Evidence-based chiropractic and documentation

1. Evidence-based chiropractic and documentation

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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”

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. CPI (cont.)

22. 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 to choose the adjective that best describes their pain level by selecting from a list of possibilities

23. The 5-point VRS

24. 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

25. 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

26. Tenderness rating of soft tissue

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. Symptom Checklist-90-Revised(SCL-90-R) • A psychometric questionnaire that can be used to assess pain in musculoskeletal patients • Contains 90 items that can be completed in 12-15 minutes • Each item is graded on a five-point (0-4) scale of distress that ranges from “not at all” to “extremely”

40. SCL-90-R (cont.) • Its reliability, validity, and utility has been well-established • Can be used by all types of health care professionals to screen patients for psychological involvement

41. Measures of function • Questionnaires that evaluate activity limitations associated with a variety of conditions • e.g., back pain, knee pain, asthma • General health assessment questionnaires and many physical tests are also considered measures of function

42. Oswestry Disability Index (ODI) • a.k.a., Oswestry low back pain disability questionnaire • One of the most commonly used OMs in the management of spinal disorders • Its validity and reliability has been well established • It is appropriate for both research and clinical practice

43. ODI (cont.) • At least four versions are available • The original authors recommend that the ODI 2.0 version be used • The Revised ODI omitted the original section 8 that deals with sex, replacing it with a section about the changing degree of pain

44. ODI (cont.) • Consists of 10 sections that each have 6 statements dealing with activities of daily living and pain • Is self-administered • Typically completed in less than 5 minutes • Scoring is straightforward and can be performed by a staff member • Statements describe the level of disability associated with various activities

45. ODI (cont.) • Scoring • A value is assigned for statements ranging from 0 to 5 • The first statement has a value of 0 and the last statement a 5 • If a patient chooses more than one box in a section, the highest score is to be taken • Statement values from each section are then combined to get a total score

46. ODI (cont.) • If the patient completes all 10 sections, simply multiply their raw score by 2 to convert to a percentage Not 50 because the patient left out a section

47. ODI sections

48. ODI sections (cont.)

49. Interpretation of ODI scores

50. ODI clinically important difference • In order to distinguish patients who have improved from those who have not, the minimum clinically important difference that is needed is 6 ODI points • Other researchers have calculated it to be as high as 15 points • To be clinically important, a patient would have to improve by at least 6 ODI points