By Ronald Rupert, DC
We have all heard the term “evidence-based” with respect to chiropractic, medicine, and other disciplines.
We know that the many key issues related to where the chiropractic profession will be with respect to healthcare reform, scope of practice, and reimbursement are closely linked to this issue of evidence.
Chiropractors endure a lengthy education process with undergraduate college, chiropractic college, and annual license renewal continuing education. Would you consider this enough to keep up with important clinical information that impacts your patient’s care, or do you need to invest a little more time with exposure to new information?
Test how well you are current and see if you can answer the following eight clinical questions (links to the answers can be found at the end):
1. Do you know how to determine the proper dosage of vitamin D for your patient?
2. Do you know which orthopedic tests are most accurate in diagnosing biomechanical sacro-iliac joint pain?
3. What new nutritional supplement may be most effective in reducing the symptoms of osteoarthritis and has the evidence to confirm it?
4. How strong is the evidence for the use of low level laser in the treatment of fibromyalgia, osteoarthritis and carpal tunnel syndrome? What wavelength and power is most effective?
5. What diet changes may reduce the risk of asthma in children?
6. The acai berry — just how good is it for you?
7. What does the evidence say is the best conservative method to care for fibromyalgia?
8. Based upon a review of all the scientific evidence, what is the best approach to the treatment for cervicogenic headache?
How well did you do? If you are like most chiropractors, keeping up with the evidence is an unmanageable task, and you probably did not know some of the answers or missed some you thought you knew.
Examining evidence-based care
Let’s take a minute to examine the concept of evidence-based care because there is a great deal of misunderstanding and a high level of emotionally charged opinions surrounding the concept.
The evidence-based movement is an attempt to put more structure and sophistication to what clinicians have always done. Good clinicians are lifetime learners. They want to keep up with the literature and adopt what is best for their patients, families, and themselves.
Bloodletting, trephining, leaches, phrenology, Rife machines, along with thousands of other diagnostic and treatment procedures are not believed to be as valuable today as they once were. So, one of the keys to evidence-based care is to develop and use skills for finding and critically evaluating literature that can translate into better patient care.
The second component is how this new grasp of better information is used. This is the source of a lot of controversy. The evidence is not meant to be a standalone component of how you treat your patients. If that were the case, most medical as well as chiropractic procedures would not be permitted.
In true evidence-based care, the three components are the patient’s needs and desires, the doctor’s experience and expertise, and the evidence. Why would you dictate care the patient can’t tolerate or pay for? Why would you use an old treatment procedure you knew was demonstrated to be ineffective or harmful? Why not use the evidence and what is best for the patient [ITAL]if[/ITAL] the patient is agreeable and [ITAL]if[/ITAL] you feel from your experience it will serve the best interests of that particular patient?
The problems with evidence-based chiropractic
There are problems associated with the evidence-based approach. The first and foremost is the misuse of evidence. Some third-party payers and governmental agencies are completely ignoring the expertise of the doctor and the needs and desires of the patient and are basing reimbursement solely on evidence.
To make matters worse, they are insisting on high-level evidence; primarily rigorous randomized clinical trials. These trials are difficult and typically very expensive. This becomes a significant challenge to a profession that has extremely limited financial resources and even fewer researchers. Based upon the misuse of evidence, the concept of evidence-based practice draws a lot of criticism from many of those in practice.
The original publications related to evidence-based care were directed at elevating the skill sets of the physician in order to make more educated decisions based upon the evidence. There are several troublesome issues embedded here.
What constitutes “evidence”? How do you weigh this evidence? To answer the latter question, the research community has developed dozens of evaluation strategies. Some for randomized trials, some for meta-analysis, and some for other levels of evidence like nonrandomized cohort studies, case series, or case reports.
Other problems are associated with elevating the skills of the physicians to become more critical consumers of the literature. Some of these include:
• Understanding the multiple biomedical databases, their search interfaces, and the indexing structure and terms.
• Developing critical reading skills that include a variety of research design concepts, selection bias, randomization strategies, threats of internal and external validity, and proper statistical analysis, to name a few.
• Being able to set aside the time to gather, critically read, and weigh the evidence.
• Much of the biomedical literature is not open access. Being able to meet the high cost of purchasing the many articles that may exist on any one topic can be cost prohibitive to the average practitioner.
Theoretically, it would be ideal to have highly trained chiropractors as well as other health providers that can execute all of the above, but the reality is they can not. It is doubtful if many of recent graduates from chiropractic colleges have these skill sets. So, as a profession, we have a long way to go. But, in the interim, we do not need to be without high-quality evidence to insure the best patient care as well as evidence to support reimbursement.
Ron Rupert, DC, is dean of research at the Research Institute of Parker College of Chiropractic. During 20 years of full-time private practice, he developed the MANTIS, the chiropractic and alternative medicine literature database which has nearly 400,000 scientific articles.
Links to the answers