Standardizing the Process of Chiropractic Care

Editor's note: Part one of this series, "Documentation and Standardized Care Plans," appeared in the Aug. 16 issue.

Standardizing the process of chiropractic care with the addition of care plans for acute, subacute, chronic stages, and mechanism of injury/illness, can significantly increase patient compliancy, recovery and chiropractor-patient rapport. In an era of cost-conscious medicine, chiropractic interventions that make use of standardized protocols and chiropractic education programs should be emphasized not only to our patients, but also to our medical physician providers.

In today's allopathic medicine, many medical doctors are still reluctant to follow established medical clinical guidelines, citing oversimplification, in part. Most medical doctors fail to follow established guidelines or may not even be aware of them; chiropractors are no exception. For example, when we look at how various medical practitioners and chiropractors treat low back pain, several different approaches can be found.

The field of evidence-based medicine is trying to change this by producing clinical practice guidelines that give health care practitioners a way to implement the latest research findings. In fact, managed care organizations and health care systems have tried to promote the use of practice guidelines and thus reduce the amount of variation in patient care.

The federal government has made clinical practice guidelines available to the health care community online at www.guideline.gov. The Web site is maintained by the Agency for Healthcare Research and Quality (AHRQ), and is cosponsored by the American Medical Association (AMA) and the American Association of Health Plans (AAHP). Most advocates of evidence-based medicine agree that reliance on practice guidelines is lower than it should be, given that guidelines are meant to represent the best available information about the treatment of specific conditions. They argue that guidelines are not meant to dictate treatment plans, but rather to direct physicians toward the most appropriate types of care.

The importance and impact of guidelines on the chiropractic profession is reflective not only of the profession's growth, but is also significant if one includes information on performance at all levels of the health care system and widespread adoption of electronic medical records and other technologies that automate the entry and retrieval of data of decision-making and quality reporting. How far behind is our profession? Certainly, there is no question we need more evidence-based research studies in the field of chiropractic.

One may choose to cite the often-outdated chiropractic research data utilized by chiropractic or Independent Physician (chiropractic) Associations (IPAs) that market to insurance HMO carriers and managed care organizations. This data is also used in utilization reviews to justify the need to limit the provider's request for specific procedures, or to reduce the number of requested office visits on preauthorizations. This raises serious questions about whether the lowest reimbursement procedure rates represent better health care, or whether they represent excessive interventions to cost-contain the patient's chiropractic care.

For example, the literature reviews cited to justify the limitation to the chiropractic procedures preauthorization request for X-rays, exams and adjustments are often outdated (most by 10 years) and often represent poor research sampling. The IPA reaps the benefits, while the provider suffers a loss in revenue and the patient suffers a lack of quality care. Why does this occur? Perhaps the chiropractic profession needs to provide more evidence-based medicine studies (otherwise known as research studies) to promote growth, while ending potential stagnation and limitation to our profession. That, of course, would be this author's report of findings. Another explanation could be that the impact of higher utilization rates (increased number of visits, and hopefully, latter reimbursement schedules) for chiropractic adjustive procedures alone on patient outcomes has not been determined.

To justify chiropractic care or treatment plans at our chiropractic group practice, we developed protocols for our busy outpatient physical medicine practice to better organize assessments of patients referred for chiropractic management. Our objectives were to improve the quality of care, minimize the variability of chiropractic procedure management, and facilitate measurement of results of care.

First, a standardized written plan of care for adults was made available. Next, a chiropractic action plan form (with written patient instructions that the patient signed as acknowledgment of receipt) and a patient problem list were developed to coordinate care. An electronic database was used to capture patient information during episodes of care. Using this intervention and outcome documentation forms, we felt (by retention and patient satisfaction surveys, and outcome assessment surveys) that we improved the quality of patient care, minimized the variability of chiropractic management, and facilitated improved measurement of results of chiropractic care. We observed a significant increase in patient referrals of friends, co-workers and family members utilizing this approach. Many patients commented on this "focused" approach to chiropractic care.

The goal with outcome assessment forms is to provide feedback from which to learn and improve care. Resources, such as our own chiropractic researchers and those who obtain chiropractic research grants and other chiropractic evidence-based initiatives, have increasingly provided the basis for chiropractic care and reimbursement decisions. Applying a standard outcome management paradigm can serve as a continuous quality-improvement tool, as observed in the multidisci-plinary emergency care teams and hospital-based care that utilize such protocols based on the best available evidence, and then work with their management to use outcome research as a tool to quantify end results of real-world care for defined patient cohorts in their own environments, to improve their medical outcomes. Chiropractors should follow suit, or we may be served the "take it or leave it" fee schedule of reimbursement by the insurance networks with whom we contract.

The purpose of this article in clinical case studies may serve to illustrate ways for chiropractic care clinicians to measure and track outcomes, optimize chiropractic clinical and economic success, and increase patient satisfaction in this increasingly challenging world of chiropractic care.

Nancy Molina, DC
San Juan Capistrano, California