Open access online resource for chiropractic research

If you are a chiropractor looking for research on a particular patient condition, a new resource sponsored by Council on Chiropractic Guidelines and Practice Parameters (CCGPP) is now available: clinicalcompass.org. This site collects the latest information on medical topics pertinent to chiropractic care and presents them free of charge as a resource for chiropractic physicians. Materials available include relevant and current peer-reviewed journal articles, either as abstracts or full-text, depending upon availability. Summaries and annotated bibliographies are available for each topic.


Best Practices: Provider & Patient ID in Clinical Record Keeping

One of the most basic elements of a clinical record is full and complete identification of the provider, the office, and the patient. Whether the record is paper to be scanned into an electronic medical record (EMR) or paper forms stored in a physical file, best practice is a complete ID on each and every page of the chart.

  • The provider should be identified by name, professional designation, physical address and telephone number.
  • The patient should be identified with a full name and date of birth or other unique identifier such as a health record number.
  • The author of the note should be clearly identified and include a verifying signature. Note: If forms are two-sided, each side should have complete identification.

Some providers complain, “Why the over-kill? I know who my patients are.” It’s true that, while the chart is in the provider’s office and under their control, everything may be clear. However, when copies are made for another health care provider, an insurance company, or even an attorney and the provider or patient’s ID is not on every side of the paper record, the receiver may not be able to tell for certain that a piece of the record is from the provider or pertains to their patient. A completely identified record with a full signature or validated electronic signature is an unassailable legal record. Also, mishaps happen. If records are vandalized, misplaced, or even just fall to the floor, proper identification of each page will allow successful reassembling of the files.

If you use an EMR system, check your software settings to ensure proper ID is printed on every page. If you are printing commonly used forms – such as a patient intake form – always allow space for the patient name and DOB or other unique ID on each page. Make sure that the clinic address and phone number is included on each page. In multiple provider offices make sure to identify the provider seeing that patient.

The best practices described here are endorsed by many health care organizations, regulatory agencies (e.g., NCQA) and state authorities. Want more information on record keeping or other best practices for integrative healthcare providers? Search “best practices” on this site to read more in this series of articles.


CDC releases survey results for physical activity levels by age

The CDC has just released data from the 2013 National Health Interview Survey (NHIS) showing the percentage by age of survey respondents who say they meet US Preventive Services Taskforce recommendations for physical activity. Compared to the NHIS from 2008 the recent numbers show slight increases in all age groups, however in the most active age group (18-44), less than 25% of respondents met “both aerobic-activity and muscle-strengthening.” The guidelines recommend moderate-intensity physical activity for ≥150 minutes per week, vigorous-intensity physical activity for ≥75 minutes per week, or an equivalent combination of moderate- and vigorous-intensity activity, and engaging in physical activities specifically designed to strengthen muscles at least twice per week. Even fewer seniors (>65) meet activity goals with only less than 15% reporting adequate physical activity.

Read the QuickStats report here.


Cochrane review of percutaneous vertebroplasty

Osteoporosis is common among the elderly, especially women. Vertebral compression fractures are a painful sequel of an osteoporotic spine and the most common complication seen in osteoporosis. More than 700,000 new compression fractures happen in the US each year at a cost of $1.5 billion. (More here.) Integrative medicine providers may treat patients with pain from osteoporotic compression fractures.

A recent innovation in surgical treatment for these painful fractures is percutaneous vertebroplasty. The procedure involves injection of cement into the fractured vertebra which then hardens and supports the fracture. A recent Cochrane systematic review of this procedure however calls into question the effectiveness of the procedure. Given the cost of the procedure and the potential for complications, conservative non-surgical treatment approaches are a reasonable alternative.


