EXPANDING EVIDENCE-BASED TECHNOLOGY ASSESSMENT FOR COVERAGE IN WASHINGTON STATE.

OBJECTIVES: We describe a new evidence-based method for screening and evaluating emerging medical technologies. Washington State agencies, under legislative direction, have granted authority to its agency Medical Directors and policy leaders to make coverage decisions on medical technologies using a "dossier" process. The dossier process is employed when technology advocates or manufacturers request Washington State healthcare purchasers to pay for new and emerging technologies. This offers the advocate an opportunity to submit scientific evidence and information classically associated with a more formal health technology assessment. METHODS: The submitted information is independently reviewed and summarized for Washington State's public healthcare purchasers allowing a more standardized coverage decision for all public purchasers in Washington State. RESULTS: This process has allowed Washington State to make twelve evidence-based coverage decisions at a fraction of the cost of classic technology assessment. To date, of twelve reviews over 6 years, one health technology was approved for coverage, ten were not covered and one did not require a coverage decision. CONCLUSIONS: This evidence-based dossier process has yielded high-value coverage decisions of new and emerging medical technologies for public healthcare purchasers in Washington State.

Improving quality, preventing disability and reducing costs in workers' compensation healthcare: a population-based intervention study.

BACKGROUND: Problems of poor quality and high costs are worse in the workers' compensation system than in the general medical care system, yet relatively little work has been done to improve performance in workers' compensation healthcare. OBJECTIVE: To evaluate the effect of a quality improvement intervention that provided financial incentives to providers to encourage adoption of best practices, coupled with organizational support and care management activities, aimed at reducing work disability for patients treated within the Washington State workers' compensation system. RESEARCH DESIGN: Prospective nonrandomized intervention study with nonequivalent comparison group using difference-in-difference models to estimate the effect of the intervention. PARTICIPANTS: Two cross-sections of data representing 33,910 workers' compensation claims filed in the baseline (preintervention) period from July 2001 to June 2003 and 71,696 claims filed in the postintervention period from July 2004 to June 2007 were analyzed. 46,928 (44%) of these 105,606 claims represent patients treated by over 275 providers recruited through Centers of Occupational Health and Education (COHEs) at 2 pilot regional sites. MEASURES: Outcomes, measured at 1-year follow-up, included work disability status, number of disability days, disability cost, and medical cost. RESULTS: COHE patients were less likely to be off work and on disability at 1 year postclaim receipt (OR=0.79, P=0.003). The average COHE patients experienced a reduction in disability days of 19.7% (P=0.005) and a reduction in total disability and medical costs of $510 per claim (P<0.01). For patients with back sprain, the reduction in disability days was 29.5% (P=0.003). Patients treated by providers who more often adopted occupational health best practices had, on average, 57% fewer disability days (P=0.001) compared with patients treated by providers who infrequently adopted best practices. CONCLUSIONS: Financial incentives, coupled with care management support, can improve outcomes, prevent disability, and reduce costs for patients receiving occupational healthcare. Owing to important disability prevention capacity, workers' compensation healthcare may be especially fertile ground for continued quality improvement innovation.

Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis.

OBJECTIVES: The purpose of this project was to review the literature for the use of spinal manipulation for low back pain (LBP). METHODS: A search strategy modified from the Cochrane Collaboration review for LBP was conducted through the following databases: PubMed, Mantis, and the Cochrane Database. Invitations to submit relevant articles were extended to the profession via widely distributed professional news and association media. The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. RESULTS: A total of 887 source documents were obtained. Search results were sorted into related topic groups as follows: randomized controlled trials (RCTs) of LBP and manipulation; randomized trials of other interventions for LBP; guidelines; systematic reviews and meta-analyses; basic science; diagnostic-related articles, methodology; cognitive therapy and psychosocial issues; cohort and outcome studies; and others. Each group was subdivided by topic so that team members received approximately equal numbers of articles from each group, chosen randomly for distribution. The team elected to limit consideration in this first iteration to guidelines, systematic reviews, meta-analyses, RCTs, and coh ort studies. This yielded a total of 12 guidelines, 64 RCTs, 13 systematic reviews/meta-analyses, and 11 cohort studies. CONCLUSIONS: As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence. There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.

