s progress Evidence-based Chiropractic

Good clinical documentation (cont.) • Practitioners are able to monitor patient progress accurately using good clinical documentation • Facilitates making the best possible clinical decisions • May alleviate problems associated with third party record reviews and medicolegal issues Evidence-based Chiropractic

The value of valid & reliable outcome measures (OMs) • Beneficial to • Patients, because they are more likely to receive appropriate care • Practitioners, who use the information to formulate diagnoses and plan care • Third-party payers and patients, who will be more likely to receive legitimate services in return for monetary expenditures Evidence-based Chiropractic

Utility of OMs • The utility of a test refers to its usefulness in meeting the needs of the patient, referrer, and payer • An OM should be sensitive to change • It should change in direct association with actual changes that occur in the patient characteristic being measured • Responsiveness Evidence-based Chiropractic

Clinical practice guidelines • Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances • Developed by experts in a field using an organized process • Evidence is assembled on the management of the kinds of conditions handled by practitioners Evidence-based Chiropractic

Clinical practice guidelines development • Best evidence is located to give clinicians tools to provide optimal patient care • Steps in guidelines development • The subject area of the guideline is identified • Guideline development groups are assembled • Evidence is obtained and assessed • Evidence is shaped into a clinical guideline • The guideline is reviewed externally Evidence-based Chiropractic

Consensus opinions • Expert opinions are sought when there is little or no scientific evidence available • One must consider that they are merely the opinions of a panel of experts • The Delphi method • A method often used in guidelines development to establish a group position • Involves serial input from a group of panel members via questionnaires Evidence-based Chiropractic

Guidelines development (cont.) Evidence-based Chiropractic

Guidelines differ in quality • Quality depends on the rigor of the methods used in their development • e.g., the Guidelines for Chiropractic Quality Assurance and Practice Parameters (Mercy guidelines) • Evidence-based guidelines • Follow a rigorous development process • Are based on the highest quality scientific evidence Evidence-based Chiropractic

Guidelines may have disadvantages • Evidence on a condition or treatment may be unavailable or of low-quality • In which case guidelines may only serve to inform clinicians about the lack of evidence • Guidelines only address one condition at a time • However, in practice patients often present with several complaints Evidence-based Chiropractic

Guidelines - disadvantages (cont.) • Recommended treatment options may not always be appropriate • Each patient is unique • There may be contraindications to treatment • Patient preferences must be considered • Consequently, guidelines should never be utilized as a treatment “cookbook” Evidence-based Chiropractic

Guidelines - disadvantages (cont.) • Guidelines should be updated periodically to incorporate new information • Although the time-frame for updates is variable • Depends on how rapidly change occurs in a topic or field • The Mercy guidelines mentioned that they should be updated, but never were Evidence-based Chiropractic

Assessing the validity of guidelines • Were good development methods used? • Methods should be thoroughly described • Rigorous systematic methods of evidence selection and appraisal should be used • Will the recommendations facilitate the care of your patients? • Should be applicable to the chiropractic setting and to chiropractic patients Evidence-based Chiropractic

Assessing the validity of guidelines (cont.) • Are the patient populations from the source articles similar to your patients? • For instance, disease prevalence or risk factors may be different • Keep in mind that guidelines are not prescriptive statements • They are designed to provide assistance and direction to patient care Evidence-based Chiropractic

Best practices • The organizational use of evidence to improve practice • Definition • Activities, disciplines and methods that are available to identify, implement and monitor the available evidence in health care • Sometimes confused with clinical guidelines, but they are actually different Evidence-based Chiropractic

OMs commonly used in chiropractic • The choice of OMs depends on • Objectives for the patient or requirements of the party or stakeholder who will receive the information • OMs useful to clinicians and patients involve measures such as pain and function • Payers are interested in cost-efficient patient management and patient satisfaction • Employers may be interested in seeing their injured employees return to work ASAP Evidence-based Chiropractic