Best Practices: Protection with Good Clinical Records

The art and science of clinical record keeping deserves – but does not often get – as much attention as delivering quality healthcare. Yet proper record keeping – initial creation of the record, ongoing entries and maintenance, and retention – protects providers in a number of ways including:

  • Compliance Standards: Health care records are both clinical and legal documents. Failure to document patient care adequately can be considered evidence of negligence. For example, Oregon Administrative Rules Chapter 811-015-0005, Records, specifies, “It will be considered unprofessional conduct not to keep complete and accurate records on all patients.”
  • Malpractice Risk: Excellent clinical records are perhaps never appreciated so much as during a malpractice lawsuit. In the unfortunate event that a provider faces a suit, a well-documented and accurate patient file is a valuable asset. Even if a provider did everything right, as the saying goes, “If it didn’t get written down, it didn’t occur.”
  • Maintaining High Quality Care: No matter how good a provider’s memory is, keeping track of each patient’s unique clinical presentation, treatment plan, progress, precautions and outcomes is impossible without a record – either electronic or written – especially in a busy practice with diverse patient populations. Without such information, it’s also impossible to give good treatment advice.

How can providers make the record keeping process simpler and more straightforward? Here are a few tips to help providers and staff.

Adopt a System
There are many styles of chart notes to choose from that can be effective. Narrative notes in SOAP format are the standard. Whether in electronic or written form, there are a variety of ways to simplify clinical record keeping, including check-box formats, pre-printed forms, computer-generated notes, and barcode SOAP notes. However, some of these shortcuts produce “canned” notes that contain little clinical content. In whatever method chosen, be sure to leave room to completely document the clinical thought process for later reference.

Get Organized
If the office is using an Electronic Health Record (EHR) system, take the time to become very familiar with the standard functions so that it is easy to use during daily patient care. If the office is using paper charts and records, know where to look in every chart for the same data.

Check the Clinical News blog every Thursday through July for more in our Best Practices series


On the (f)utility of pain measures

Karl C. Kranz, DC, Esq., is the Executive Director/Staff Counsel for the New York State Chiropractic Association. In this post Dr. Kranz offers an “interesting twist on the concept of pain…” and a few thoughts. These call into question the “utility” of pain measures and, in some ways, the “futility” of justifying reimbursement based on a demonstration of “functional improvement” if that “improvement” is based, in part, on a subjective pain measurements. In our quest to help patients with their pain, it is necessary and helpful to remember that a patient’s goal of “0” pain on a pain scale may not always be the best target for our interventions.

As brief as the article link below is, it speaks again to the subjective nature of pain. As you may recall from a previous email (Mar 2), a journalist questioned recently what it mean to be a “2” out of “5” (or 10) on pain particularly since there is no standard for a “2” or “5” (“10″). In a Cartesian mind-body dualistic and theoretical point of view, this article calls into question again the “utility” of pain measures and, in some ways, the “futility” of justifying reimbursement (including Workers’ Compensation) based on a demonstration of “functional improvement” if that “improvement” is based, in part, on a subjective pain measurements.  While the “numbers” supplied by patients and scored from different tests and measures might assuage us into believing that there is some sort of quantifiable, deterministic objectivity in patient supplied numbers, the specificity of the exercise seems deceptive.  The whole pain measurement system seems messy and slipshod but what is the alternative?

The article also underscores, albeit in an indirect and subtle way, the two-decade long debate about whether evidence-based medicine is applicable to CAM; the insistence of medical critics of CAM that nothing from CAM should be accepted by medicine without evidence from systematic reviews of randomized controlled trials of CAM, as if all of medicine were supported by such evidence. [See: Bloom BS. Commentary. What is this nonsense that complementary and alternative medicine is not amendable to controlled investigation of population effects? Acad. Med. 2001; 76(12): 1221-1223.; Gorski DH, Novella SP. Clinical trials of integrative medicine: testing whether magic works?  Trends in Molecular Medicine, 2014; DOI: 10.1016/j.molmed.2014.06.007; Byerstein BL. Alternative Medicine and Common Errors of Reasoning. Acad. Med. 2001; 76: 230-237.; Sierpina VS, Philips B. Need for scholarly, objective inquiry into alternative therapies. Acad. Med. 2001; 76: 863-864.]

