Chiropractic: a critical evaluation.

PURPOSE Communication between specialists and primary care clinicians is suboptimal, and access to referrals is often limited, which can lead to lower quality, inefficiency, and errors. An electronic consultation (e-consultation) is an asynchronous, non-face-to-face consultation between a primary care clinician and a specialist using a secure electronic communication platform. The purpose of this study was to conduct a randomized controlled trial of e-consultations to test its efficacy and effectiveness in reducing wait times and improving access to specialty care. METHODS Primary care clinicians were randomized into a control (9 traditional) or an intervention (17 e-consultation) arm for referrals to cardiologists. Primary care clinicians were recruited from 12 practice sites in a community health center in Connecticut with mainly medically underserved patients. Two end points were analyzed with a Cox proportional hazards model where the hazard of either a visit or an e-consultation was linked to study arm, sex, race, and age. RESULTS Thirty-six primary care clinicians participated in the study, referring 590 patients. In total, 69% of e-consultations were resolved without a visit to a cardiologist. After adjusting for covariates, median days to a review for an electronic consultation vs a visit for control patients were 5 and 24, respectively. A review of 6-month follow-up data found fewer cardiac-related emergency department visits for the intervention group. CONCLUSION E-consultation referrals improved access to and timeliness of care for an underserved population, reduced overall specialty utilization, and streamlined specialty referrals without any increase in adverse cardiovascular outcomes. e-consultations are a potential solution for improving access to specialty care.

https://www.annfammed.org/content/annalsfm/14/2/133.full.pdf

Electronic Consultations to Improve the Primary Care-Specialty Care Interface for Cardiology in the Medically Underserved: A Cluster-Randomized Controlled Trial

From its origins as an unconventional therapy in the late 19th century through decades of marginalization during the 20th century, chiropractic has acquired legitimacy and prominence (Meeker and Haldeman 2002). Signs of its success abound. They include a broadening of the laws and regulations affecting its licensure, scope of practice, and reimbursement; greater acceptance by both physicians and health plans; and a sustained demand for its services. Chiropractic's political base is strong, and it enjoys a high degree of patient satisfaction. Moreover, it is at the vanguard of complementary and alternative medicine (CAM), which receives ever greater proportions of health expenditures (Eisenberg et al. 1993, 1998) and which is being increasingly integrated into conventional medicine (Macy Foundation 2001).

Even so, chiropractic's future seems uncertain. Recent expansions of chiropractic colleges are swelling the ranks of practitioners while managed care is restricting payment for what chiropractors do and evidence-based medicine is demanding that what they do must have demonstrable value.

Chiropractic is the best established of the alternative health care professions. Although marginalized for much of the 20th century, it has entered the mainstream of health care, gaining both legitimacy and access to third-party payers. However, the profession's efforts to validate the effectiveness of spinal manipulative therapy, its principal modality, have yielded only modest and often contrary results. At the same time, reimbursement is shrinking, the number of practitioners is growing, and competition from other healing professions is increasing. The profession's efforts to establish a role in primary care are meeting resistance, and its attempts to broaden its activities in alternative medicine have inherent limitations. Although patients express a high level of satisfaction with chiropractic treatment and politicians are sympathetic to it, this may not be enough as our nation grapples to define the health care system that it can afford.

/pdf/chiropractic-in-the-united-states-trends-and-issues-1196mb9cjh.pdf

Chiropractic in the United States: trends and issues.

BACKGROUND Most patients using alternative practitioners also receive care from physicians. It is unclear, however, how well alternative practitioners and physicians communicate and coordinate the care of shared patients. OBJECTIVE To describe the communication and coordination of care for shared patients between chiropractors and family physicians as well as potential barriers to effectively sharing care. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional national random sample survey of 400 chiropractors and 400 family physicians. MAIN OUTCOME MEASURES Reports on shared patients including information on adverse events, treatment, and health status. Attitudes toward perceived expertise as well as perceived liability and economic competition involved in sharing care were also assessed. RESULTS Surveys were completed by 360 (49%) of the 736 eligible practitioners, including 227 chiropractors and 133 family physicians. Although a high degree of interaction occurs between the practitioners, family physicians received information from chiropractors on 26.5% of referred patients while chiropractors received information from family physicians in 25.0% of cases (P = .73). Both groups believed that they did not receive enough information on adverse health outcomes or treatment plans for shared patients. Although neither group was particularly oriented toward wanting to share care, family physicians were much less likely than chiropractors to feel comfortable sharing care (P<.001). CONCLUSIONS These findings indicate that care is fragmented between chiropractors and the general medical sector, with little information communicated between health care providers on issues with critical importance to quality of care. Further study is needed to identify ways to improve communication and coordination of care.

Fragmentation of patient care between chiropractors and family physicians.

Objectives. We compared chiropractic practice volume in areas of high versus areas of low or no shortages of primary care providers. Methods. Using data from a cross-sectional survey of US chiropractors and data from the Bureau of Health Professions’ Area Resource File, we conducted multiple linear and logistic regression modeling of the effects of rural or Health Professional Shortage Area location on chiropractic practice volume and wait times. Results. Chiropractors in rural and high-shortage areas have busier, higher-volume practices than do those in other locales (after control for other chiropractors in the same market service area). Conclusions. Chiropractic providers render a substantial amount of care to underserved and rural populations. Health policy planners should consider the full complement of providers available to improve access to care. (Am J Public Health. 2002;92:2001–2009)

Chiropractic Health Care in Health Professional Shortage Areas in the United States

Abstract Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

C McLachlan

Papers

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Working together in rural South Dakota: integrating medical and chiropractic primary care.