Researching the Appropriateness of Care in the Complementary and Integrative Health Professions Part 3: Designing Instruments With Patient Input

ObjectivesThe purpose of this article is to describe how we designed patient survey instruments to ensure that patient data about preferences and experience could be included in appropriateness decisions. These actions were part of a project that examined the appropriateness of spinal manipulation and mobilization for chronic low back pain and chronic neck pain.MethodsWe conducted focus groups, cognitive interviews, a literature review of measures in prior chiropractic and complementary and integrative health research, and a pilot study to develop questionnaires of patient preferences, experiences, values, and beliefs.ResultsQuestionnaires were administered online to 2024 individuals from 125 chiropractic clinics. The survey included 3 long questionnaires and 5 shorter ones. All were administered online. The baseline items had 2 questionnaires that respondents could complete in different sittings. Respondents completed shorter biweekly follow-ups every 2 weeks and a final questionnaire at 3 months. The 2 initial questionnaires had 81 and 140 items, the 5 biweekly follow-up questionnaires had 37 items each, and the endline questionnaire contained 121 items. Participants generally responded positively to the survey items, and 91% of the patients who completed a baseline questionnaire completed the endpoint survey 3 months later. We used “legacy” measures, and we also adapted measures and developed new measures for this study. Preliminary assessment of reliability and validity for a newly developed scale about coping behaviors indicates that the items work well together in a scale.ConclusionsThis article documents the challenges and the efforts involved in designing data collection tools to facilitate the inclusion of patient data into appropriateness decisions.     

Patient Willingness to Pay for Reductions in Chronic Low Back Pain and Chronic Neck Pain

Many recommended nonpharmacologic therapies for patients with chronic spinal pain require visits to providers such as acupuncturists and chiropractors. Little information is available to inform third-party payers’ coverage policies regarding ongoing use of these therapies. This study offers contingent valuation-based estimates of patient willingness to pay (WTP) for pain reductions from a large (n = 1,583) sample of patients using ongoing chiropractic care to manage their chronic low back and neck pain. Average WTP estimates were $45.98 (45.8) per month per 1-point reduction in current pain for chronic low back pain and $37.32 (38.0) for chronic neck pain. These estimates met a variety of validity checks including that individuals’ values define a downward-sloping demand curve for these services. Comparing these WTP estimates with patients’ actual use of chiropractic care over the next 3 months indicates that these patients are likely “buying” perceived pain reductions from what they believe their pain would have been if they didn't see their chiropractor—that is, they value maintenance of their current mild pain levels. These results provide some evidence for copay levels and their relationship to patient demand, but call into question ongoing coverage policies that require the documentation of continued improvement or of experienced clinical deterioration with treatment withdrawal.PerspectiveThis study provides estimates of reported WTP for pain reduction from a large sample of patients using chiropractic care to manage their chronic spinal pain and compares these estimates to what these patients do for care over the next 3 months, to inform coverage policies for ongoing care.     

Patient Characteristics Associated With Self-Reported Adherence to Chiropractic Treatment Recommendations: A Feasibility Study

ObjectiveThe purpose of this study was to examine the feasibility of developing and administering a patient adherence survey to assess self-reported adherence to treatment recommendations from a chiropractic doctor within an academic health center.MethodsThe survey items were developed by the authors and vetted by the university's students and faculty, who serve as health care practitioners at an academic health center. Adult patients with spine pain who were seen by a doctor of chiropractic at an academic health center were included in this survey study. A 32-item survey was administered between October 2019 and March 2020.ResultsA total of 62 respondents completed the anonymous survey. We found that 89% of respondents adhered to their clinic appointments. Although 82% of respondents said that their doctor's recommendation made sense, only 44% reported completely following treatment recommendations for at-home stretching and exercise.ConclusionThis study determined that it is feasible to assess patient self-reported adherence to chiropractic treatment within an academic health center setting. In our sample we found that although patient adherence to clinic appointments was high, adherence to treatments was not.     

