Ian D. Coulter

Patients using chiropractors in North America: who are they, and why are they in chiropractic care?

SUMMARY OF BACKGROUND DATA AND OBJECTIVES Alternative health care was used by an estimated 42% of the U.S. population in 1997, and chiropractors accounted for 31% of the total estimated number of visits. Despite this high level of use, there is little empirical information about who uses chiropractic care or why. METHODS The authors surveyed randomly sampled chiropractors (n = 131) at six study sites and systematically sampled chiropractic patients seeking care from participating chiropractors on 1 day (n = 1275). Surveys collected data about the patients reason for seeking chiropractic care, health status, health attitude and beliefs, and satisfaction. In addition to descriptive statistics, the authors compared data between patients and chiropractors, and between patients and previously published data on health status from other populations, corrected for the clustering of patients within chiropractors. RESULTS More than 70% of patients specified back and neck problems as their health problem for which they sought chiropractic care. Chiropractic patients had significantly worse health status on all SF-36 scales than an age- and gender-matched general population sample. Compared with medical back pain patients, chiropractic back pain patients had significantly worse mental health (6-8 point decrement). Roland-Morris scores for chiropractic back pain patients were similar to values reported for medical back pain patients. The health attitudes and beliefs of chiropractors and their patients were similar. Patients were very satisfied with their care. CONCLUSION These data support the theory that patients seek chiropractic care almost exclusively for musculoskeletal symptoms and that chiropractors and their patients share a similar belief system.

Use of chiropractic services from 1985 through 1991 in the United States and Canada

OBJECTIVES The purpose of this paper is to describe the demographic and clinical characteristics of chiropractic patients and to document chiropractic visit rates in 6 sites in the United States and Canada. METHODS Random samples of chiropractors from 5 US sites and 1 Canadian site were selected. A record abstraction system was developed to obtain demographic and clinical data from office charts. RESULTS Of the 185 eligible chiropractors sampled, 131 (71%) participated. Sixty-eight percent of the selected charts showed that care was sought for low back pain, while 32% recorded care for other reasons. Spinal manipulative therapy was recorded in 83% of all charts. There was a greater than 2-fold difference in the median number of visits related to low back pain per episode of care across sites. The chiropractic visit rates in the US sites and Ontario are estimated to be 101.2 and 140.9 visits per 100 person-years, respectively. CONCLUSIONS The chiropractic use rate in these sites is twice that of estimates made 15 years ago. The great majority of patients receive care for musculoskeletal conditions of the back and neck. The number of visits per episode varies appreciably by site.

Effect of supplemental vitamin E for the prevention and treatment of cardiovascular disease

AbstractOBJECTIVE: To evaluate and synthesize the evidence on the effect of supplements of vitamin E on the prevention and treatment of cardiovascular disease. DESIGN: Systematic review of placebo-controlled randomized controlled trials; meta-analysis where justified. MEASUREMENTS AND MAIN RESULTS: Eighty-four eligible trials were identified. For the outcomes of all-cause mortality, cardiovascular mortality, fatal or nonfatal myocardial infarction, and blood lipids, neither supplements of vitamin E alone nor vitamin E given with other agents yielded a statistically significant beneficial or adverse pooled relative risk (for example, pooled relative risk of vitamin E alone=0.96 [95% confidence interval (CI), 0.84 to 1.10]; 0.97 [95% CI, 0.80 to 1.90]; and 0.72 [95% CI, 0.51 to 1.02] for all-cause mortality, cardiovascular mortality, and nonfatal myocardial infarction, respectively. CONCLUSIONS: There is good evidence that vitamin E supplementation does not beneficially or adversely affect cardiovascular outcomes.

