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Chiropractic Journal of Australia : CJA June 2013
Chiropractic Journal of Australia Volume 43 Number 2 June 2013 69 or researcher might deem justifed if the ultimate judge – the patient, is not satisfed. RECOMMENDATIONS There are many questions arising from the current system of evidence-based health care. While the term might sound idealistic and even appropriate, there are almost unlimited variables, complexities and complications in applying the traditional EBP formula to practice considerations. It is time for an innovative overhaul of the means of assessing patient care, both as substantiating care, and assessing outcomes. An analogue scale of assessment is proposed here. It is appreciated that the following recommendations place the emphasis on patient-centred clinical outcomes as being more signifcant than the traditional evidence-based system. However, it does not negate the need for incorporating at least some of the more traditional system. Patient Self-Assessed Comfort/Improvement Scales 1. That it be deemed essential, if not mandatory, for clinicians to record patients' self-assessed satisfaction of response to care. 2. That this initially be implemented as a patient outcome index on a visual or verbal analogue scale of 1 to 6. (Visual Analogue Scale - Patient (VAS-P), with 6 being highest level of satisfaction). 3. That this VAS– P constitute 30% of the primary weight of evidence substantiating care. (i.e. 30% of total assessment) 4. That similarly, the clinicians conduct a visual or verbal VAS (1-6) as to how they assess a patient's response to care. (Visual Analogue Scale – Clinician (VAS –C) – with 6 being the expected level of progress. 5. That this VAS - C constitute a further 30% of the primary weight of evidence substantiating care. (i.e. 30% of total assessment) 6. That VAS --P's and VAS-C's - the patient and the practitioner assessments (verbal or written - and recorded), be the primary weighted evidence substantiating care comprising 60% of the total assessment - 2 X 30%. 7. That VAS-C and the VAS-P patient satisfaction index scores be conducted as a Patient Progress Index (PPI), and that they be recorded on a regular basis under the following circumstances.65 (Based on Yeomans44 ) First visit At least weekly if under concentrated care. Every 2-4 weeks -- as visit intervals extend. At return to work If exacerbation occurs On recurrence If under maintenance -- every 2-3 visits. At discharge [Frequent use of these VAS's would be in the interest of patients, clinicians, third party payers and P/I insurers.] Other Questionnaires and Assessments 8. That a more detailed physical, orthopaedic, neurological or other appropriate examination be conducted at least monthly, on a patient under extended care or if a patient is not responding as expected. 9. That regular use of more detailed and condition-specifc questionnaires to be encouraged. These would be in addition to the clinician-assessed and patient self- assessed progress/comfort scales – the VAS-C and VAS-P scales. These should be conducted at times of re-assessment or on a monthly basis if under continued care. 10. That it be noted that other 6-point and 7-point self- assessed patient satisfaction questionnaires are also available. Such forms include the following: 41,61 Willingness to listen to what you have to say. Answers given to your questions Explanation of treatment Skill and ability of the chiropractor Courtesy, politeness and respect shown by the practitioner Care received overall Other Evidence 11. That greater emphasis is granted to empirical and anecdotal evidence in the literature base, at least 20%, noting that this is a one ffth of the evidence together with the traditional levels of evidence in the assessment of clinical outcomes. It is aimed at overcoming the many variables in patients’ response to care. 12. That up to 20% of the evidence base comprise other published literature -- RCTs, meta-analyses, systematic reviews etc. While the offered transcript is intended to open discussion on the topic, at this early stage additional research is also recommended regarding the form that any modifcations may take. Summary of Recommendations 13. Should a practitioner be called on to substantiate his procedure(s) or rationale, and as a means of rating his justifcation, it could comprise the following : Patient Satisfaction VAS/Feedback/Questionnaires 30% Practitioner VAS and appropriate questionnaires. 30% Anecdotal & Empirical Evidence 20% Formal Evidence -- Meta analysis/RCTs /Systematic. Reviews 20% PATIENT-ORIENTED EBP ROME
CJA March 2013
CJA September 2013