Loretta Kopelman, PhD argues that “CAM should not be exempt from rigorous testing and should be examined using either the best available methods or the same methods used to test conventional therapies. This is because, first, CAM cannot be differentiated well enough from conventional interventions to justify different testing standards.  I will argue . . .  that important and well-known proposals about how to separate conventional medicine and CAM fail to distinguish them for the purpose of excusing CAM from rigorous testing standards. If they cannot be clearly distinguished, it is questionable why one set of interventions should be exempt from rigorous testing and another should not.” [Kopelman LM. The Role of Science in Assessing Conventional, Complementary, and Alternative Medicines. In Callahan D. (Ed). The Role of Complementary and Alternative Medicine. Accommodating Pluralism. Washington, DC: Georgetown University Press, 2002, pp: 36-53.]

And at the opposite pole . . . several critics to the Academic Medicine articles above, point out that the authors of those articles “went beyond healthy skepticism and showed a strong bias toward how to reveal the ‘quacks,’ and that looking for the evidence supporting complementary and alternative medicine (CAM) is a failure or misconception,” since “it is diametrically opposed to the development of evidence-based medical practice.” [Frenkel M, Ben-Arye E. Letters to the Editor. Acad. Med. 2002 Sep; 77(9):869-875.  Those who intimate that the biomedical research hierarchy may not be applicable to CAM are convinced but less strident than CAM opponents.  See: Astin JA. Complementary and alternative medicine and the need for evidence-based criticism. Acad. Med. 2002; 77(9): 864-868.; Tonelli MR, Callahan TC. Why alternative medicine cannot be evidence-based. Acad. Med. 2001 Dec; 76(12) 1213-1220.; Tonelli MR. The philosophical limits of evidence-based medicine. Acad. Med. 1998 Dec; 73(12): 1234-1240.; Taylor DK, Buterakos J. Commentary. Evidence-based medicine: not as simple as it seems. Acad. Med. 1998 Dec; 73(12): 1221-1222.; Keshet Y. The untenable boundaries of biomedical knowledge: epistemologies and rhetoric strategies in the debate over evaluating complementary and alternative medicine. Health 2009; 13(2); 131-155.]

Clearly, as Julia Segar pointed out the obvious, “[d]ebates over the efficacy of complementary and alternative medicine (CAM) are highly polarized . . . .” [Segar J. Complementary and alternative medicine: Exploring the gap between evidence and usage. Health 2011; 16(4): 366-381.]

It seems that ideological dogmatism springs forth from all sides, which raises an interesting epistemological question of why people believe the things that they do and why do they often appear so certain in their personal beliefs.

One problem seems to be that those in control of health care reimbursement are populated by the former rather than the latter and that, justified or not, reimbursement revolves around the biomedical, evidence-based research hierarchy and tyranny of the evidence (a Triano-ism) [See: Cohen MH. Chapter 8: Third-Party Reimbursement.  In: Cohen MH. Complementary and Alternative Medicine. Legal Boundaries and Regulatory Perspectives. Baltimore, MD: John Hopkins University Press, 1998, pp. 96-108.]

In any case, after that long aside, this article points to a piece of an alternative research hierarchy based, in part, on ethnography and ethnographic fieldwork, similar perhaps, to the sort of fieldwork promoted by Ian Coulter, PhD at RAND, and a part of Health Services Research. [See: Coulter ID, Khorsan R. Chapter 7. Health Services Research as a Form of Evidence and CAM.  In: Lewith GT, Jonas WB, Walach H. (Eds). Clinical Research in Complementary Therapies. Principles, Problems and Solutions. (Second Ed) New York: Churchill, Livingstone, Elsevier, 2011, pp.: 135-147.]

Here, the author highlights his “longitudinal ethnographic fieldwork” which adds fodder to the debate about whether the RCT is or should be the center of the universe around which evidence-based medicine turns, or is it an ideological black hole sucking air out of scientific epistemology, after all, how can you measure a patient’s pain and suffering with an RCT objectively except by subjective proxy measures. And are these proxy measures really objective quantifiers of science, or quantifiers of subjective science? It is interesting on how the author, or rather his patients and acquaintances distinguish between “pain” and “suffering” . . .  And his interpretation of their spoken language, not only focuses attention on the problem of communicating what is in the patient’s mind, and communicating meaning in terms of the subjective philosophy of language and linguistics, but it illustrates the ongoing dilemma of the mind-body dualism and its post-modernistic interpretation.

Open access at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60708-5/fulltext


If sitting is “the new smoking”, what are the evidence-based strategies to kick the habit?

