Chiropractic Featured at IHI Conference

Becoming a Natural Part of the Health Care Landscape

By Editorial Staff

ST. LOUIS, Missouri -- The Institute for Healthcare Improvement (IHI), as part of the "Breakthrough Series," hosted a February 18-19 conference, "Providing More Effective Care for Low Back Pain."

The IHI is a nonprofit organization that seeks to incorporate practice guidelines into clinical practices.

Some of their previous efforts have included:

reducing Cesarean section rates
reducing treatment delays
improving asthma care
reducing adverse drug events
improving adult intensive care
improving adult cardiac surgery

The planning group for the project consisted of familiar names from U.S. academic and research institutions: Richard Deyo, MD, MPH; Tim Carey, MD; Daniel Cherkin, PhD; and James Weinstein, DO, editor of Spine. Robert Mootz, DC, associate medical director for Washington state's department of labor and industry, gave the planning group the points of view of chiropractic and those of a state agency.

The project consisted of 22 teams trying to make significant improvement in the cost and quality of care for low back pain patients:

Blue Cross of California
Blue Cross Blue Shield of Georgia
Blue Cross and Blue Shield of Kansas City
Camcare Health Systems
Columbia St. Mary's/Health Care Network of Wisconsin
Community Hospitals Indianapolis
Group Health Cooperative of Puget Sound
Harvard Pilgrim Health Care
Health Care Plan
Integra Health and Wellmark Blue Cross Blue Shield of Iowa
Kaiser Permanente/Community Health Plan Northeast Division
Lovelace Health Systems
Luther/Midelfort -- Mayo Health System
Mayo Clinic -- Rochester
Medical Value Plan
Mercy Healthcare Sacramento
OSF St. Francis Medical Center
Palmer Center for Chiropractic Research
Rochester Community Individual Practice Association
Texas Back Institute
University of North Carolina Medical Center
Washington State Department of Labor and Industries

The teams had about nine months to plan, implement and measure changes in their delivery of back pain care. While the approaches were different, many of the teams had similar goals:

Goals # of Teams with That Goal

* hasten patients return to work
1

* reduce absenteeism
3

* reduce bed-rest recommendations
2

* reduce inappropriate referrals
2

* reduce unnecessary x-rays
8

* reduce unnecessary MRIs
5

* reduce unnecessary CT scans
4

* reduce unnecessary myelography
2

* reduce PT referrals
5

* eliminate repeat low back pain visits
4

* decrease time to treatment on first patient visit
1

* reduce narcotics prescribing
1

* reduce epidural steroid injections
1

The above list reflects interventions thought to be overutilized or ineffective. Most of the teams were effective in reaching their goals. The teams learned the value of the multidisciplinary approach, involving specialists, evaluating systems, and focusing on the patient as an essential member of the team.

Of the 22 teams, about a quarter included chiropractic as part of their health care. Three of the teams were heavy with chiropractic representation: Palmer College of Chiropractic, Palmer College of Chiropractic-West, and the Texas Back Institute. Results from all three organizations were presented twice the workshop, "Implementing Change in Chiropractic Clinics or Specialty Setting that Incorporate Chiropractic Practice."

Palmer's efforts were presented their director of radiology, Ian McLean, DC, DACBR. Dr. McLean reviewed the aims, obstacles and results of three projects conducted in the college clinic:

"The Impact of an Educational Intervention on the Use of Radiography in a Chiropractic Teaching Clinic"
"Streamlining Data Collection Techniques to Decrease Total Patient Visit Time in a Chiropractic Teaching Clinic"
"Modifying Patient Perceived Outcomes through Low Back Pain Education"

One of the more important changes made in the Palmer clinics are that new patient education materials for low back pain are now available.

Palmer Chiropractic College-West's presentation was made by Thomas Souza, DC, director of clinics. PCCW's primary aims were to:

reduce variation in diagnostic assessment of low back pain; * decrease time to treatment on first patient visit; * decrease unnecessary utilization of radiographic studies for low back pain patients;
improve compliance to existing radiographic guidelines.

The Palmer colleges were the only two college clinics involved in the program, and both had to address the conflict of reducing the number of x-rays taken, while teaching students how to take and use that technology. Even so, the Palmer West clinics were successful in excising unnecessary radiographs.

John Triano, MA, DC, was the presenter for the Texas Back Institute (TBI). TBI's chiropractic division cut their radiography usage in half, while increasing their total number of patients by 200 percent. Dr. Triano attributes this result to an increase confidence on the part of managed care companies and gatekeepers. He believes that by demonstrating a conscientious effort to reduce x-rays, payers are more likely to believe that unnecessary care will be kept to a minimum.

TBI also presented a segment of the workshop, "Changing Patient Expectations: Pre-Clinic Triage Systems, Public Services Messages, and Innovative Methods of Patient Education." Daniel Hansen, DC, TBI's quality improvement coordinator, presented the results of a study of the attitudes of providers, patients, payers and employers as customers of the health care system. The results of the survey and focus groups provided interesting insight into the expectations of each group (see graph on page ##).

One of the last workshops of the conference featured Robert Mootz, DC, addressing "Building Provider-Business Partnerships." Dr. Mootz was part of a broad panel from various aspects of health care.

From this conference, there are a number of "take home messages" for the chiropractic profession. Perhaps the most important are:

Local consortiums of payers, employers and providers are being formed to confront unnecessary care. Many of the ones presenting this conference included DCs. If chiropractic is to retain its place among the decision makers, local chiropractors will need to seek and volunteer to serve on such panels.
While chiropractic is usually provided in a very cost-effective manner, the business and payer community are looking for all providers to participate in striving for higher efficiency and better outcomes.
Chiropractic continues to be a natural part of the health care landscape because doctors of chiropractic volunteer their time to participate. Without participation, chiropractic will be forced to accept the decisions of others.