Researching the Appropriateness of Care in the Complementary and Integrative Health Professions Part 4: Putting Practice Back Into Evidence-based Practice by Recruiting Clinics and Patients

ObjectivesThis paper focuses on the methods of a single study, incorporating data from chiropractic clinics into an evidenced-based investigation of the appropriateness of manipulation for chronic back pain.MethodsA cluster sample of clinics (125) from 6 sites across the United States was chosen for this observation study. Patients with chronic low-back and neck pain were recruited using iPads, completed a series of online questionnaires, and gave permission for their patient records to be scanned. Patient records for a random sample were also obtained. The RAND staff and clinic personnel collected record data.ResultsWe obtained survey data from 2024 patients with chronic low back pain, chronic neck pain, or both. We obtained patient record data from 114 of 125 clinics. These included the records of 1475 of the individuals who had completed surveys (prospective sample), and a random sample of 2128 patients. Across 114 clinics, 22% of clinics had patient records that were fully electronic, 32% had paper files, and 46% used a combination. Of the 114 clinics, about 47% scanned the records themselves with training from RAND. We obtained a total of 3603 scanned records. The patient survey data were collected from June 2016 to February 2017, the provider surveys from June 2016 to March 2017, and the chart pull from April 2017 to December 2017.ConclusionsClinics can be successfully recruited for practice-based studies, and patients can be recruited using iPads. Obtaining patient records presents considerable challenges, and clinics varied in whether they had electronic files, nonelectronic records, or a mixture. Clinic staff can be trained to select and scan samples of charts to comply with randomization and data protection protocols in transferring records for research purposes.     

Chiropractic management of postsurgical lumbar spine pain: a retrospective study of 32 cases

Objective

Although chiropractic manipulation is commonly used for low back pain, applying this procedure to the patient with postlumbar spine surgery has not been adequately studied. The purpose of this retrospective chart review is to report on the results of chiropractic management (including Cox flexion distraction technique) of patients with postsurgical lumbar spine pain to determine the change in reported pain based on surgical type.

Methods

Ten years of patient files from one chiropractic practice were electronically screened for lumbar spine surgery occurring before presenting for chiropractic care. Of the 58 patients with a postsurgical diagnosis, 32 files contained all pertinent components for this study including treatment with Cox flexion distraction manipulation (in addition to adjunct procedures) for at least 2 weeks and pretreatment and posttreatment pain measures using the Numeric Pain Scale (NPS) that ranged from 0 (no pain) to 10 (worst pain imaginable).

Results

A change was observed in the mean pretreatment and posttreatment NPS pain scores of 6.4 to 2.3, a reduction of 4.1 of 10. The mean number of treatments was 14, with a range of 6 to 31. When stratified by surgical type, the mean change in pain was most remarkable in patients who underwent a surgery that combined lumbar discectomy, fusion, and/or laminectomy, with an average NPS pain reduction of 5.7 of 10. No adverse events were reported for any of these postsurgical patients.

Conclusions

The results of this study showed improvement for patients with low back pain subsequent to lumbar spine surgery who were managed with chiropractic care.     

Adding Chiropractic Treatment to Individual Rehabilitation for Persistent Pelvic Girdle Pain 3 to 6 Months After Delivery: A Pilot Randomized Trial

ObjectiveThe purpose of this study was to investigate the feasibility of conducting a study examining the influence of individualized rehabilitation and chiropractic treatment, compared with individualized rehabilitation alone, in women with persistent dominating 1-sided pelvic girdle pain (PGP) 3 to 6 months after delivery.MethodsWomen were recruited from an outpatient clinic at Stavanger University Hospital, Norway and in a private chiropractic clinic in Stavanger. Those with persistent, dominating 1-sided PGP were included in this pilot study. Those who met inclusion criteria were randomized into 2 groups, one group received individualized rehabilitation and chiropractic treatment and the other group women received individualized rehabilitation alone. Treatment was measured for 20 weeks.ResultsOf 330 consenting women who were recruited who reported pelvic pain during pregnancy, 68 reported PGP or low back pain, and 63 consented to fill in a questionnaire. Forty-seven women underwent a clinical examination 3 to 6 months after delivery. During the examination, the women were diagnosed into subgroups for PGP. After exclusion of the women with low back pain only, a total of 13 women were diagnosed with dominating 1-sided PGP and thus included in this study. Six were randomized to the individualized rehabilitation and chiropractic treatment group and 5 to the individualized rehabilitation alone group. After 20 weeks of intervention, both groups reported improvement in disability and pain, but not in general health status. No serious or long-lasting adverse events were registered after treatment or training.ConclusionWe found that a study of this nature is feasible. However, the conditions of patient recruitment need to be considered carefully. We learned that a trial to investigate the effect of chiropractic treatment for PGP pain should include all subgroups of PGP to reach an acceptable sample size.     