Epidemiological studies of the association between the hours per day spent sitting and mortality have observed correlations especially with cardiovascular disease, but also with obesity, Type 2 diabetes, depression and musculoskeletal problems. But what does the research tell us about how to combat this sitting epidemic?

In a study of over 123,000 men and women published in 2010 in the American Journal of Epidemiology researchers from the American Cancer Society found that even after controlling for smoking, body mass index and other factors, sitting for more than 6 hours per day was associated with death from cardiovascular and other chronic disease.

A recent systematic review and meta-analysis in The Annals of Internal Medicine considered 47 published articles that assessed correlations between sedentary behavior and disease incidence, hospitalization and mortality. (Abstract here.) While the evidence is weakened by reliance on self-report by participants, there appeared to be a clear relationship between a sedentary lifestyle and increased incidence of bad outcomes. What is more, poor outcomes were more pronounced among the most sedentary individuals.

A free infographic from Juststand.org summarizes much of what is known about the “Sitting Disease.”

A number of strategies have been promoted to address physical inactivity. MoveIt Monday “is a campaign from the Monday Campaigns, a non-profit public health initiative associated with Johns Hopkins, Columbia, and Syracuse universities that dedicates the first day of the week to health.” JustStand.org promotes a variety of products such as “sit-stand” work surfaces. While these interventions sound reasonable, the research that supports them is pretty thin.

A Cochrane Collaboration review of “Workplace interventions for reducing sitting time at work” concluded that, “…at present there is very low quality evidence that sit-stand desks can reduce sitting at work. However, the evidence for policy measures (such as walking breaks), or information and counselling is inconsistent. There is a need for high quality research to assess the effectiveness of different types of interventions. There are many trials being conducted at present and their results may change the conclusions of this research in the near future.

Puig-Ribera and colleagues published “Patterns of Impact Resulting from a ‘Sit Less, Move More’ Web-Based Program in Sedentary Office Employees” among office workers in Spain. The Walk@WorkSpain program was found to be “a feasible and effective evidence-based intervention that can be successfully deployed with sedentary employees to elicit sustained changes on “sitting less and moving more”. A similar workplace “sit less, walk more” intervention launched in Queensland, Australia, is here.

The University of Pittsburgh has recently received a $3 million NIH grant to “investigate whether they can improve the health of sedentary, overweight people with a program initially focusing on decreasing the amount of time they spend sitting… The new grant will put the concept of sitting less right up front as the primary movement goal.”

The first step is the recognition that there is a problem. Fortunately, steps are being taken to produce evidence clarifying association, correlation, or causality. Additionally, initiatives are being developed and deployed to the general public. Vehicles like social media, social networks, and mainstream media are being used to good effect. We believe it is at the provider level where the greatest impact can be delivered. Be a part of the solution by inquiring about your patients sitting habits and recommending movement strategies.


What’s that sound?

One signal feature of chiropractic adjustments is the “crack” that often accompanies the manipulation. The cause of the noise has recently been investigated by a team lead by Greg Kawchuk, DC, of the University of Alberta, Canada. “Real Time Visualization of Joint Cavitation” was published on April 15, 2015 in PLOS One and available in full text here. The researchers performed real-time MRI images of an interphalangeal joint of a finger and found a “rapid cavity inception at the time of joint separation and sound production after which the resulting cavity remained visible.”


Oregonians working together for Antibiotic Resistance Education

Since its inception in 2001, the Oregon Alliance Working for Antibiotic Resistance Education (AWARE) has promoted judicious use of antibiotics for respiratory infections. CHP is a supporter of AWARE. As you’ll see here, Oregon has made some progress over the last decade, but antimicrobial resistance still poses significant health threats: each year in the United States, resistant bacteria cause at least 2 million serious infections and kill at least 23,000 people.

Note on link above from the Oregon Health Authority website: The CD Summary is a fortnightly publication of the Oregon Health Authority, Public Health Division. Its intended audience is licensed health care providers; public health and health care agencies; media representatives; medical laboratories; hospitals; and other individuals and institutions with an interest in epidemiology and public health interests. It’s free to your email inbox and subscription is easy.