AMERICAN COLLEGE OF
CHIROPRACTIC CONSULTANTS

OFFICIAL NEWSLETTER
Volume 4 Issue 1 - Spring/Summer 2003

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Executive Board: Dan Bowerman, DC President Jeffrey Cates, DC, MS - VP David Cox, DC - Secretary Scott Becker, DC - Treasurer ________  Stephen Perle, DC, MS - Editor Jeffrey Cates, DC, MS - Web Editor This newsletter is a service of the American College of Chiropractic Consultants and is designed to provide readers with pertinent information concerning the College, its examining board (ABCC) and utilization management activities. Readers may save and use information contained therein only for personal use. No other use, including reproduction, transmission or editing, of the newsletter information may be made without the prior written permission of the ACCC, which may be requested by contacting the ACCC headquarters. ACCC makes no warranty, guarantee, or representation as to the accuracy or sufficiency of the information printed within, and the ACCC assumes no responsibility or liability regarding the use or misuse of such information.The opinions expressed in the ACCC newsletter are not necessarily those of the College. Advertisements appearing in the ACCC newsletter do not imply approval nor endorsement. Providers should consult their respective state licensing boards concerning the use of advertised products or services. Hyperhomocysteinemia   Hyperhomocysteinemia, now that’s a mouthful, has recently been shown in any study in Italy to be more common on months those who have had spontaneous dissection of the cervical artery.  This paper is a follow-up by the same authors of the earlier study looking at a subgroup of patients with cervical artery dissection who had chiropractic manipulation of the cervical spine.  This opens up an interesting line of future investigation toward determining risk factors for stroke from cervical manipulation.  However, it should be noted that the initial study had 35 cases and this subgroup had only four patients.  Thus, more research is needed. Line of Drive? This study from the University of Waterloo and CMCC is very interesting in that it challenges the concept of a line of drive at an angle other than perpendicular to the skin.  I first heard about this study when one of the authors, Dr. Kim Ross (the chair of CMCC’s Technique Department), presented this data at an ACC Technique Consortium meeting.  Their findings suggest that any line of drive (at least in the thoracic spine which is all they tested) that is other than perpendicular to the skin results in nothing more than stretching of the skin.  Thus, a typical adjustment in the thoracic spine of, for example 500N directed at a 45 degree angle towards the head and rationalize the vectors.  This will result in 354.6N force directed 90 degrees to the skin and a 354.6N force which will stretch the skin.  For a large doctor to essentially throw away 30% of the force generated during an adjustment (using it to just stretch the skin) may not be so bad.  But for smaller doctors to waste that much force is another story.  This has caused me to rethink the way I teach adjusting and how I adjust. Bereznick DE, Ross JK, McGill SM. The frictional properties at the thoracic skin-fascia interface: implications in spine manipulation. Clin Biomech (Bristol, Avon) 2002;17(4):297-303.