Antioxidants Vitamin C and Vitamin E for the Prevention and Treatment of Cancer

OBJECTIVE: To evaluate the evidence of the supplements vitamin C and vitamin E for treatment and prevention of cancer.METHODS: Systematic review of trials and meta-analysis.DATA SOURCES AND MAIN RESULTS: Thirty-eight studies showed scant evidence that vitamin C or vitamin E beneficially affects survival. In the ATBC Cancer Prevention Study Group, no statistically significant effect of treatment was seen for any cancer individually, and our pooled relative risk (regardless of tumor type) for α-tocopherol alone was 0.91 (95% confidence interval [CI]: 0.74, 1.12). All cause mortality was not significant. In the Linxian General Population Trial, the relative risks for cancer death for vitamin C (combined with molybdenum) was 1.06 (95% CI: 0.92, 1.21) and for vitamin E (combined with β-carotene and selenium) was 0.87 (95% CI: 0.76, 1.00). We identified only 3 studies that reported statistically significant beneficial results: vitamin C (in combination with BCG) was found to be beneficial in a single trial of bladder cancer and vitamin E (in combination with ω-3 fatty acid) increased survival in patients with advanced cancer. In the ATBC trial, in analyses of 6 individual cancers, the prevention of prostate cancer in subjects treated with α-tocopherol was statistically significant (RR=0.64, 95% CI: 0.44, 0.94).CONCLUSIONS: The systematic review of the literature does not support the hypothesis that the use of supplements of vitamin C or vitamin E in the doses tested helps prevent and/or treat cancer in the populations tested. There were isolated findings of benefit, which require confirmation.

The politics of interprofessional working and the struggle for professional autonomy in nursing

This study of interprofessional work relations in a Canadian mental health team examines how nursing deployed different forms of power in order to alter the mental health division of labour, to gain administrative, organizational and content control over its own work, expand its jurisdictional boundaries by expropriating the work of other professionals, and exclude others from encroaching on its old and newly acquired jurisdictions. This is set against the context of nursings long-standing professional project to consolidate and expand its professional jurisdiction. Using an ethnographic study of a single interprofessional mental health team in a psychiatric hospital in Canada, the paper attempts to understand the politics and paradoxes involved in realizing nursings professional project and how the politics of professional autonomy and professional dominance are actually conducted through micro-political struggles. The data demonstrates the effects of the political struggles at the organizational and work process levels, particularly in the forms of collaboration that result. Nurses gained substantial autonomy from medical domination and secured practical dominion over the work of non-medical professionals. New forms of interprofessional collaboration were accomplished through both simultaneous and sequential micro-political struggles with psychiatrists and non-medical professionals, and the formation of political alliances and informal agreements. Nursing solidarity at the elite level and substantial effort by the elite nurses and their committed colleagues to mobilize their less enthused members were fundamental to their success. The nurses deployed political (power) strategies and tactics to organize and reorganize themselves and other professionals on multiple levels (politically, organizationally, ideologically, socially and culturally). This study reveals the complexity and robustness of micro-political dynamics in the constitution of professional and collaborative interprofessional work relations.

Associations of self-reported oral health with physical and mental health in a nationally representative sample of HIV persons receiving medical care

Background: The impact of oral health on HIV patients has not been sufficiently documented. Objective: To estimate the associations between measures of oral and generic health-related quality of life in persons receiving medical care for HIV. Design: This is a longitudinal study of interview data collected in a probability sample of adults with HIV receiving health care in the US. The data were collected at three points in time. Patients: Two thousand eight hundred and sixty-four HIV-infected adults using medical care. Measurements: Physical and mental health were assessed using 28 items and oral health was assessed using seven items on oral-related pain and discomfort, worry, appearance, and function. Clinical measures included CD4 count, oral symptoms, physical symptoms, and stage of HIV. Physical functioning and emotional well-being were measured on a 0–100 scale with higher scores indicating better health. Oral health was measured using seven items with a five point scale. Results: In multivariate analyses, oral symptoms had the strongest association with oral health-related quality of life. Each additional oral symptom was associated with an average decrease in oral health (0–100 possible range) of 3.97 points (p = 0.000). In addition, oral health was significantly associated with both physical and mental health. A one-point increase in oral health was associated with a 0.05 (p = 0.000) increase in mental health and 0.02 increase in physical health (p = 0.031). Conclusions: Oral health is strongly associated with physical and mental health but provides noteworthy unique information in persons with HIV infection. Thus, physical and mental health measures of HIV patients should incorporate indicators of oral functioning and well-being.

