RESUMO
The use of photography in routine clinical practice has the potential to increase the efficiency of overall patient care as well as improve clinical documentation and provider-to-provider communication. This is particularly important in the setting of provider burnout in the electronic health record era and during the COVID-19 pandemic. Despite the potential of photographs to enhance workflows and patient care, challenges remain that hinder the successful incorporation of medical photography into clinical practice, often because of inconsistent structure and implementation. Our proposed consolidated framework for clinical photography consists of five key aspects: appropriate informed consent; proper preparation and positioning; image acquisition with consideration of the field of view, orientation, focus, resolution, scale, and color calibration; streamlined and secure image storage and documentation; and interoperable file exchange. Overall, this viewpoint is a forward-looking paper on leveraging medical photography as an electronic health record tool for clinical care, research, and education.
RESUMO
BACKGROUND: Chiropractic maintenance care (MC) has been found to be effective for patients classified as dysfunctional by the West Haven-Yale Multidimensional Pain Inventory (MPI). Although displaying good psychometric properties, the instrument was not designed to be used in clinical practice to screen patients for stratified care pathways. The aim was to develop a brief clinical instrument with the intent of identifying dysfunctional patients with acceptable diagnostic accuracy. METHODS: Data from 249 patients with a complete MPI dataset from a randomized clinical trial that investigated the effect and cost-effectiveness of MC with a 12-month follow-up was used in this cross-sectional analysis. A brief screening instrument was developed to identify dysfunctional patients, with a summary measure. Different cut-offs were considered with regards to diagnostic accuracy using the original instrument's classification of dysfunctional patients as a reference. Very good diagnostic accuracy was defined as an area under the curve (AUC) metric between 0.8 and 0.9. The instrument was then externally validated in 3 other existing datasets to assess model transportability across populations and medical settings. RESULTS: Using an explorative approach, the MAINTAIN instrument with 10 questions (0-6 Likert responses) capturing 5 dimensions (pain severity, interference, life control, affective distress, and support) was developed, generating an algorithm-based score ranging from - 12 to 48. Reporting a MAINTAIN score of 18 or higher, 146 out of the 249 patients were classified as dysfunctional with 95.8% sensitivity and 64.3% specificity. At a score of 22 or higher, 109/249 were classified as dysfunctional with 81.1% sensitivity and 79.2% specificity. AUC was estimated to 0.87 (95% CI 0.83, 0.92) and Youden's index was highest (0.70) at a score of 20. The diagnostic accuracy was similar and high across populations with minor differences in optimal thresholds for identifying dysfunctional individuals. CONCLUSION: The MAINTAIN instrument has very good diagnostic accuracy with regards to identifying dysfunctional patients and may be used as a decision aid in clinical practice. By using 2 thresholds, patients can be categorized into "low probability (- 12 to 17)", "moderate probability (18 to 21)", and "high probability (22 to 48)" of having a good outcome from maintenance care for low back pain. TRIAL REGISTRATION: Clinical trials.gov; NCT01539863; registered February 28, 2012; https://clinicaltrials.gov/ct2/show/NCT01539863 .