Reflexiones nerviosas. Los fantasmas / Reflections nerve. The ghosts

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Building a disease risk model of osteoporosis based on traditional Chinese medicine symptoms and western medicine risk factors.

In the Traditional Chinese Medicine (TCM) cross-sectional survey conducted by our team, we were interested in determining the risk factors of osteoporosis. To analyze this TCM study, we had to deal with three statistical problems: (1) a very large number of potential risk factors, (2) interactions among potential risk factors, and (3) nonlinear effects of some continuous-scale risk factors. To address these analytic issues, we used two data mining methods, support vector machine recursive feature elimination and random forest; to deal with the curse of high-dimensional risk factors, we applied another data mining technique of association rule learning to discover the potential associations among risk factors. Finally, we employed the generalized partial linear model (GPLM) to determine nonlinear effects of an important continuous-scale risk factor. The final GPLM model shows that TCM symptoms play an important role in assessing the risk of osteoporosis. The GPLM also reveals a nonlinear effect of the important risk factor, menopause years, which might be missed by the generalized linear model.

The relationship between social factors and attitudes toward conventional and CAM practitioners.

CONTEXT: The research results on the relationship between social factors and attitudes toward complementary and alternative medicines (CAMs) and conventional practitioners are equivocal. Some researchers theorize a relationship between social factors and attitudes toward providers, with CAM being more attractive to socially and economically marginalized groups. OBJECTIVES: To evaluate the relationships between selected sociodemographic factors and attitudes toward CAMs in the general US population. DESIGN: A subset of data from a 1997-1998 nationally representative survey was examined using descriptive and univariate analyses. RESULTS: Five outcomes exploring preference for CAM or conventional medical practitioners are considered. Age was positively related to favoring one's conventional medical doctor. Subjects who reported using CAM for wellness/prevention reported significantly less confidence in their conventional doctors than individuals who did not report using CAM for wellness/prevention. Those with low income were also significantly less confident in their medical doctors and less satisfied with their conventional medical practitioners than those with higher incomes. CONCLUSIONS: While more prospective work is needed, this analysis suggests that social factors may be related to practitioner preference. Finding out why these relationships exist is important for the effectiveness of health care.

Measurement in clinical vs. biological medicine: the Rasch model as a bridge on a widening gap.

In the dominant Bio-medical paradigm Medicine is mostly Biology applied to Man. Measurement in Biology stems from physical sciences and has established validity. This is not the case for whole-person variables such as behaviors and psychic conditions (disability, pain, knowledges). The very existence of these variables can only be inferred by observing samples of representative behaviors. The quantity of the inferred variable may only come from subjective and discrete counts (scores) of events (coming in a questionnaire). Contemporary statistics demonstrated that raw scores intrinsically lack fundamental properties for scientific measurement, whatever their algebraic manipulations. This adds to the stigmatization of Clinical Medicine as "soft science", compared to Bio-medicine. In the 1960s Georg Rasch inaugurated a new statistical approach allowing transformation of raw scores into objective linear measures comparable to physical measures. This may help the Bio-medical paradigm to redirect resources from laboratory bench back to bedside.

Musculoskeletal disorders: does the osteopathic medical profession demonstrate its unique and distinctive characteristics?

The authors used the National Ambulatory Medical Care Survey: 1999 Summary to compare the practice patterns of osteopathic and allopathic physicians in the management of musculoskeletal disorders in family practice settings. Patient and physician characteristics, diagnostic test ordering patterns, treatments, and amount of time spent with patients during visits were compared. Patients who visited osteopathic physicians were more likely to be middle-aged and referred, with injury-related visits that were self-paid. Osteopathic physicians spent more time with patients, ordered a greater number of nontraditional diagnostic tests, and provided more manual and complementary modes of therapy. In contrast, although most of the patients seen by both osteopathic and allopathic physicians were white, allopathic physicians had a greater percentage of patients who were of an ethnic minority or under Medicaid or Medicare. Allopathic physicians ordered a greater number of traditional diagnostic tests and prescribed more medications. Based on the nationally representative data, osteopathic physicians used physiotherapy (including osteopathic manipulative treatment and physical modes of therapy) and complementary treatments to a greater degree in their physician-patient contacts. In contrast, allopathic physicians spent more resources on diagnosis versus treatment (eg, physiotherapy) and seemed to focus on the search for a nonstructural medical cause.

Predictors of alternative and complementary medicine use in inflammatory bowel disease: do measures of conventional health care utilization relate to use?