Congruence between Decisions To Initiate Chiropractic Spinal Manipulation for Low Back Pain and Appropriateness Criteria in North America

The direct and indirect costs of low back pain, one of the most common symptoms in adults, are estimated at

Use of Dental Care by HIV-infected Medical Patients:

60 billion annually in the United States [1, 2]. Practice guidelines recently developed in the United States recommend spinal manipulation for patients with uncomplicated acute low back pain [3]. If followed, these guidelines can be expected to significantly increase the number of patients referred by medical physicians to chiropractors, who provide most manipulative therapy delivered in the United States [4]. Concerns have been raised about the quality of chiropractic care [5], but systematic data are lacking. How are patients and medical physicians to have confidence in chiropractors in the absence of data on the quality of chiropractic care? To assess the appropriateness of the use of spinal manipulation for patients with low back pain, we used a method for assessing appropriateness that has been used to study various medical procedures in North America and Europe [6-16]. In these studies, predetermined criteria for the appropriateness (as defined by expected risk versus benefit) of the study procedure (for example, hysterectomy or coronary angioplasty) are used to retrospectively assess the care delivered. We report the results of our evaluation of the use of chiropractic spinal manipulation at five geographic sites in the United States and one site in Canada. Methods Development of Appropriateness Criteria and Record Abstraction System For our study, spinal manipulation was defined as a manual procedure that involves specific short-lever dynamic thrusts (or spinal adjustments) or nonspecific long-lever manipulation. Nonthrust procedures, such as flexion-distraction and mobilization, were not considered part of manipulative therapy. The development of appropriateness criteria for spinal manipulation for low back pain has been described in detail elsewhere [17]. In brief, we first performed a systematic review of the literature. A 9-member panel of back experts was convened, consisting of 3 chiropractors, 2 orthopedic spine surgeons, 1 osteopathic spine surgeon, 1 neurologist, 1 internist, and 1 family practitioner. Six panel members were in academic practice, 3 were in private practice, and 4 performed spinal manipulation as part of their practice. The panel members represented all major geographic regions of the United States. The panel used a scale of expected risk and benefit (ranging from 1 to 9) to rate the appropriateness of a comprehensive array of indications, or clinical scenarios, in patients who might present to a chiropractors office. We defined appropriate as an indication for which the expected health benefits exceeded the expected health risks by a sufficiently wide margin that spinal manipulation was worth doing. We used a formal group-judgment process, which incorporated two rounds of ratings, a group discussion, and feedback of group ratings between rounds. Experts were to use their best clinical judgment in addition to the evidence from the systematic review we presented them. Panel disagreement on an indication occurred when two or more panelists rated the indication as appropriate and two or more panelists rated it as inappropriate. This definition of disagreement is arbitrary but is based on a face-value assessment of what constitutes disagreement among experts. The final result of the process is a rating of appropriate, inappropriate, or uncertain (depending on net expected health benefits) for each indication. Indications with a median panel rating of 7 to 9, without disagreement, were classified as appropriate. Indications with a median panel rating of 1 to 3, without disagreement, were classified as inappropriate. Indications with a median panel rating of 4 to 6 and all indications with disagreement were classified as uncertain. The panel of experts met in April 1990, before the beginning of the Agency for Health Care Policy and Research (AHCPR) Low Back Problems Clinical Practice Guideline effort in 1992. Four members of our panel later participated in the AHCPR process. The AHCPR guidelines cover patients with acute and subacute low back pain only and are similar to the appropriateness criteria created for our project. We developed a chiropractic record abstraction system that allows collection of data from a chiropractic office record about the patient, history of the back problem, findings on physical examination and diagnostic studies, and treatment rendered. The system is designed to collect sufficient information to allow the classification of delivered care as appropriate, inappropriate, or uncertain, according to the panels ratings. The abstraction instrument collects data on more than 70 clinical variables that may be present in the record. The instrument uses skip-pattern logic so that only relevant clinical variables are sought. For example, if the patients onset of back pain was associated with trauma, additional information about the type of trauma was sought. We pilot-tested our system on numerous chiropractic records obtained from colleagues around the United States and pilot-tested our methods for data collection and analysis on a small sample of chiropractors in southern California [18]. Identification of Sample We chose San Diego, California; Portland, Oregon; Vancouver, Washington; Minneapolis-St. Paul, Minnesota; Miami, Florida; and Toronto, Ontario, Canada, as sites for our study because of their geographic diversity and because they reflect a varying concentration of practicing chiropractors and differ in the chiropractic scope of practice allowed. We also included the rural areas surrounding the Portland, Minneapolis-St. Paul, and Toronto areas. We have previously shown that the base populations at the U.S. sites are similar to the general U.S. population in terms of the variables known to affect chiropractic use [19]. The geographic sampling area around Toronto encompasses 75% of the population of Ontario. At each site, we constructed our sampling frame from a combination of the telephone book yellow pages, the state or provincial board licensing list, and the mailing list of the local chiropractic college, if any. The final list was the summation (excluding duplicates) of the individual lists. We drew a random sample from this list and sent the sampled chiropractors a letter that explained the study and invited them to participate. Each letter was accompanied by cover letters from the national chiropractic association and the local chiropractic association or chiropractic college, indicating support for the study. We followed this mailing with a telephone call to determine eligibility and request participation. To be eligible, a chiropractor must have been practicing in the geographic area since 1990. Eligible chiropractors who declined our initial invitation were contacted by one or more influential state, provincial, or local chiropractors and were again urged to participate. Participating chiropractors and their staff were given, in total, a