Breaking Ice Breaking the ice, just starting work on any endeavor is the hardest thing to do.  It is inertia that tends to prevent us from changing, whether that change is to start or for that matter to stop any particular action.  In this case of inertia that I needed to get past is starting the ACCC’s Newsletter.  Since, having broken through the inertia of continuing to do nothing, I will be able to produce a newsletter on a regular basis. In order to do this I need certain help from the membership. I need people to e-mail me with ideas of what they would like me to cover.  That is if you have a particular topic you would like me to cover please let me know.  Likewise, if members have articles they would like to submit to the newsletter, please send them to me.  If anyone has any resource material resource material that could be used for an article sending that led also be greatly appreciate.               Stephen M. Perle, D.C., M.S.   HIPAA Hip Hooray? One would have to have one’s head buried in the sand to not know that the biggest story of the past year in the insurance industry was the implementation of the privacy rules as imposed by Health Insurance Portability and Accountability Act of 1997 more popularly and with economy of phonemes  known as HIPAA.  If history has taught us anything, it is that the implementation of the government regulations often sprouts up new industries.  In recent memory one of the best examples of this is the development of a complete industry surrounding the“millennium bug” and our attempts at Y2K preparedness.  Likewise, the healthcare industry has found that this legislation also stimulated the development of an entirely new industry to provide consulting, education and products purportedly appropriate and maybe (or maybe not) necessary to HIPAA compliance.  One need only do a search on the web for HIPAA and find the large collection of companies which have sprouted in the fertile soil left behind as a result of the final implementation of regulations pursuant to HIPAA. The big news must be Aetna’s decision to require electronic claims submission for any reimbursement by September.  This is a stunning decision as it will have a number of far reaching effects.  Those who thought because they have no electronic transactions can avoid HIPAA have a rude awakening because, besides having to comply with the privacy rules anyway, they are now going to have to comply just to get paid.  The Luddites who have not computerized are going to have to enter the 21st century kicking and screaming for payment.  Aetna’s start date will for some hasten their compliance with HIPAA.  And finally one must see Aetna’s action as the beginning of the end for paper claims submission.  Although the first one must expect that each insurance company will in its own turn make similar announcements that all claims must be electronic. The government’s reputation for writing instructions of a thousand pages when one would have done has significantly helped stimulate the development of this new industry.  However, any time spent on the government’s web sites devoted to HIPAA and one will find the government’s penchant for obfuscation seems to be relegated to the IRS because Health and Human Services (HHS) seems to have found those who can actually write.  Specific web sites you should be acquainted with are: http://privacyruleandresearch.nih.gov/ http://www.cms.gov/hipaa/ http://www.hhs.gov/ocr/hipaa/ http://www.hhs.gov/ocr/hipaa/links.html http://aspe.hhs.gov/admnsimp/ http://telehealth.hrsa.gov/pubs/hipaa.htm  _____________ DON'T MISS OUR 2003 FALL CONVENTION! Click Here For Convention Information Click Here To Register for Convention

Who’s Watching the Shop?

Under the Clinton Administration healthcare fraud was a priority enforcement issue for the federal government and in fact if you search the Department of Justice’s web site you’ll find reports on its healthcare fraud for fiscal years 1997 - 2001.  There is no report for fiscal year 2002, which ordinarily would have appeared in April of 2003.  Interestingly, back in June of 2002, Sen. Grassley of Iowa, specifically complained to the Department of Justice for its current inaction in healthcare fraud suggesting that the provisions of the 1986 False Claims Act (he was a coauthor space of provisions of this act) had not been adequately enforced. 

One might say it is not any lack of the importance for the issue but more so a greater importance for tasking the manpower of the Department of Justice to work on antiterrorism issues.  Although the previous reports on healthcare fraud were done in conjunction with the Department of Justice and Department of Health and Human Services, a review of the HHS web site and the HHS Inspector Generals office shows that there is no anti-fraud activity currently reported.  In fact featured prominently on HHS’ web site is a link to a report on fraud entitled “Market Survey of Health Care Fraud, Waste, and Abuse Detection Technology.” Unfortunately the link is no longer valid and as it is the report is from the year 2000.

As has been the case in the past when the government relaxes enforcement on any particular crime the level of the crime expands dramatically.  Thus, if the government is relaxing the criminal space investigations then the health insurance industry can be expected to expand their internal investigations which are likely to mean more work for clinical consultants.  

Finally, it should be noted that the National Health-Care Anti-Fraud Association’s  literature to the public about fraud specifically mentions chiropractic.  In one instance they discuss chiropractic it is about a specific case of fraud in the state of Texas in 2001.  In this case a chiropractor was convicted for submitting more than $5.7 million and false claims of which $3.2 million actually had been paid. In the second instance they discuss chiropractic in relationship to the offers of free services.  They do, however, note other free services, such as free foot care and free dental care, as examples of potential healthcare fraud that consumers should be wary of. 

 Literature Update

 “He treats you as a person not just like a number”

The above is the unusual title of an article appeared in the British Journal of Medicine.  This paper is interesting in two respects.  First, is that it was published into distantly different formats.  One used the title noted above and a style more reminiscent of any magazine than a biomedical journal.  In the new format is very easy to pick up the important features of the paper, although someone interested in critiquing the scientific quality of study would not get the requisite information from this new style.  The other version of the paper was entitled “Qualitative study of the meaning of personal care and general practice” and is in a style typical of other papers one would find in BMJ. 

