The Agency for Health Care Policy and Research (AHCPR) is funding several major projects to look at back patients care and guidelines for that care. In an exclusive interview, Dr. Richard Deyo, M.D., MPH, principal investigator for the AHCPR's back pain outcome research team speaks about these projects and how they may impact the chiropractic profession.
"DC": How was the AHCPR panel on back pain outcome assessment developed?
Dr. Deyo: I want to draw a distinction between two activities that the AHCPR is involved with for back pain. On the one hand there is the patient outcome research team of which I am the director. On the other hand there is a guideline panel. This is also supported by AHCPR which is charged with producing clinical practice guidelines (please see "AHCPR Supports Low Back Disorder Panel" in the January 3, 1992 issue). The agency is eager to keep the two distinct, that is, the research team is explicitly not charged with producing practice guidelines, whereas the guideline panel is. The research team was assembled in a competitive research application process. The guideline panel was assembled by the AHCPR staff based on recommendations from people all over the country and is designed to be multidisciplinary.
"DC": Can you explain the PORT program for us?
Dr. Deyo: The Congress and the AHCPR have been concerned by the enormous geographic variations that have now been well-described and how medical care delivered for many conditions, back pain in particular, and decided that it was important at this point to fund a research effort to understand why these variations exist and if there are some services that may be unnecessary, as you might anticipate, given these wide variations. If some services are actually not effective, then obviously third-party payers will prefer not to be paying for them. So I think the intent of the patient outcome research team was to better characterize the outcomes of medical care and alternative types of medical care to decide which may be most effective and if effectiveness is similar, which may be less expensive.
"DC": Who are the participants and how were they selected for your team?
Dr. Deyo: Our team is a multidisciplinary group that is comprised on the one hand of clinicians representing the medical specialties with an interest in back pain. For example, we have a neurosurgeon, an orthopedic surgeon, internists, a clinical psychologist, and rehabilitation specialists all as a part of our team. We also have a group of methodologic experts: a biostatistician, sociologists, health economists: persons who bring methodologic expertise that we need for the kind of research that we're doing. Those people really were assembled as part of a research team from the University of Washington, by and large, although we have an important collaborative effort with Group Health Cooperative of Puget Sound and with the Maine Medical Assessment Foundation. So it was assembled to be a team that would represent the major medical specialties with an interest in the relevant methodological specialties.
"DC": Is chiropractic represented and, if so, how?
Dr. Deyo: The chiropractic profession is represented on our advisory committee, which is a group that meets annually to advise our research team, which also gives us feedback and guidance more informally throughout the year. There are two chiropractors on that advisory panel: Dr. Reed Phillips and Dr. Dan Hansen who have influenced our thinking substantially in terms of priorities for the project, and in fact have been very supportive of our interest in developing at least a pilot study to compare the effectiveness of chiropractic care and conventional physical therapy.
"DC": What is your team currently working on and what has been the focus of the team's research?
Dr. Deyo: It is a five-year project, and we are now right in the middle of that five-year interval. The work itself functionally is divided into literature based work, which we are trying to search the scientific literature for the best evidence on the effectiveness and outcomes of various treatments for low back pain. Another component is the analysis of claims, such as Medicare claims or other large hospital discharge registries to try to understand what we can about outcomes of surgical and hospital care. The third component is a prospective cohort study of patients who come to surgeons' offices to understand better what the outcomes of surgical and nonsurgical care may be for that subset of patients who appear in surgeons' offices. As you might guess from this description, the focus of the team's research has been largely on low back surgery and hospital care for low back pain, those were explicitly the emphases of our original grant proposal and that's where the majority of our work has been. There is no question that our research team has an interest in looking at earlier stages in the management of back pain, trying to evolve to a greater focus on primary care, early management and non-surgical management.
"DC": From what I understand, chiropractic care was not originally considered as a major focus of the early part of the research project. In your opinion, is the efficacy of chiropractic care less controversial than maybe it was originally considered?
Dr. Deyo: Our grant initially focused on surgery and hospital care because they were high cost and high visibility episodes of care. That really was the reason, more than anything else, for not making chiropractic care a major focus of the original grant proposal. Nonetheless, I think our growing interest and our movement to greater evaluation of chiropractic care has been prompted by a number of factors, one being that chiropractic care is such an enormous part of the management of low back pain and from a health services perspective it is almost an imperative that we consider and evaluate this major component of care for back pain. I think our research team already had an interest in chiropractic care, had already done some research in that area, and with the encouragement of our advisory committee felt that it was appropriate fairly early on for further evaluation into that type of care.
"DC": Can you explain the importance of the term outcome in the process of outcome assessment in the project?
