Barry R. Greene

Referral patterns and attitudes of Primary Care Physicians towards chiropractors

BackgroundDespite the increasing usage and popularity of chiropractic care, there has been limited research conducted to examine the professional relationships between conventional trained primary care physicians (PCPs) and chiropractors (DCs). The objectives of our study were to contrast the intra-professional referral patterns among PCPs with referral patterns to DCs, and to identify predictors of PCP referral to DCs.MethodsWe mailed a survey instrument to all practicing PCPs in the state of Iowa. Descriptive statistics were used to summarize their responses. Multivariable logistic regression analyses were conducted to identify demographic factors associated with inter-professional referral behaviors.ResultsA total of 517 PCPs (33%) participated in the study. PCPs enjoyed strong intra-professional referral relationships with other PCPs. Although patients exhibited a great deal of interest in chiropractic care, PCPs were unlikely themselves to make formal referral relationships with DCs. PCPs in a private practice arrangement were more likely to exhibit positive referral attitudes towards DCs (p = 0.01).ConclusionPCPs enjoy very good professional relationships with other PCPs. However, the lack of direct formalized referral relationships between PCPs and chiropractors has implications for efficiency, continuity, quality, and patient safety in the health care delivery system. Future research must focus on identifying facilitators and barriers for developing positive relationships between PCPs and chiropractors.

Geocoding Health Data : The Use of Geographic Codes in Cancer Prevention and Control, Research and Practice

Introduction Geocoding Methods, Materials, and First Steps toward a Geocoding Error Budget M.P. Armstrong and C. Tiwari Using ZIP codes as Geocodes in Cancer Research K.M.M. Beyer, A.F. Schultz, and Z. Chen Producing Spatially Continuous Prostate Cancer Maps with Different Geocodes and Spatial Filter Methods G. Rushton, Q. Cai, and Z. Chen The Science and Art of Geocoding: Tips for Improving Match Rates and Handling Unmatched Cases in Analysis F. Boscoe Geocoding Practices in Cancer Registries T. Abe and D. Stinchcomb Alternative Techniques for Masking Geographic Detail to Protect Privacy D.L. Zimmerman, M.P. Armstrong, and Gerard Rushton Preserving Privacy: Deidentifying Data by Applying a Random Perturbation Spatial Mask Z. Chen, G. Rushton, and G. Smith Spatial Statistical Analysis of Point- and Area-Reference Public Health Data L.A. Waller Statistical methods for Incompletely and Incorrectly Geocoded Cancer Data D. L. Zimmerman Using Geocodes to estimate Distances and geographic Accessibility for Cancer Prevention and Control M. Armstrong, B. Greene, and G. Rushton Cancer Registry Data and Geocoding: Privacy, Confidentiality, and Security Issues J. Gittler Conclusions Appendix: Cancer Reporting and Registry Statutes and Regulations J. Gittler

The use of chiropractors by older adults in the United States

BackgroundIn a nationally representative sample of United States Medicare beneficiaries, we examined the extent of chiropractic use, factors associated with seeing a chiropractor, and predictors of the volume of chiropractic use among those having seen one.MethodsWe performed secondary analyses of baseline interview data on 4,310 self-respondents who were 70 years old or older when they first participated in the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD). The interview data were then linked to their Medicare claims. Multiple logistic and negative binomial regressions were used.ResultsThe average annual rate of chiropractic use was 4.6%. During the four-year period (two years before and two years after each respondents baseline interview), 10.3% had one or more visits to a chiropractor. African Americans and Hispanics, as well as those with multiple depressive symptoms and those who lived in counties with lower than average supplies of chiropractors were much less likely to use them. The use of chiropractors was much more likely among those who drank alcohol, had arthritis, reported pain, and were able to drive. Chiropractic services did not substitute for physician visits. Among those who had seen a chiropractor, the volume of chiropractic visits was lower for those who lived alone, had lower incomes, and poorer cognitive abilities, while it was greater for the overweight and those with lower body limitations.ConclusionChiropractic use among older adults is less prevalent than has been consistently reported for the United States as a whole, and is most common among Whites, those reporting pain, and those with geographic, financial, and transportation access.

Facilitators and barriers to improving interprofessional referral relationships between primary care physicians and chiropractors.