What is also of interest in this study are the specific findings.  These are consistent with what has been published previously on making the healthcare more humanistic.  The findings of this paper are very similar to those noted in the textbook I use in my ethics class in a chapter on humanistic healthcare.  Patients want human communication.  This means that they’re looking for more than having the doctor listen to them talk about regarding their particular health problems but also that they want a human approach to communication, which is more like social interaction, including the use of humor.  This is also in line with research that shows better quality care is care that involves more doctor-patient time together.

Patients want their healthcare individualized and tailored to their specific needs. I have said to my students often.  Patients want individual health care.  They want to be treated as unique but they certainly hope they don’t have a unique health condition, for being that “special” would mean that they have something nobody knows how to treat.

This paper also found patients want a whole person or holistic care.  This does not necessarily mean holistic healthcare such as implementing CAM type procedures.  It means that someone deals with the whole person and that they understand the patient and they understand their families.

The increased market penetration of managed care plans has to some degree in healthcare destroyed goodwill as saying part of the business.  This is something that many of us in healthcare have lamented. It appears that this study found similar findings from the standpoint that patients believe that any continuing relationship is important to personal care in practice.  Patients even believe that personal care can be offered during brief encounters.  This reminds me of a story that my mother told me.  She was waiting in the reception room of a hospital when her PCP of ten years saw her.  He came up to her and said “don’t I know you from someone?” To say the least she was quite insulted.  

When I first started in practice, I recall people often telling me that one of the most important things in my office was the receptionist.  They said to me that this person can make or break a practice and it appears from this study that this is true also.  Receptionists are important.  

New style:      http://bmj.com/cgi/data/326/7402/1310/DC1/1 

Old style:          http://bmj.com/cgi/reprint/326/7402/1310.pdf

 
Predicting patients’ response to spinal manipulation

A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement was on relation.  This paper was published in 2002 and spine.  And I feel like it has not received the media attention in the chiropractic profession it so richly deserves.  In the study patients with lower back pain were treated with manipulation provided by a physical therapist.  Patients were not randomized into any other treatments, as the important part of this study was to determine who actually would respond to manipulation.  

The manipulative technique used in this study was a bit unusual.  The patient was supine with the doctor contacting the contralateral scapula and ASIS.  The scapula is lifted and the thrust is on the ASIS. As opposed to many studies done by physical therapist on “manipulation,” in this study therapist actually delivered a high velocity thrust and in fact it was noted whether cavitation was heard or felt by the patient and the therapist.  If no cavitation was experienced then manipulation was attempted again.  However, if no cavitation was experienced after the second attempt, then up to two attempts were made to cavitate by manipulating the opposite side.  

To date studies on the diagnostic accuracy of the pre-manipulative evaluation have been less than encouraging.  We know that it is hard to determine on an a priori basis who will respond positively to manipulative treatment. The most important feature of this paper are the findings on a clinical prediction rule for classifying patients who are most likely to respond to manipulation.  The clinical prediction rule contains five different variables: the duration of the patient symptoms (less is predictive of success 3 weeks vs. 8 weeks average duration for successes and failures respectively), at least 35 degrees of hip internal rotation, lumbar hypermobility, no symptoms distal to the knee, and a Fear Avoidance Beliefs Questionnaire (FABQ) work subscale score less than 18.  If the patient had  four of five tests positive 95% will respond to manipulation and if there were three positive tests 68 percent responded.  Thus, a patient with three of five test positive should reasonably be treated with manipulation.  Of special note is that those tests intended to specifically determine if a patient should be manipulated were not found to be useful in determining who will respond to manipulation.  

- Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 2002;27(24):2835-43.

Cost Chiropractic Care in California’s 
Worker’s Compensation System  

I recently received a copy of a March 21 report from the Industrial Claims Information System which is a data warehouse developed by the California Workers Compensation Institute on the cost of chiropractic care in California’s workers compensation system.  This report is to say the least very disturbing.  Over a seven-year period from 1993 to 2000 there has been a decrease in the percentage of Californians seeking chiropractic care for work-related injuries from 8% in ‘93 to 6.1% in 2000.  While I am sure for chiropractors in California this is a troubling statistic, because it shows that fewer people are seeking chiropractic care, this is not the most troubling statistic in this report.  The study shows that the average amount of payment for chiropractic treatment has increased per claim over the seven years.  In addition the following averages have increased over the 7 years: number of visits, number of procedures, number of unique procedures, number of visits and most troubling is that the percent of money paid for chiropractic care has increased while the same time we know that the percent of patients seeking chiropractors have decreased.   