Measuring work disability: what can administrative data tell us about patient outcomes?

OBJECTIVE: The purpose of this study was to assess the association between administrative measures of work disability and self-reported work, pain, and functional status. METHODS: We conducted baseline and follow-up interviews to assess pain, functional status, work status, and demographic factors in workers with low back injuries, carpal tunnel syndrome, and upper and lower extremity fractures. Administrative measures of work disability were obtained from the Washington State Department of Labor and Industries. RESULTS: Pain intensity and impairment levels were lowest in those who had not received any disability payments, somewhat higher for those who were no longer receiving time loss benefits, and highest for workers receiving time loss payments at the time of interview. CONCLUSIONS: Administrative measures of work disability are significantly associated with self-reported outcomes and can be an efficient tool for tracking and evaluating outcomes of medical treatments, surgical procedures, and occupational health programs.

Chiropractic's current state: impacts for the future.

The chiropractic profession is currently facing a shift in practice and health care environments. This editorial reflects on the current state of the profession and suggests that the profession should move from the thinking and practice styles of the past that primarily attempted to prove patient care and practice to a more productive approach that strives to improve patient care and practice. The following primary areas that require attention are discussed: (1) evidence-based and best practices-oriented research priorities; (2) constructive engagement of the greater health care system; and (3) successful ethical business models.

Health services research related to chiropractic: review and recommendations for research prioritization by the chiropractic profession.

PURPOSE: This project updates a previous effort to inventory health services research conducted on chiropractic and makes recommendations for a subsequent research agenda. A qualitative review of social sciences, medical, chiropractic, and health services research literature regarding chiropractic was done with emphasis on research published since the initial health services research agenda effort in 1995. This work informed development of updated health services research recommendations. METHODS: Literature was gathered through searches of electronic health care database retrieval systems and citation tracking. In addition to general collecting of new studies, the authors considered to what extent the 1995 research recommendations had been addressed in the new literature. A seed set of refined recommendations was formulated and initially distributed expert review and revision. The recommendations were made available for public comment and hearing at the 10th Annual Research Agenda Conference for Chiropractic in March 2005. DISCUSSION: The past 10 years have seen numerous health service research studies related to chiropractic; however, nearly all of the research priorities identified in 1995 remain unaddressed and remain as important priorities. Thus, recommendations were reprioritized and revised to submit for open comment and hearing. CONCLUSION: A smaller number of more concise recommendations with more specific action steps are proposed for clinical quality improvement, performing cost analyses, and assessing use barriers for chiropractic.

Characteristics of chiropractic practitioners, patients, and encounters in Massachusetts and Arizona.

OBJECTIVE: To describe chiropractic care using data collected at the time of each patient visit. METHODS: Random samples of chiropractors licensed in Arizona and Massachusetts were recruited to participate in interviews about their training, demographics, and practice characteristics. Interviewees were then recruited to record information about patient condition, evaluation, care, and visit disposition on 20 consecutive patient visits. RESULTS: Data for 2550 chiropractic patient visits were recorded. Care for low back, head and neck pain accounted for almost three quarters of visits. Extremity conditions and wellness care accounted for approximately half of the remaining visits. Spinal and soft tissue examinations were the most frequently reported diagnostic procedures (80% and 56% of visits, respectively), and high-velocity spinal manipulation techniques were the most frequently reported therapeutic procedures (almost 85% of visits). Rehabilitation exercises, thermal modalities, electric stimulation, and counseling/education/self-care were each performed during approximately 25% of visits. Approximately 85% of patients seen were self-referred, whereas only approximately 5% came from medical physicians. Approximately 35% of visits had an expected source of payment directly from the patient. Approximately 80% of visits ended with a plan for the patient to return at a specified time. CONCLUSION: These findings are consistent with the findings of previous studies and confirm that chiropractors use conventional patient assessment approaches with specific attention to spinal and musculoskeletal procedures, infrequently incorporating interventions commonly associated with other complimentary and alternative care providers. These findings illustrate that diagnostic assessment and follow-up are integral to chiropractic clinical encounters and offer a baseline for best practices development. The data also offer insight into chiropractic use and may be of interest to chiropractic leaders and education planners for professional development purposes.

