Practicing Evidence-Based Chiropractic and Increasing Referrals

By Ronald Feise, DC

Improved Results

Evidence-based chiropractic (EBC) must become the preferred practice in our profession for one simple reason - it offers the best opportunity to deliver the best patient results. EBC does this by helping practitioners integrate those therapies most likely to provide patient benefit, while avoiding those less likely to provide benefit.

A recent prospective study compared the effectiveness and cost-effectiveness of care modalities for acute low-back pain.¹ The researchers concluded that compared with good usual care, evidence-based care (including manipulation) for acute low-back pain produces:

1. greater reduction in pain;
2. greater patient satisfaction;
3. greater rates of full recovery;
4. less expense; and
5. less need for continuing care.

Demanding Proof

Unlike many chiropractors, EBC practitioners demand data from vendors and are not convinced by marketing promises. If a vendor claims an analytical/diagnostic tool provides "accurate clinical information," an EBC practitioner will ask to see published, peer-reviewed research that demonstrates the tool's reliability, validity and clinical value. Likewise, if a vendor claims a treatment technique provides "beneficial results," an EBC practitioner will ask to see evidence proving these benefits. Armed with this information, EBC practitioners can avoid less-effective interventions and thereby save their patients unnecessary expense and trauma. For example, EBC practitioners have known for more than a decade that ephedra demonstrates no long-term benefits. By avoiding this product, these doctors have saved their patients from wasting money and possibly suffering serious harm.^2,3

Not Just Data

EBC is not a cookbook process in which patients are treated according to some strict scheme derived exclusively from research. Rather, EBC regards research information as an important component in the health care decision-making process. Such information should be used in conjunction with clinical experience and judgment, clinical circumstances, and patient preferences.

Practicing EBC means choosing an action after weighing the risks and benefits of the alternatives. While all clinical decisions are made under conditions of uncertainty, the degree of uncertainty decreases when clinical decisions are based on directly relevant, valid evidence.

Enhancing MD Alliances

In addition to the satisfaction gained from providing optimal patient results, how can practitioners benefit from EBC? One of the primary ways is through enhanced relationships with medical doctors. Over the past two decades, great strides have been made in the public's acceptance of chiropractic. Researchers have found that most patients who visit chiropractors are seeking treatment for spinal conditions,⁴ but approximately three times as many patients visit medical professionals for such conditions.⁵ So, the majority of spinal cases are still within the control of our medical colleagues. Furthermore, medical practitioners are more likely to have professional dealings with physiotherapists than with chiropractors.⁶ But savvy EBC practitioners can alter the physiotherapist referral pattern by forging evidence-based alliances with MDs.

Health care observers have noted that treatment of spinal complaints is the chiropractic profession's strength and the medical profession's weakness. Moreover, general practitioners are not interested in treating back pain cases and want help managing these patients.⁷ Only 5 percent of general practitioners claim to have good knowledge of chiropractic,⁸ and three out of four say they would be interested in receiving more information.^8,9 Therefore, the time is ripe for us to communicate.

Providing the Right Information

Medical doctors are seeking alliances with practitioners who provide high-quality communications, because good communication between health care professionals improves patient care.¹⁰ But communication between primary and secondary health care professionals, including chiropractors, is far from ideal.^11-13

MDs rate most written reports from chiropractors as poor.⁸ Furthermore, they dislike chiropractors' technical jargon (e.g., subluxation) and their dogmatic adherence to certain practice protocols: extended treatment schedules for all patients, charging "front-end" lump sums for treatment programs, encouraging patient dependency, radiographic examination (and re-examination) of all patients, advocating against vaccination, and treating outside a musculoskeletal scope.^8,9,14,15 Obviously, attempting to "educate" a medical practitioner regarding these protocols would be counterproductive.