ICIS in summarizing their research believe that the data show that chiropractors are becoming more aggressive in their treatment of injured workers.  This is based on the fact that the average number of procedures per claim at 12 and 24 months post injury show that there is an increased utilization of chiropractic care that occurs in the early life of the claim.  The report goes on to discuss the work of Stanford University economist Dr.  Victor Fuchs who rode 25 years ago “if the physician/population ratio should increase  . . .  the result will probably be higher rather than lower fees and also more operations.”  The authors implied that this has been demonstrating California has there has been a 27.5% increase in the number of chiropractors in California between 1995 and 2000.  The authors go on to conclude: “Bottom-line: the combined effect of the increase in the number of chiropractic providers servicing fewer injured workers with higher levels of chiropractic services per claim has increased both the average cost per claim an overall cost of chiropractic care in California workers’ compensation.” ICIS does close with an admission that there are alternative explanations for these findings, such as more severely injured workers, that chiropractic care is associated with better outcomes and that these findings may be an implication of changes in compensation laws in 1993.  

On the other side of the coin, I have read two MGT of America studies on workers compensation, one in the State of Texas and the other in Florida.  Both of these rather extensive reports found that chiropractic care is less expensive than other care and ultimately is saving the workers’ compensation systems in both of the states.  Obviously, more research is needed, however, it is problematic when studies like the ICIS one appear.  

http://www.cwci.org/icissays3.PDF  

 
Effect of Interpretive Bias on Research Evidence  

I would like to thank Dr.  David Young for bringing this paper to my attention.  This is a relatively short paper, only three pages but it provides an outstanding lesson on how people’s bias affects the way they view the published literature.  The paper is written by Ted Kaptchuk for those of you who are not aware Dr. Kaptchuk is an Oriental Medical Doctor (OMD) trained in China but originally from United States.  His book “The Web That Has No Weaver” is an outstanding introduction into traditional Oriental medicine.  It is also important to note that Dr.  Kaptchuk is a faculty member at Harvard Medical School and has published quite a few papers with Dr.  Eisenberg.  I will not go into depth about what this paper discusses, I think any cannot do it justice (please read it).  However, I would like to point out in particular that bias runs both ways.  We often see the bias of those opposed to chiropractic but we also have to be aware of the bias that we have toward papers we think are positive about chiropractic.  

Kaptchuk TJ. Effect of interpretive bias on research evidence. Bmj 2003;326(7404):1453-5.

http://bmj.com/cgi/reprint/326/7404/1453.pdf  

Evidence or Influence  

At the last ACC/RAC conference in New Orleans Dr. Robert Mootz used the phrase evidence influenced health care as opposed to evidence-based health care.  This change in terminology instantly resonated with me and I thought that I had heard him say where he had originally heard this.  So when I returned home I searched for this phrase.  While I found a source, it appears that was not his source.  From my conversations with Dr.  Mootz  it appears that great minds think alike.  The earliest source I confined for this phrase in the biomedical literature is a paper or by Davies and Nutley.  These two are public policy experts working at the University of St.  Andrews.  In a paper they presented in 2001 in an international conference on evidence-based policies they say: “the term ‘evidence-based’ when attached as a modifier to policy or practice has become part of the lexicon of academics, policy people, practitioners and even client groups.  Yet such glib terms can obscure the sometimes only-limited role that evidence can, does, or even should, play.  In recognition of this, we would prefer ‘ evidence influenced’, were even just ‘evidence-aware’ to reflect a more realistic view what can be achieved.”  

Davies HTO, Nutley SM. Evidence-based policy and practice: moving from rhetoric to reality. In: Third International, Inter-disciplinary Evidence-Based Policies and Indicator Systems Conference; 2001; Durham, England: CEM Centre, University of Durham; 2001. p. 86-95.

http://bmj.com/cgi/reprint/320/7240/998.pdf

Manual Therapy

If you are not a subscriber of this journal, I submit you have been missing a wealth of studies that are very important to the chiropractic profession.  But fear not the new world order of journal publishing started by BMJ.com going free full text is having some converts.  Many other journals have also gone free full text.  You can find Manual Therapy at:

http://www.sciencedirect.com/science/journal/1356689X

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