Patient satisfaction, treatment experience, and disability outcomes in a population-based cohort of injured workers in Washington State: implications for quality improvement.

OBJECTIVE: To determine what aspects of patient satisfaction are most important in explaining the variance in patients' overall treatment experience and to evaluate the relationship between treatment experience and subsequent outcomes. DATA SOURCES AND SETTING: Data from a population-based survey of 804 randomly selected injured workers in Washington State filing a workers' compensation claim between November 1999 and February 2000 were combined with insurance claims data indicating whether survey respondents were receiving disability compensation payments for being out of work at 6 or 12 months after claim filing. STUDY DESIGN: We conducted a two-step analysis. In the first step, we tested a multiple linear regression model to assess the relationship of satisfaction measures to patients' overall treatment experience. In the second step, we used logistic regression to assess the relationship of treatment experience to subsequent outcomes. PRINCIPAL FINDINGS: Among injured workers who had ongoing follow-up care after their initial treatment (n = 681), satisfaction with interpersonal and technical aspects of care and with care coordination was strongly and positively associated with overall treatment experience (p < 0.001). As a group, the satisfaction measures explained 38 percent of the variance in treatment experience after controlling for demographics, satisfaction with medical care prior to injury, job satisfaction, type of injury, and provider type. Injured workers who reported less-favorable treatment experience were 3.54 times as likely (95 percent confidence interval, 1.20-10.95, p = .021) to be receiving time-loss compensation for inability to work due to injury 6 or 12 months after filing a claim, compared to patients whose treatment experience was more positive.

Use of attorneys and appeal filing in the Washington State workers' compensation program: does patient satisfaction matter?

LEARNING OBJECTIVES: Specify the frequency with which injured workers in Washington State's compensation system retained an attorney or filed an appeal, and the personal and job-related correlates of these actions. Analyze the relationship between workers' legal actions and their satisfaction in two domains: how well the claim was managed administratively, and how well the worker and claim manager communicated with one another. Characterize the relationship between retaining an attorney and long-term disability. ABSTRACT: Little is known about how often injured workers retain attorneys or file appeals in the workers' compensation system. We conducted a population-based study to examine the frequency of attorney retention and appeal filing in the Washington State workers' compensation program and the factors related to this event. Data for the study were provided by a survey conducted on 804 injured workers who were interviewed an average of 159 days after claim receipt. Attorney retention and appeal filing were examined up to 28 months later. Seven percent of the workers either retained an attorney or filed an appeal. Workers who were less satisfied with claims administration procedures were more likely to retain an attorney or file an appeal (P<0.05). The average length of time from claim receipt to attorney retention (368 days) suggests that retaining an attorney is a correlate rather than a predictor of long-term disability.

Improving the quality of occupational health care in Washington State: new approaches to designing community-based health care systems.

The need for concerted action to improve quality was stressed in the recent Institute of Medicine report, Crossing the Quality Chasm: A New Health Care System for the 21st Century. This article describes an innovative community-based delivery system initiative designed to improve quality and health outcomes for occupational health conditions. Known as the Occupational Health Services (OHS) project, this Washington State initiative focuses on three targeted conditions: low back sprain, carpal tunnel syndrome, and fractures. To fulfill its purpose, which is to provide clinical resources and training opportunities and foster quality improvement activities on a community-wide basis, the OHS incorporates several key delivery system components, including systems to track patient and employer satisfaction and health outcomes; formal physician agreements that will provide incentives for using best-practices; and community-based Centers of Occupational Health and Education (COHEs) that will function as a resource for providers, patients, and employers. Our experience in developing the OHS quality improvement initiative should have relevance for health care clinicians, administrators, policy makers, and researchers engaged in similar pursuits outside the field of occupational health.