Besides correspondence about patients, medical practitioners want presentations and scientific literature pertaining to safety and effectiveness, clinical referral guidelines and your clinic's outcome data.^8-9,14 Additionally, they have a predisposition toward referring their patients to those professionals who are most closely aligned with their own medical training. For example, chiropractic referral for musculoskeletal care enjoys substantial support, whereas referral for chiropractic intervention in visceral conditions continues to be largely opposed by members of the medical profession.¹⁶ To create a lasting collaboration, we must consider the factors our medical colleagues value.

Generating EBC Referrals

Successful medical referral programs bring together the values of evidence-based chiropractors and medical practitioners. In fact, chiropractors using a specialized EBC referral program have been able to generate an average of about 60 more new patient referrals per year from MDs.¹⁷ An EBC referral program is an integral component in practice development, and an emerging and underused economic model for our profession.

References

1. McGuirk B, King W, Govind J, Lowry J, Bogduk N. Safety, efficacy, and cost effectiveness of evidence-based guidelines for the management of acute low back pain in primary care. Spine 2001;26:2615-22.
2. Bent S, Tiedt TN, Odden MC, Shlipak MG. The relative safety of ephedra compared with other herbal products. Ann Intern Med 2003;138:468-71.
3. Shekelle PG, Hardy ML, Morton SC, et al. Efficacy and safety of ephedra and ephedrine for weight loss and athletic performance: a meta-analysis. JAMA 2003;289:1537-45.
4. Coulter ID, Hurwitz EL, Adams AH, Genovese BJ, Hays R, Shekelle PG. Patients using chiropractors in North America: who are they, and why are they in chiropractic care? Spine. 2002;27:291-8.
5. Media General Chiropractic Survey. Richmond, Virginia, February 2002.
6. Simpson JK. A study of referral patterns among Queensland general medical practitioners to chiropractors, osteopaths, physiotherapists and others. J Manipulative Physiol Ther 1998;21:225-31.
7. Schers H, Wensing M, Huijsmans Z, van Tulder M, Grol R. Implementation barriers for general practice guidelines on low back pain. A qualitative study. Spine 2001;26:E348-53.
8. Langworthy JM, Birkelid J. General practice and chiropractic in Norway: how well do they communicate and what do GPs want to know? J Manipulative Physiol Ther 2001;24:576-81.
9. Brussee WJ, Assendelft WJ, Breen AC. Communication between general practitioners and chiropractors. J Manipulative Physiol Ther 2001;24:12-6.
10. Peters R. Steun voor intercollegiale communicatie [Support for communication between colleagues]. Med Contact 1995;50:746-7.
11. Jamison J. Chiropractic's functional integration into conventional health care: some implications. J Manipulative Physiol Ther 1987;10:5-10.
12. Matthews A, Langworthy J. Anticipating Change: An Opinion Survey of the Membership of the British Chiropractic Association in the Year of the Chiropractors Act. Reading, England: British Chiropractic Association; 1996.
13. Mainous AG, Gill JM, Zoller JS, Wolman MG. Fragmentation of patient care between chiropractors and family physicians. Arch Fam Med 2000;9:446-50.
14. Curtis P, Bove G. Family physicians, chiropractors, and back pain. J Fam Pract 1992;35:551-5.
15. Menke JM. Integrating Chiropractic in Health Systems. In: Faass N, editor. Integrating Complementary Medicine in Health Systems. Gaithersburg (MD): Aspen Publishers; 2001. p.594-600.
16. Jamison JR. Chiropractic referral: the views of a group of conventional medical practitioners with an interest in unconventional therapies. J Manipulative Physiol Ther 1995;18:512-8.
17. Feise RJ. Evidence-based chiropractic: the responsibility of our profession. JACA 2001;1:50-2.

Ron Feise, DC
Fort Collins, Colorado

Ron Feise, DC, is the president of the Institute of Evidence-Based Chiropractic, an organization that helps chiropractors achieve optimal patient outcomes through the use of evidence-based strategies.