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Chiropractic Journal of Australia : CJA June 2013
68 Chiropractic Journal of Australia Volume 43 Number 2 June 2013 If the subjective reporting by patients of their symptoms is a part of care history, surely the subjective reporting of their response, result, and satisfaction is equally important. 62,63 Comprehensive patient questionnaires are becoming much more prominent and available in health care practices, they have been termed patient’s Global Rating of Change scales (GRC)64 – the patient’s impression of their rate of change. There is a range for both specifc and general conditions. They cover a degree of severity, the rate of change, and lifestyle changes of patients under care.65 It is appreciated that it could be diffcult to change the mind-set of traditionalists, but the importance of evidence- based practice must be more patient oriented - and change is needed. However, it is time to question this 'Holy Grail'. SUMMARY Patient Satisfaction Feedback It is noted that an authorative texts include a signifcant section on patient-centred assessments and satisfaction. It is important that patient self-assessment feedback by patients be implemented. It is argued here that it should be accorded signifcant importance along with other forms of evidence -- at least 30% (plus 30% of the practitioner's assessment plus 40% from questionnaires and outcome testing). (See ‘Recommendations 1-7) It would also be an asset towards practice management by recording a straightforward, regular review of patient progress in addition to the standard clinical outcome tests and forms. (See Recommendation 1-7) It is suggested that the proposed Satisfaction Index Monitoring System (SIMS) would not be particularly time-consuming or onerous on practitioners. Indeed it is likely to be less demanding on practitioners than current expectations. Evidence Hierarchy It is noted that the current trend is away from strict (published) evidence-based practice and is now focussing more on patient satisfaction – a logical move. As health professions are based on hypotheses, and due to the many variables in clinical practice one cannot completely measure clinical practice through a strict upper category research model. The variability of patients’ biology, the nature of the diagnoses, co-morbidities, severity and stage of conditions, race, body types, postures, temperaments, age, compliance, previous histories and current status, make standard evidence measurements much less meaningful and difficult to incorporate into daily practice. That it has been acknowledged for some time that traditional laboratory research, experimental studies and literature reviews of evidence may not be the most appropriate for the manual clinical health issues. Empirical and Anecdotal Evidence In addition, it is proposed that greater emphasis be placed on empirical and anecdotal evidence as part of the literature base of supporting hierarchical evidence. It is appreciated that traditionalists may have diffculty in accepting such novel recommendations for such a fundamental change. The essence of reservations concerning the current EBP model is encapsulated by Lonn when he states; "My personal hope is that we will move beyond the big hit RCTs, and start gathering information from our practices and our broader patient population as they turn up to our surgeries using clever data collection, aggregation and analysis technologies. The days of the arbitrary Fisherian 0.05 barrier are numbered, as are the meta-analyses and Cochrane reviews that rely on them. Trials of highly selected subjects who are nothing like our patients, assessed against a number pulled out of thin air in the 1920s and 1930s by a eugenecist statistician, have become a drain on research funds, and have poor evidence of translating to better clinical outcomes. I know it's hard to leave the past behind, but mathematics and statistics have moved on, and Bayesian methods for iterating towards better and better answers seem more in keeping with the work a doctor does, and the information a doctor needs." 66 CONCLUSION It is submitted that evidenced-based health care is in the process of transition to a more practical and clinically useful model with more emphasis on case studies and outcomes. There is also a need for greater patient input of satisfaction -- as well as the traditional academic measures. A call is acknowledged here for considerable blinded, randomised studies into the effcacy of patient-assessed outcomes and satisfaction. The Chiropractic Report confrms growing recognition for patient involvement in that care when it stated that there are "Compelling reasons for measuring patient satisfaction (and that) this is overall the most important outcome for patients and third party payers...and you as a clinician will want to know how satisfed your patients are.” 65 The relevance of the traditional hierarchy of evidence is under review. Wood et al concluded, challenge the higher levels of evidence by noting possibility of bias in such studies. 25 In another fnding, Muchow and colleagues also queried a possible weakness in a meta-analyses of papers concerning the cervical spine.67 Ultimately, the optimal test is the successful result of a particular intervention. However, is that for the clinician, insurance company, patient or all three to determine? Practices will succeed or fail on the practitioners' results. In the end, it is these results at the coalface that count. A modifed system could be made by implementation of a more practical and rapid analogue-scale-type monitoring method, on a regular basis. These should be conducted at least weekly during more concentrated care - then at each visit as intervals between visits are extended. More detailed assessments should be conducted as per those recommended by Yeomans.44 (See also under Recommendation 1-7.) If patient outcome is to be the yardstick, as it should be, there is no point in applying certain studies that a clinician PATIENT-ORIENTED EBP ROME
CJA March 2013
CJA September 2013