Patient-reported improvements of pain,disability, and health-related quality of life following chiropractic care for back pain – A national observational study in Sweden

BackgroundChiropractic care is a common but not often investigated treatment option for back pain in Sweden. The aim of this study was to explore patient-reported outcomes (PRO) for patients with back pain seeking chiropractic care in Sweden.MethodsProspective observational study. Patients 18 years and older, with non-specific back pain of any duration, seeking care at 23 chiropractic clinics throughout Sweden were invited to answer PRO questionnaires at baseline with the main follow-up after four weeks targeting the following outcomes: Numerical Rating Scale for back pain intensity (NRS), Oswestry Disability Index for back pain disability (ODI), health-related quality of life (EQ-5D index) and a visual analogue scale for self-rated health (EQ VAS).Results246 back pain patients answered baseline questionnaires and 138 (56%) completed follow-up after four weeks. Statistically significant improvements over the four weeks were reported for all PRO by acute back pain patients (n = 81), mean change scores: NRS -2.98 (p < 0.001), ODI -13.58 (p < 0.001), EQ VAS 9.63 (p < 0.001), EQ-5D index 0.22 (p < 0.001); and for three out of four PRO for patients with chronic back pain (n = 57), mean change scores: NRS -0.90 (p = 0.002), ODI -2.88 (p = 0.010), EQ VAS 3.77 (p = 0.164), EQ-5D index 0.04 (p = 0.022).ConclusionsPatients with acute and chronic back pain reported statistically significant improvements in PRO four weeks after initiated chiropractic care. Albeit the observational study design limits causal inference, the relatively rapid improvements of PRO scores warrant further clinical investigations.     

Pain Experiences and Coping Strategies in Rural Older Adults With Chronic Musculoskeletal Pain in Mountainous Areas of Taiwan

BackgroundAlthough rural communities are home to a higher proportion of older residents, they provide fewer healthcare services than do urban core communities. Chronic musculoskeletal (MSK) pain is often associated with reduced daily activity and quality of life in older adults, particularly those in rural areas.AimsThis study investigated the pain experiences and coping strategies in rural older adults with MSK pain in Taiwan.MethodsA structured questionnaire was used to collect data from rural older adults with chronic MSK pain in mountainous areas of Taiwan.ResultsIn total, 55 rural older adults were enrolled in this study. The most common pain sites were the low back and knees. The main cause of pain was osteoarthritis. Three quarters of the participants suffered from moderate to severe chronic MSK pain on average. The results revealed that behavioral strategies were used more often than cognitive strategies. Regarding behavioral strategies, the most common non-pharmacologic and pharmacologic pain coping strategies were to rest and to take Chinese medicine, respectively. The most common cognitive strategy for pain coping was to talk to others.ConclusionsThe findings suggested that pain management for chronic MSK pain in rural older adults was inadequate in mountainous areas of Taiwan. Most rural older adults used multiple coping strategies to deal with their pain, and behavioral strategies were favored over cognitive strategies.     

Patient characteristics and physicians' practice activities for patients with chronic low back pain: a practice-based study of primary care and chiropractic physicians

BACKGROUND: Chronic low back pain sufferers are among those who account for the greatest usage of health care resources. Primary care medical (MD) physicians and chiropractic (DC) physicians treat most of these patients. OBJECTIVES: To study patient characteristics and physician practice activities for patients with chronic low back pain treated by DC physicians and MD physicians. METHODS: A longitudinal, practice-based observational study was undertaken in 14 general practice and 51 DC community-based clinics. A total of 2945 consecutive patients with ambulatory low back pain of mechanical origin were enrolled; 835 patients were in the chronic subgroup. Patients were followed for 12 months. Data were obtained on all of the following: patient demographics, health status, and psychosocial characteristics; history, duration, and severity of low back pain and disability; physicians' practice activities; and low back complaint status at 1 year. RESULTS: Patients treated by MD physicians were younger and had lower incomes; their care was more often paid for by a third party; their baseline pain and disability were slightly greater. In addition, patients treated by MD physicians had one fourth as many visits as patients treated by DC physicians. Utilization of imaging procedures by enrolling physicians was equivalent for the two provider groups. Medications were prescribed for 80% of the patients enrolled by MD physicians; spinal manipulation was administered to 84% of patients enrolled by DC physicians. Physical modalities, self-care education, exercise, and postural advice characterized low back pain management in both provider groups. Patients' care-seeking was not exclusive to one provider type. Most patients experienced recurrences (patients treated by MD physicians, 59.3%; patients treated by DC physicians, 76.4%); 34.1% of patients treated by MD physicians and 12.7% of patients treated by DC physicians reported 12 months of continuous pain. Only 6.7% of patients treated by MD physicians and 10.9% of patients treated by DC physicians reported 1 resolved episode during the year. CONCLUSIONS: Differences in sociodemographics, present pain intensity, and functional disability may distinguish patients with chronic low back pain seeking care from primary care medical physicians from those seeking care from DC physicians. Although the primary treatment modality differs, the practice activities of MD physicians and DC physicians have much in common. Long-term evaluation suggests that chronic back pain is persistent and difficult to treat for both provider types.     