Measures in Chiropractic Research: Choosing Patient-Based Outcome Assessments

130 (in both U.S. and Canadian dollars) honorarium for participation. Data Collection Trained chiropractic data collectors (senior chiropractic students or recent graduates) visited participating chiropractors during regular working hours. These data collectors underwent 2 days of training conducted by two of the authors. The data collectors were unaware of the details of the appropriateness criteria. The reliability and accuracy of the data collection were assessed in several ways. First, after classroom training, the data collectors abstracted a common set of test records obtained from various different practices and geographic areas. These were returned to one of the authors for correction, and any errors in abstraction were reviewed with the data collectors. Second, the same author accompanied the data collectors on a practice session with a local volunteer chiropractor, who agreed to let the collectors practice sampling and data abstraction in his or her office during working hours. Again, errors in either process were reviewed with the data collectors. Finally, the same author accompanied the data collectors on one of the early office visits to a chiropractor included in the sample at each geographic site. Here, the author reviewed all abstracted records; if more than one data collector was working, both data collectors abstracted a few records. Any discrepancies were reviewed with this author. In all, about 4% of records included in the sample were assessed for reliability and validity. We did not calculate formal reliability statistics. To select records, all office records were measured in inches as if they were books on a shelf. A random-number table was used to select a random number of inches measured from the start. To avoid fat-chart bias, we selected the record immediately to the right of the record located at the specified number of inches. This chart was then pulled and examined to see whether it described a first visit for low back pain that occurred between 1 January 1985 and 31 December 1991. If so, data were abstracted by using the research instrument. This process was repeated until 10 records for low back pain were abstracted from each participating practitioners office. If more than one chiropractor practiced in the same office, we abstracted data from the records of only one practitioner. Consultation with back pain experts suggested that 10 records per office is a sufficient number that is likely to fairly represent the diversity of that offices practice. Data Analysis We compiled descriptive data on the patients and the care that they received. The care of patients was classified into appropriateness categories by using the criteria determined by the expert panel. This was done with a computer program that uses unique combinations of variables that define individual indications. The reliability of this program was verified by drawing a random sample of records and comparing

Introduction - taking stock of integrative medicine: broadening biomedicine or cooption of complementary and alternative medicine?

Although increasing attention has been paid to the use of dental care by HIV patients, the existing studies do not use probability samples, and no accurate population estimates of use can be made from this work. The intent of the present study was to establish accurate population estimates of the use of dental services by patients under medical care. The study, part of the HIV Cost and Services Utilization Study (HCSUS), created a representative national probability sample, the first of its kind, of HIV-infected adults in medical care. Both bivariate and logistic regressions were conducted, with use of dental care in the preceding 6 months as the dependent variable and demographic, social, behavioral, and disease characteristics as independent variables. Forty-two percent of the sample had seen a dental health professional in the preceding 6 months. The bivariate logits for use of dental care show that African-Americans, those whose exposure to HIV was caused by hemophilia or blood transfusions, persons with less education, and those who were employed were less likely to use dental care (p < 0.05). Sixty-five percent of those with a usual source of care had used dental care in the preceding 6 months. Use was greatest among those obtaining dental care from an AIDS clinic (74%) and lowest among those without a usual source of dental care (12%). We conclude that, in spite of the high rate of oral disease in persons with HIV, many do not use dental care regularly, and that use varies by patient characteristics and availability of a regular source of dental care.