OBJECTIVE: Alternative and complementary therapies (ACM) have gained increasing attention in the past few years. It was our purpose to determine whether increased ACM use is associated with increased use of conventional health care resources. Additionally, demographics of use, subjective benefit, and cost were analyzed. METHODS: We enrolled 150 inflammatory bowel disease (IBD) patients from a tertiary care center and performed a phone survey of their ACM use in the past year. A population-based administrative database was accessed to extract data regarding use of conventional medicine (hospitalizations, doctor visits, and GI specific doctor visits). Patients were divided into three groups: (i) no ACM (n = 60) (ii) users of exercise, diet, and prayer (EDP) exclusively (n = 47) (iii) other ACM use (n = 43) which included those who may have used EDP as well as any of acupuncture, chiropractic, homeopathy, naturopathy, herbology, massage, relaxation, reflexology, hypnotherapy, aromatherapy, meditation, or support group. RESULTS: ACM was used by 60% (EDP 31%, other ACM 29%). There were no significant differences in use between the three groups by disease diagnosis, education level, employment status, use of IBD medications, number of hospitalizations, doctor visits, or GI specific doctor visits. The EDP group was more likely to be married (p = 0.006) and female (p = 0.04) compared to no ACM. The EDP group tended to be older than the no ACM (p = 0.001) and other ACM (p = 0.01). The other ACM had shorter disease duration than EDP (p = 0.04) and no ACM (p = 0.04). The most commonly used therapies were diet (45%), herbal (17%), exercise (15%), prayer (11%), and relaxation (10%). ACM was sought for pain/cramps (64%), diarrhea (60%), and gas/bloating (21%). Seventy-three percent of EDP interventions incurred no cost compared to 33% with other ACM (p < 0.0001). The median annual amount spent on other ACM was $56 (range $0-$4800). Subjectively, patients felt helped by trials of EDP 95% of the time whereas other ACM helped 67% of the time (p < 0.0001). CONCLUSIONS: ACM use could not be predicted by either greater or less hospitalizations, conventional doctor visits, or GI specific visits. ACM was sought mostly to palliate pain or diarrhea. Those using EDP are more likely to be older married women. Subjectively other ACM is of less benefit (67%) than EDP (95%). If doctor visits or hospitalizations represent degree of increased disease activity then this too is not predictive of using ACM.

Comparison of work and time estimates by chiropractic physicians with those of medical and osteopathic providers.

BACKGROUND: Resource-based relative value scales (RBRVS) have become a standard method for identifying costs and determining reimbursement for physician services. Development of RBRVS systems and methods are reviewed, and the RBRVS concept of physician "work" is defined. OBJECTIVE: Results of work and time inputs from chiropractic physicians are compared with those reported by osteopathic and medical specialties. Last, implications for reimbursement of chiropractic fee services are discussed. METHODS: Total work, intraservice work, and time inputs for clinical vignettes reported by chiropractic, osteopathic, and medical physicians are compared. Data for chiropractic work and time reports were drawn from a national random sample of chiropractors conducted as part of a 1997 workers' compensation chiropractic fee schedule development project. Medical and osteopathic inputs were drawn from RBRVS research conducted at Harvard University under a federal contract reported in 1990. Both data sets used the same or similar clinical vignettes and similar methods. Comparisons of work and time inputs are made for clinical vignettes to assess whether work reported by chiropractors is of similar magnitude and variability as work reported by other specialties. RESULTS: Chiropractic inputs for vignettes related to evaluation and management services are similar to those reported by medical specialists and osteopathic physicians. The range of variation between chiropractic work input and other specialties is of similar magnitude to that within other specialties. Chiropractors report greater work input for radiologic interpretation and lower work input for manipulation services. CONCLUSIONS: Chiropractors seem to perform similar total "work" for evaluation and management services as other specialties. No basis exists for excluding chiropractors from using evaluation and management codes for reimbursement purposes on grounds of dissimilar physician time or work estimates. Greater work input by chiropractors in radiology interpretation may be related to a greater importance placed on findings in care planning. Consistently higher reports for osteopathic work input on manipulation are likely attributable to differences in reference vignettes used in the respective populations. Research with a common reference vignette used for manipulation providers is recommended, as is development of a single generic approach to coding for manipulation services.

Disabling low back Oregon workers' compensation claims. Part III: Diagnostic and treatment procedures and associated costs.

Claimants in Oregon with disabling low back injuries attending chiropractors were found to have more treatments over a longer duration and at greater cost than claimants attending medical physicians with similar clinical presentations. These findings are attributed to: a) a higher proportion of chiropractic claimants than medical physician claimants with low back risk factors which may have adversely affected the course of recovery (chronic or recurrent low back conditions, obesity, extremity symptomatology, frequency of exacerbations); b) differences in age and gender of DC and MD claimants; c) the greater physician-patient contact hours characteristic of chiropractic practice; d) differences in therapeutic modalities employed; and e) the physician reimbursement permitted under Oregon workers' compensation law. The findings of this study emphasize the need for prospective studies of treatment outcome.

Disabling low back Oregon Workers' Compensation claims. Part II: Time loss.

This paper reports on time loss incurred by chiropractic (DC) and medical (MD) claimants with disabling low back work-related injuries in Oregon. Clinical categorization was accomplished using medical records and was based on reported symptomatology, objective clinical findings and functional impairment. The median time loss days for cases with comparable clinical presentation (severity) was 9.0 for DC cases and 11.5 for MD cases. Chiropractic claimants had a higher frequency of return to work with 1 wk or less of time loss. No difference was seen in time loss days for MD or DC claimants with no documented history of low back pain. However, for claimants with a history of chronic low back problems, the median time loss days for MD cases was 34.5 days, compared to 9 days for DC cases. It is suggested that chiropractors are better able to manage injured workers with a history of chronic low back problems and to return them more quickly to productive employment.