慢性心力衰竭患者自我护理行为与应对方式的研究

目的:描述慢性心力衰竭患者自我护理行为及应对方式现状,探讨应对方式对自我护理行为的影响。方法:采用慢性心力衰竭自我护理行为量表和医学应对方式问卷对天津市某三级甲等综合性医院心内科102例慢性心力衰竭患者进行问卷调查。结果:慢性心力衰竭患者常采用面对的应对方式,自我护理行为平均分为(2.41±0.69)分。多元逐步回归结果提示,应对方式是自我护理行为的重要影响因素。结论:护理人员应帮助患者建立有效的应对方式,从而提高其自我护理行为。     

How do patients develop self-care behaviors to live well with heart failure?: A focus group interview study

BackgroundHeart failure (HF) requires distinctive lifelong self-care behaviors. However, self-care behaviors in the context of HF are poorly understood. Exploring how to develop self-care behaviors among patients with HF can help nurses understand patient perspectives and promote effective patient engagement with self-care for a healthy transition to living well with HF.AimTo explore how patients with HF adhere to self-care and create self-care agency after HF diagnosis by examining their experiences.MethodsFocus group interviews (FGI) were conducted to explore views from patients with HF who attended a cardiology outpatient clinic. Five focus groups (FGs) with a total of 25 participants with a mean age of 66.64 ± 7.97 were interviewed. FGs ranged in size from three to seven individuals. All interviews were recorded, transcribed, and analyzed using a thematic analysis approach.FindingsAnalysis revealed four main themes: (a) Patient perspectives on living with HF; (b) Health information-seeking behaviors; (c) Motivation and readiness regarding HF self-care; and (d) Healthy transitions. This study shows that accepting and understanding HF is an important first step for patients to move forward with managing their disease and living well with HF.ConclusionOur study shows that patients motivate themselves to engage in self-care behaviors when they perceive HF as a chronic disease with an uncertain and unpredictable illness trajectory and gain sufficient health information. Moreover, perceived social support and self-efficacy are essential components in creating HF self-care agency. Healthcare professionals should provide education and social support and encourage patients to adopt self-care behaviors.     

Characteristics of Chiropractic Patients Being Treated for Chronic Low Back and Neck Pain

Objectives

Chronic low back pain (CLBP) and chronic neck pain (CNP) are the most common types of chronic pain, and chiropractic spinal manipulation is a common nonpharmacologic treatment. This study presents the characteristics of a large United States sample of chiropractic patients with CLBP and CNP.

Disability Among Persons With Chronic Severe Back Pain: Results From a Nationally Representative Population-based Sample

We evaluated the association between the chronic severe back pain with disability and participation, in U.S. Adults using data from the US 2019 National Health Interview Survey. In our sample of 2,925 adults (weighted n: 20,468,134) who reported having chronic severe back pain, 60% reported mobility disability, 60% had work limitations, 34% were limited for social participation and 16% had self-care limitations. Older age (65+) was associated with mobility difficulties (OR 1.99, 95% CI 1.28,6.09) and work limitation (OR 2.21, 95% CI 1.61,3.05). Lower socioeconomic status was associated with increasing odds of disability across the 4 categories. Being obese was only associated with mobility difficulties (OR 1.95, 95% CI 1.41,2.71), while not working in the past week was associated with difficulties in mobility (OR 3.55, 95% CI 2.64,4.75), self-care (OR 3.34, 95% CI 2.20,5.08), and social participation (OR 3.20, 95% CI 2.13,4.80). Comorbidities were highly associated with limitations in all 4 categories. Those deeming their ability to manage their pain ineffective were twice as likely to have limitations in self-care, social and work participation but not mobility. Identifying factors associated with disability and limitation may help target appropriate management for persons with chronic pain at high risk for disability.PerspectiveWe evaluated the association between the chronic severe back pain with disability and participation, in a representative sample of Americans. Identifying factors associated with a likelihood of disability may help target appropriate pain management for persons at high risk for disability due to chronic severe back pain.