Health-related quality of life (HRQL) measures • Questionnaires that are designed to assess the physical, psychological, emotional, and social well-being of patients • Reported from the patient’s perspective • Criticized as being subjective and unreliable • However, HRQL measures are typically more reliable than “objective” OMs Evidence-based Chiropractic

HRQL measures (cont.) • Findings are meaningful to patients • HRQL measures are helpful in the assessment of patients’ functional limitations • They are appropriate and useful in monitoring the effects of treatment Evidence-based Chiropractic

Two general categories of HRQL measures • Generic instruments • Designed to evaluate patients’ overall health status • e.g., the SF-36 health survey and the Sickness Impact Profile • Specific instruments • Designed to assess specific conditions, patient groups, or areas of function • e.g., the Neck Disability Index Evidence-based Chiropractic

General categories of HRQL measures (cont.) • Condition-specific instruments have advantages over generic • They evaluate elements of function that are relevant to the specific condition under consideration • As a result, they are generally more responsive to changes in patients’ primary conditions Evidence-based Chiropractic

Measures of pain • Measures of pain and function are the most commonly used OMs in chiropractic • It is not possible to measure pain directly • It must be estimated from replies to oral or written queries • The process can be influenced by the patient’s culture, conditioning, education, etc. • Then the pain replies must be interpreted by the clinician Evidence-based Chiropractic

Measures of pain (cont.) • Quite a few tools are available that can convert the subjective experience of pain into valid and reliable measures • Once chosen, the same instrument should be used for follow-up evaluations Evidence-based Chiropractic

Numeric Rating Scale (NRS) • a.k.a., numeric pain scale or 11-point pain scale • Very common in research and practice • Patients estimate the severity of their pain on a 0 to 10 scale • 0 = no pain • 10 = worst possible pain Evidence-based Chiropractic

NRS (cont.) • Patients are asked to circle the number that matches their level of pain • May be used verbally • e.g., “On a 0 to 10 scale, where 0 means no pain and 10 is the worst possible pain, what is your level of pain?” Evidence-based Chiropractic

NRS (cont.) • Interpretation of the intensity of NRS pain scores • 1-4 = mild pain • 5-6 = moderate pain • 7+ = severe pain • 101-point NRS(NRS-101) • Occasionally encountered in the literature • Provides little more than the 11-point scale Evidence-based Chiropractic

Visual Analog Scale (VAS) • A 10 centimeter line with descriptive phrases at each end that depict the extremes of pain 10 cm Measure mm to mark Evidence-based Chiropractic

Other uses of NRS & VAS • Measure the impact pain has on daily living e.g., sleep interference and lifting capacity • Can also be adapted to assess anxiety or depression levels in pain patients COMPLETELY INTERFERES DOES NOT INTERFERE Evidence-based Chiropractic

Characteristic Pain Intensity (CPI) • A scale that averages the patient’s pain levels right now, typical or on average, and when it is at its worst • Patients presenting for evaluation at a particularly good or bad time are able to convey their true pain level better • Uses 3 VAS pain intensity ratings that represent different points in time Evidence-based Chiropractic

CPI (cont.) Evidence-based Chiropractic

CPI (cont.) • In research, the CPI correlated better with measures of pain-related disability, pain medication use, and standard pain measures than individual ratings • CPI scores were more normally distributed Evidence-based Chiropractic

Verbal Rating Scales (VRS) • A scale that depicts pain intensity using a series of adjectives that reflect the extremes of pain (e.g., from no pain to intense pain) • Patients are asked choose the adjective that best describes their pain level by selecting from a list of possibilities Evidence-based Chiropractic

The 5-point VRS Evidence-based Chiropractic

VRS (Cont.) • The VRS is preferred by patients because of its simplicity • It is not as sensitive or reliable as other pain scales • VRS data can easily be misinterpreted because word descriptions may not have the same meaning for different persons Evidence-based Chiropractic