A communitywide intervention to improve outcomes and reduce disability among injured workers in Washington State.

One pressing challenge facing the U.S. health care system is the development of effective policies and clinical management strategies to address deficiencies in health care quality. In collaboration with researchers at the University of Washington, the Washington State Department of Labor and Industries has created a communitywide delivery system intervention to improve health outcomes and reduce disability among injured workers. This intervention is currently being tested in two sites in western and eastern Washington. So far, it appears to be possible to engage physicians and health care institutions in quality improvement initiatives and to form effective public-private partnerships for this purpose. Furthermore, collaborating with university researchers may help enhance the scientific rigor of the quality improvement initiative and create more opportunities for a successful evaluation.

Characteristics of licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians.

BACKGROUND: Despite the growing popularity of complementary and alternative medical (CAM) therapies, little is known about the professionals who provide them. Our objective was to describe the characteristics of the four largest groups of licensed CAM providers in the United States and to compare them with the characteristics of conventional physicians. METHODS: Random statewide samples of licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians living in Arizona, Connecticut, Massachusetts and Washington were interviewed by telephone. Sociodemographic, training, and practice characteristics of CAM providers were elicited and compared with data on conventional physicians published by the American Medical Association. RESULTS: More than 160 providers in each profession were interviewed. Participation rates ranged between 78% and 94% except for Arizona chiropractors (61%). The proportion of female respondents was highest for massage therapy (85%) and acupuncture and naturopathy (almost 60%) and was lowest for chiropractic (about 25%) and conventional medicine (23%). Except for acupuncturists, only 5% of CAM providers were nonwhite. CAM providers were more likely than conventional physicians to practice solo (51%-74% vs 26%, respectively), and less than 10% practiced with medical physicians. Massage therapists saw the fewest patients per week (about 14), and chiropractors and conventional physicians the most (about 100). Chiropractors and conventional physicians saw about 3 patients per hour compared with roughly 1 patient per hour for the other CAM professions. Interstate differences were small. CONCLUSIONS: This characterization of CAM providers will help inform decisions about the future role of CAM providers in the health care system.

Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians.

BACKGROUND: Despite growing popularity of complementary and alternative medical (CAM) therapies, little is known about the patients seen by CAM practitioners. Our objective was to describe the patients and problems seen by CAM practitioners. METHODS: We collected data on 20 consecutive visits to randomly sampled licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians practicing in Arizona, Connecticut, Massachusetts, and Washington. Data were collected on patient demographics, smoking status, referral source, reasons for visit, concurrent medical care, payment source, and visit duration. Comparative data for conventional physicians were drawn from the National Ambulatory Medical Care Survey. RESULTS: In each profession, at least 99 practitioners collected data on more than 1,800 visits. More than 80% of visits to CAM providers were by young and middle-aged adults, and roughly two thirds were by women. Children comprised 10% of visits to naturopathic physicians but only 1% to 4% of all visits to other CAM providers. At least two thirds of visits resulted from self-referrals, and only 4% to 12% of visits were from conventional physician referrals. Chiropractors and massage therapists primarily saw musculoskeletal problems, while acupuncturists and naturopathic physicians saw a broader range of conditions. Visits to acupuncturists and massage therapists lasted about 60 minutes compared with 40 minutes for naturopathic physicians and less than 20 minutes for chiropractors. Most visits to chiropractors and naturopathic physicians, but less than one third of visits to acupuncturists and massage therapists, were covered by insurance. CONCLUSIONS: This information will help inform discussions of the roles CAM practitioners will play in the health care system of the future.