Dr. Deyo: Within the medical world, in my view, there has long been an excessive, almost exclusive focus on organ functioning and physiological changes as outcomes of medical care, sometimes to the exclusion of measuring the patient's symptoms and functioning in more subjective aspects of outcomes of care. This research initiative clearly elevates those concerns and asks, "Are patients feeling better as a result? Are they functioning better as a result of a given clinical intervention?" On the one hand we are broadening the definition of important outcomes to be measured; on the other hand we are focusing less on the process of care, less interested in whether the care that is delivered meets someone's idea of how care should be delivered than whether the patients are actually better off for having gone through that process.
"DC": In your opinion, how could the results of this team's work affect the chiropractic profession?
Dr. Deyo: I have to speculate here quite a bit. We are in the process right now of getting a pilot study that would compare chiropractic care with physical therapy and also with our less intensive type of management in primary care patient with low back pain. I think that depending on the outcome of that pilot study, we may try to implement a large-scale trial along the same lines, which would require probably separate funding and would go on for several years. If we are able to do that study and design it in a scientifically rigorous manner, I think the results may be influential in terms of both how medical physicians practice and refer patients, and potentially, also in how reimbursement by third-party payers is structured.
"DC": How will the results of your work be disseminated and implemented, and can you discuss the contribution of Dr. Harold Goldberg?
Dr. Deyo: The research will be disseminated in conventional scientific peer reviewed publications and the usual forums for academic dissemination, but beyond that we are trying to design and actually test more extensive information and dissemination efforts in which we will actually work within several hospitals and communities in Washington state, to try to provide not only detailed information about our most recent research results to physicians and patients but also to provide feedback on practice patterns within those localities and how they may compare with their peers. Part of that effort will also be a program intended to better educate patients about surgical decisions, in particular, and empower them to be more involved in surgical decision making. That whole effort is headed by Dr. Harold Goldberg who is also an internist but has a major interest in how research information gets to the practice community and how to have the most impact and disseminate that information.
"DC": You mentioned patient education programs. You have developed an interactive patient education tool on video disc. Can you explain how that would be used?
Dr. Deyo: This video disc production has been produced to present to patients not only what we believe is the most objective information about outcomes of alternative treatments, that is surgical and non-surgical treatment, but also the opportunity to see interviews with patients that have experienced different types of treatment and have had both good and bad outcomes of their care, and can describe what that experience is like. The program is designed to run on a microcomputer, in part, so there is an opportunity for the patients to interact with the program, to select segments they are most interested in and view the material in a sequence that they select. So an individual would have some power within the educational program to pick and choose in sequence what they learn about. We are hoping to test this video disc program by implementing it in hospitals in the state where we are disseminating research results. If that seems successful, we hope that the video disc will undergo a much wider evaluation and dissemination around the country.
"DC": What is your opinion of the chiropractic profession in regards to its position in health services research and health policy?
Dr. Deyo: I am both encouraged and excited at what I see as a growing level of interest by the chiropractic profession in rigorous scientific research and objective evaluation of their own types of treatment and care. The medical profession, I think, has a parallel growing interest in critically evaluating what it is doing, and I think that now is an exciting time, when perhaps there is a growing convergence in the methods by which we evaluate ourselves and the criteria by which we evaluate ourselves and, therefore, a growing opportunity to really understand what types of treatment and what systems of care may be the most effective for a particular kind of problem.
"DC": What other types of AHCPR projects may be on the horizon that would affect the chiropractic profession?
Dr. Deyo: There are AHCPR funded initiatives in a number of musculoskeletal areas right now, although, like our team, those are mostly focused on outcomes of surgical interventions. For example, there are PORT teams devoted to studying outcomes of hip replacement and outcomes of knee replacement. There is funding that's now going into developing outcome measurement tools for studying trauma patients and outcomes of care for fractures. Some of those may have some impact on the chiropractic profession, although I think that probably our research devoted to back pain may be more directly relevant. There is another project currently funded at the University of North Carolina Chapel Hill funded by the AHCPR which is studying back pain in primary care, which really has a more direct focus on the process, costs, and outcomes of alternative primary care treatments for back pain. That project will be including chiropractic care among the range of primary care treatments that it studies. The principal investigator is Dr. Tim Carey
"DC": In summary, is there anything you would like to add about your project or the chiropractic profession or anything that may relate?
Dr. Deyo: I guess I would just summarize by saying that our project has been largely focused on studying outcomes of surgical interventions and expensive forms of hospital care. I think though that we as a team are very interested in looking further into primary and non-surgical forms of treatment for low back pain, and I think for the reasons I have already alluded to, there is a real opportunity now for growing collaboration and research cooperation between chiropractic and medical professions.
"DC": Thank you very much Dr. Deyo.
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