Tenderness Rating Scales • Used to quantify the degree of discomfort associated with palpation, typically of myofascial tissues • The patient’s interpretation of tenderness is correlated with the examiner’s observation of their reaction to a pain stimulus which can help objectify information gained from palpation Evidence-based Chiropractic

Tenderness rating of soft tissue Evidence-based Chiropractic

Pain drawings • Patients simply shade or mark the regions of a blank body image where they are experiencing pain • Can be used independently or incorporated into questionnaires • Their utility can be enhanced when used along with other OMs Evidence-based Chiropractic

Pain drawings (cont.) Patient circles area of pain and notes ache • Codes are often used • to depict the qualities • of pain, e.g., • A = ache • D = deep • B = burning • N = numbness • OR • //// = stabbing • 000 = pins & needles • XXX = burning Evidence-based Chiropractic

Margolis system: Patient marks areas of pain on a blank body image and then a trans- parent grid depicting 45 regions of the body is superimposed over the completed image Completed drawings can be scored as to the percentage of body surface in the shaded regions by referring to a list of weighted values Evidence-based Chiropractic

Pain drawing from the American Academy of Physical Medicine & Rehabilitation Includes a description of pain levels Evidence-based Chiropractic

Pain drawings (cont.) • Test-retest reliability has been established in several studies, even when administered in diverse settings • Sometimes used by clinicians to identify psychological disturbances in pain patients • However, this method has low sensitivity and positive predictive value Evidence-based Chiropractic

McGill Pain Questionnaire (MPQ) • Developed by Melzak in 1975 • Provides a quantitative measure of pain • One of the most widely tested pain measures of all time • Often used as a gold standard, against which newly developed pain instruments are tested Evidence-based Chiropractic

MPQ (cont.) • Made up of 3 major classes of word descriptors, including words that describe • Sensory qualities • Affective, in terms of tension, fear, and autonomic responses to the pain • Evaluative words that describe the intensity of the pain Evidence-based Chiropractic

MPQ (cont.) • Consists of 4 major parts: • A pain drawing • 78 pain descriptors (e.g., sharp, intense, pinching) that span 20 categories • Questions that assess how the pain changes over time and what relieves or increases it • A pain intensity section Evidence-based Chiropractic

SHORT FORM McGILL PAIN QUESTIONNAIRE(SF-MPQ) Pain drawing 1 2 3 Scored as follows: Mild = 1 Moderate = 2 Severe = 3 Unchecked = 0 Sensory Affective VAS Sensory score, 33 possible Affective score, 12 possible VAS score Evidence-based Chiropractic

Psychometric measures • Questionnaires that deal with patients’ emotional and psychological state • Chronic pain can bring about anxiety, depression, and hopelessness • It can aggravate existing depression • In some cases, depression can cause chronic pain Evidence-based Chiropractic

Psychometric measures (cont.) • Psychometric questionnaires can be used by chiropractors to screen pain patients • Mild depression associated with pain can be monitored • When persistent or more than mild, some patients may need a psychological referral Evidence-based Chiropractic

Beck Depression Inventory (BDI) • The most commonly used self-administered scale for measuring depression world-wide • Can be integrated into a busy clinical practice without difficulty • Requires no special training to administer • 21 items dealing with statements about how patients perceive themselves Evidence-based Chiropractic

BDI (cont.) • For example • 0 – “I don't feel disappointed in myself” • 1 – “I am disappointed in myself” • 2 – “I am disgusted with myself” • 3 – “I hate myself” • Score 10-18, patient is mildly depressed • 19-21 may have borderline clinical depression Evidence-based Chiropractic

BDI (cont.) • The test’s validity and reliability has been established • It has high internal consistency and high content validity • Good discriminate validity • Is able to distinguish depressed from non-depressed subjects • It is sensitive to change Evidence-based Chiropractic

Evidence-based chiropractic and documentation