Well, here goes may latest foray: quality improvement. I've been on the health services research, technology assessment, health policy, and quality improvement bandwagons for some time now, and as a result was recently invited to become a faculty member for a year- long "Breakthrough Collaborative" series on improving low back pain care sponsored by the Institute for Healthcare Improvement (IHI).
The mission of this non-profit, Boston-based organization is to provide clinicians and health care administrators with the knowledge and tools they need to improve health outcomes, satisfaction, and efficient delivery of services, while reducing costs. (Think about making health care as competitive and upgradeable as the auto and computer industries.) To date, this group has run "collaboratives" on reducing waiting times in emergency rooms, improving prescription practices, caring for patients with asthma, and reducing cesarean sections, all things I believe we could agree are in need of improving within the health care system.
IHI believes that by bridging the gap between what science tells us and what current practice is, health care outcomes, quality, and efficiencies can be improved. They have already demonstrated that it can be done in the areas just mentioned. The organization has established quite a track record. The institute's organizers came out of the Harvard Community Health Plan that basically started the whole clinical guideline and outcomes management thing in the '80s. Today, some of the largest most progressive clinics in the country (not to mention major corporations, managed care organizations, and insurance companies) participate in collaboratives to "get ahead of the competition curve," if you will.
Unfortunately, although several chiropractic institutions and organizations know about this project, none of them could justify committing to participation in the low back collaborative, probably because it costs too much or there wasn't enough time to prepare properly. But perhaps we think we are already so good at back pain care that we don't need to improve or be competitive. (Are we risking having to learn the lessons IBM, General Motors, and the steel industries learned for ourselves?)
So who is the real "competition" for low back pain care? In my opinion, it's primary care physicians (PCPs), not the physical therapists, not orthopedists, DOs, physiatrists or neurologists. Why do I think this, you ask? Because low back pain is one of the 5 or 6 most common complaints that primary care physicians see. And because acute low back pain is a lot like another condition family doctors can't do much for, the common cold. (Think about it: 80-90% of the time it goes away without any intervention, when you've got it, it's ugly but not life-threatening, and you'll probably get it again.)
Also, because all of the basic effective interventions (return to activity, avoid imaging and specialist consults too soon, non-steroidal anti-inflammatory medications, and yes, even mobilization or manipulation) are typically within a PCP's scope of practice. Additionally, because no matter how hard the world tries to make it otherwise, health care delivery is structured around a single generalist gatekeeper delivery model by default. And mostly because on numerous occasions over the past year I have heard leaders within the PCP and medical specialty communities exclaim things to the effect that: "We must reclaim low back pain into the realm of the family practitioner where it belongs. We cannot continue to let it go to the specialists or surgeons, or therapists or chiropractors who do too much treatment for far too long."
But primary care doctors don't do well with low back pain sufferers, you say! They don't like 'em or want 'em. And they don't know how to manipulate. I agree, but would add only one word: "yet." So here I go, being a messenger, possibly to be shot at for being "anti-chiropractic" because I'm implying there's room for chiropractic to get better than it already is. But here is what the "competition" and the system at large is doing these days about low back pain:
- Improving the knowledge base of primary care doctors about how to best manage episodes of low back pain. This includes encouraging a return to activities, use of nonsteroidal anti-inflammatory medications, avoiding unnecessary diagnostic tests (imaging, etc.) and expensive specialty (including physical therapy and chiropractic) consults unless it doesn't go away by itself. Basically, they're implementing the AHCPR guidelines. (Don't worry; I'll talk more about manipulation in a minute.)
- Setting up delivery structures to make specialists (like orthopedists and neurosurgeons) available on a routine "clinical rounds" type basis to PCPs to answer specific questions about low back patients, so they don't have to worry about missing something important.
- Developing and implementing standardized condition-specific guidelines and protocols operationalized for their individual delivery settings.
- Teaching PCPs and their staff to develop better patient skills; to have more confidence in dealing with low back pain, reinforced and attenuated by administration of patient satisfaction surveys; and gearing delivery to meet and exceed the expectations of their customer base (both patients and payers).
- Coming to grips with spinal manipulation. In what way? Some may use physical therapists to deliver it. Some may even refer for two weeks of it by a chiropractor or osteopath. And some may begin to try and develop skills at administering it themselves.
Am I the only chiropractor who is worried that with the right protocols, information, and processes that medicine could significantly improve the quality, outcomes, and satisfaction of delivering musculoskeletal care? Am I the only DC who thinks it's not OK to overutilize chiropractic care beyond what can be clearly justified in terms of tangible clinical appropriateness? Am I the only one who thinks so much variation in what we do is a problem, and as a result we are undergoing greater scrutiny than ever before? Am I the only chiropractor who thinks it's well past time for our profession to take a good, hard look at what we do and identify ways to do it better, cheaper, quicker, and with more customer satisfaction than we have ever done before? I doubt it, but sometimes it feels that way.
What do we need to do, and how do we need to go about doing it? First of all, we have to get humble in a hurry. That means recognizing that if we want to maintain a presence in low back pain care, we have to not take it for granted any more. Typically LBP is 50-60% of our practices but less than 10% of a primary care physician's practice. It's important to us. If I were to trade away one condition from my scope of practice, it would not be low back pain.
We need to embrace low back pain clinically, intellectually, and academically: not to the exclusion of other problems people have or the general clinical management skills we chiropractors should have, but we need to elevate it to a position of greater importance in our professional identity, and our institutional and political agendas.
Next, we need to identify what needs to be done to improve chiropractic care for LBP and what is important to our customers. "Customer" means payers, policymakers, and society at large, as well as patients. We need to adopt a customer-oriented approach to always being the best at it, in 1997, 2010 and beyond, not just in 1949, when the only benchmark for comparison the competition had was unnecessary spine surgery.
We need to prioritize resources for research to examine comparative effectiveness of various chiropractic approaches and get better information on what most influences meaningful outcomes (including return to activity, work, and function, as well as total cost of care). We need to examine the reasons for variation in practice and find appropriate justification for such differences and/or strive to reduce them (e.g., two visits from one DC, versus lifetime care from another for the same kind of patient with the same kind of problem).
Although we should never lose sight of the need for ongoing attention to patient satisfaction, we should recognize two things about it. First, the competition is working hard to improve their patient satisfaction with low back pain care. Second, it is unlikely that patient satisfaction is important enough to justify paying twice as much for chiropractic care that patients judge to be 12% more satisfying than medical care, with all other outcomes being equal.
I could go on, but you get the idea. We cannot take low back pain for granted, nor should we risk wagering it away for some holistic ideal. We are very good at working with patients who have it, but we can always systematically look at what it would take to do a better job. The chiropractic profession needs to engage in explicit, critical self-appraisal relative to the care of patients with low back pain and how we might best interface with the current American health care delivery system. We also need to decide who within the profession should address these tasks (individual providers, researchers, colleges, political organizations, or trade associations? How about teams of non-chiropractors too, from the rest of our customer base?)
Further, we should not underestimate the abilities of others in the health care system to do a better job at taking care of back pain patients, nor in their ability to continue to improve how they care for patients. In my opinion, the difference between flourishing and floundering in the future of back pain care is in changing our own mind-set from a doctor/profession-centered paradigm to a customer-centered paradigm. It's classic quality management that the business sector has been engaging in for decades. The competition is getting better, smarter, faster, and cheaper about caring for low back pain. What happens when they get more satisfaction, too?
Robert D. Mootz, DC, DABCO, FICC
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