ObjectiveFindings from recent studies suggest that there are poor interprofessional referral relationships between primary care physicians (MDs) and chiropractors (DCs) and this can lead to fragmentation of care. The objective of this study is to identify potential facilitators and barriers to developing positive interprofessional referrals relationships between MDs and DCs. MethodsWe conducted 2 rounds of focus group interviews on a convenience sample of MDs and DCs. The focus groups were audiotaped, and transcripts were prepared for each focus group interaction. These data were analyzed through content analysis by 2 independent evaluators to determine the key themes and concepts provided by the focus groups. ResultsBoth MDs and DCs suggested that good communication, openness to discussion by providers, and patient interest are key factors for developing positive interprofessional referral relationships and implementing interprofessional practice–based research networks. Barriers to interprofessional relationships include lack of good communication between the 2 provider types, bias toward alternative medicine, lack of knowledge or understanding of chiropractic care, geographic constraints, and economic considerations. ConclusionsThis study identified several facilitators and barriers for developing positive referral relationships between primary care physicians and chiropractors. Future studies must focus on demonstrating the role of these factors on developing positive interprofessional relationships.

The CAM movement and the integration of quality health care: the case of chiropractic.

High and increasing consumer demand for complementary and alternative medicine (CAM) services necessitates a concerted focus to determine the effectiveness of such practices and to ensure that future possible integration of CAM with conventional medicine is founded on sound evidence-based principles of quality health care delivery. The example of chiropractic provides useful insights to guide further research and integration of evidence-based CAM into mainstream health care in the United States. A critical point of departure for this area of inquiry is identifying and addressing barriers to conducting scientifically sound and meaningful cross-disciplinary, practice-based research.

Intra-professional and inter-professional referral patterns of chiropractors

BackgroundWith the increasing popularity of chiropractic care in the United States, inter-professional relationships between conventional trained physicians (MDs and DOs) and chiropractors (DCs) will have an expanding impact on patient care. The objectives of this study are to describe the intra-professional referral patterns amongst DCs, describe the inter-professional referral patterns between DCs and conventional trained medical primary care physicians (MDPCPs), and to identify provider characteristics that may affect these referral behaviors.MethodsA survey instrument to assess the attitudes and patterns of referral and consultation between MD primary care physicians (MDPCPs) and DCs was developed and sent to all DCs in the state of Iowa. Multivariable logistic regression models were built to assess the impact of provider characteristics on intra-professional and inter-professional referral patterns.ResultsOf all DCs contacted, 452 (40.7%) participated in the study. Close to 8% of DCs reported that they never send a case report when referring a patient to another DC, while 13% never send a case report to a MDPCP. About 10% of DCs never send follow-up clinical information to referring doctors. DCs that perform differential diagnosis were significantly more likely to have engaged in inter-professional referral than DCs who did not perform differential diagnosis.ConclusionThe tendency toward informality, in both referral practices and sharing of clinical documentation for referred patients between MDPCPs and DCs, is an explicit marker of concerns that need to be addressed in order to improve coordination and continuity of care for patients shared between these provider types.

A conceptual model for transformational clinical leadership within primary care group practice.

The patient-centered medical home provides an operational framework for implementing the Institute of Medicines 6 quality aims within primary care. Successful implementation of the patient-centered medical home necessitates transformation at the group practice level. This article describes a conceptual model for transformational clinical leadership, based on the paradigm of the care pilot and the tools and training for effective implementation of this role within primary care group practice. In addition, we propose an innovative academically based system to train and support the care pilot and practice transformation in primary care and rural practice settings.

Reinventing CME: the role of the care pilot in the medical group practice.

This article recommends that the content of traditional continuing medical education be changed significantly to include the concepts and skills necessary to enable practice teams to feedback information into the practice, which would result in the creation of a learning organization with the ability to plan for and anticipate future activities. The primary role in this new organization would be called a care pilot who would have as a primary responsibility, the successful navigation and improvement of the 6 aims as spelled out in the Institute of Medicine report Crossing the Quality Chasm.

Tracking the Six Aims of the IOM Report: Crossing the Quality Chasm—Healthcare in the 21st Century

This special issue is devoted to the examination of both the conceptual and the ambulatory care research related to the 6 aims of the Institute of Medicine Crossing the Quality Chasm: Health Care in the 21st Century (IOM Report). An important part of the IOM Report was the development of a roadmap called the Six Aims. These Six Aims were patient-centered care, patient safety, timeliness or responsive care, efficient care, effective care, and equitable care. In this special issue, we will look at initiatives targeting these Six Aims through different administrative, clinical service areas as well as a focus on patient-centered care. The first article by Greene and Filerman is titled “Reinventing CME: The Role of the Care Pilot in the Medical Group Practice.”This article presents a systems-based practice model for redesigning and increasing the organizational capacity of small medical groups. Group practices, large or small, function in complex environments. The basic contention of the article is that CME should be developed along parallel lines to go well beyond the traditional focus on clinical services improvement, to the reinvention of CME content focused on educating clinical care pilots to navigate group practices toward the Six Aims of the IOM Report. Such a set of activities would position group practices as learning organizations capable of providing more efficient and effective healthcare. In the second article, Gamm and colleagues look at connecting policy and system change leadership with a goal of sustainable organizational change. In “Organizational Technologies for Transforming Care: Measures and Strategies for Pursuit of IOM Quality Aims,” these authors point out that organizational analysis has been understudied when compared to the analysis of direct clinical services provided for the patient. Their approach is to study 4 types of organizational technologies to guide and assess progress on the Six Aims called for in the IOM Report. Dr Donaldson’s article, “Use of Patient-Reported Outcomes in Clinical Oncology Practice: A Nonvisit Approach to Patient Care Based on the IOM Report,”provides a new role for the patient in the care process. Dr Donaldson examines both the continuity of care and the concept of patient-centered outcomes by describing how medical practices might create continuous healing relationships using methods that are independent of patient visits to monitor and address problems that may occur during cancer care. If done correctly, a new kind of patient report would result which would reduce the burden for patients, clinicians, and administrative staff. Dr Neale Chumbler and colleagues at the University of Florida (“Healthcare Utilization Among Veterans Undergoing Chemotherapy: The Impact of a Cancer Care Coordination/HomeTelehealth Program”) look at the coordination of the care process of veterans. The study compared the use of VA inpatient with space outpatient services of cancer patients enrolled in the telehealth program. They studied both preventable service utilization and cancer-related service utilization. Dr John Croghan and colleagues at Northwestern (“Comprehensive Approach to Automated Assistive Telemanagement for Seniors in Their Home or Residence—Pilot Program Results”)conducted a pilot study to examine how remote senior monitoring of important vitals information and virtual nurse visits conducted remotely via videophone would affect seniors’ adherence to care plan, and enable them to remain in their homes longer. The focus was on coordination and share quality through the improvement of data made available to the physician by way of alert management and monthly reports. In the article titled “Innovative Approach to the Aims for Improvement: Emergency Department Patient Throughput in an Impacted Urban Setting,” Rubino and colleagues provide a case analysis, and a systems approach, using the 6 aims of the IOM

Guest Editorʼs Preface

A fundamental challenge for the US health system remains quality improvement of chronic disease diagnosis and treatment. This series begins with the work of Schrader and colleagues at the Carle Clinic of Illinois, which is one of 16 national sites selected by the Centers for Medicare and Medicaid Services to test programs aimed at chronically ill Medicare beneficiaries. It is an initiative to focus on best practices, and the focal organization of this article is Carle’s Medicare Coordinated Care Demonstration (MCCD). The study uses a prospective, longitudinal randomized treatment-control group design approach to assess the effectiveness of Carle’s MCCD. Individuals are enrolled in the demonstration if they have a diagnosis of coronary artery disease, congestive heart failure, atrial fibrillation, diabetes, chronic obstructive pulmonary disease, or asthma; live in the 13 county service areas; and have Medicare Parts A & B. The Carle MCCD is reimbursed a per member per month fee for every treatment group patient enrolled. These payments fund the clinical operation of the demonstration, including staff salaries/benefits, physician reimbursement for patient and team conferences, expanded patient services, and education of providers and patients. Through August 2004, Carle has enrolled 2702 patients. The interventional components of the Carle MCCD parallel those of the Chronic Care Model. The components include (1) the healthcare organization; (2) community resources and policies; (3) delivery system design; (4) self-management support; (5) decision support; and (6) clinical information systems. The first 2 components emphasize an organization’s commitment to new ways of care delivery and integration with the community. The other components provide the foundation for effective chronic care delivery. Four of these articles examine developments in technologies in the ambulatory care programs. Gamm, Nelson Bolin, and Kash, researchers from Texas A&M University, consider selected structural and technological attributes of chronic disease management programs in their article. They consider 4 systems in 4 different states, which are built on multispecialty group practices and include a major clinic, multiple primary care sites, hospitals in 3 of the 4 systems, and 1 or more health plans. The disease management programs function under different internal auspices and support across the 4 systems, employ a variety of technologies, pursue management of a number of chronic conditions, and are viewed positively on a number of criteria by participants in all 4 systems. Through interviews and survey data collection, the researchers are able to study the variety of social, administrative, and clinical organizational technologies and the implications for disease management. Prince’s group at Northwestern University describe the integration of traditional ambulatory care services with telehealth technology services, which now allows delivery of “virtual assisted living” services at home that can more efficiently meet Senior health requirements, and can simplify