Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults - An Evidence-Based Approach: Introduction
André E. Bussières, DC, Cynthia Peterson, DC, RN, MMedEd, John A.M.
Purpose: Imaging technology can improve patient outcomes by allowing greater precision in diagnosing and treating patients. However, there is evidence that overuse, underuse and misuse of imaging services occur. The purpose of this project was to develop evidence-based diagnostic imaging practice guidelines for musculoskeletal complaints for use by doctors of chiropractic and other primary health care professionals.
Methods: An electronic search of the English and French language literature (phase 1) was conducted on several databases. Cross references and references provided by clinicians were also used. Independent assessment of the quality of the citations used to support recommendations in the guidelines was performed using the QUADAS, the AGREE and the SPREAD evaluation tools.
A first draft of a diagnostic imaging practice guideline was produced, using the European Commission's Referral Guidelines for Imaging document as a template. Results were sent to 12 chiropractic specialists for a first external review. A modified Delphi process, including 149 international experts, was used to generate consensus on recommendations for diagnostic imaging studies. The reliability of proposed recommendations was further tested on field chiropractors and on a group of specialists both in chiropractic and in medicine in both Canada and the United States. All recommendations were graded according to the strength of the evidence.
Results: The research procedure resulted in the recommendations for diagnostic imaging guidelines of adult extremity and spine disorders supported by more than 685 primary and secondary citations. High levels of agreement among Delphi panelists were reached for all proposed recommendations. Comments received by specialists were generally very favorable and reflected high levels of agreement with the proposed recommendations, perceived ease of use of guidelines and implementation feasibility.
Conclusions: These evidence-based diagnostic imaging practice guidelines are intended to assist chiropractors and other primary care providers in decision making on the appropriate use of diagnostic imaging for specific clinical presentations. In all cases, the guidelines are intended to be used in conjunction with sound clinical judgment and experience. Application of these guidelines should help avoid unnecessary radiographs, increase examination precision and decrease health care costs without compromising the quality of care. All guidelines are documents to be refined and modified regularly with new information and experience.
Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults - An Evidence-Based Approach
André E. Bussières, DC, John A.M. Taylor, DC, Cynthia Peterson, DC, RN, MMedED
Purpose: The aim of this study was to develop evidence-based diagnostic imaging practice guidelines to assist chiropractors and other primary care providers in decision making for the appropriate use of diagnostic imaging of lower extremity disorders.
Methods: A comprehensive search of the English and French language literature was conducted using a combination of subject headings and keywords. The quality of the citations was assessed using the Quality of Diagnostic Accuracy Studies (QUADAS), the Appraisal of Guidelines Research and Evaluation (AGREE), and the Stroke Prevention and Educational Awareness Diffusion (SPREAD) evaluation tools. The Referral Guidelines for Imaging (Radiation Protection 118) coordinated by the European Commission served as the initial template. The first draft was sent for external review. A Delphi panel composed of international experts on the topic of musculoskeletal disorders in chiropractic radiology, clinical sciences and research were invited to review and propose recommendations on the indications for diagnostic imaging. The guidelines were pilot tested and peer reviewed by field chiropractors, and by chiropractic and medical specialists. Recommendations were graded according to the strength of the evidence.
Results: Recommendations for diagnostic imaging guidelines of adult lower extremity disorders are provided, supported by more than 174 primary and secondary citations. Except for trauma, the overall quality of available literature is low. On average, 57 Delphi panelists completed 1 of 2 rounds, reaching more than 83% agreement on all 56 recommendations. Peer review by specialists reflected high levels of agreement, perceived ease of use of guidelines and implementation feasibility.
Conclusions: The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be updated regularly. Dissemination and implementation strategies are discussed. Future research is needed to validate their content.
Chiropractors as Safety Net Providers: First Report of Findings and Methods from a US Survey of Chiropractors
Monica Smith, DC, PhD, Lynne A. Carber, MPM
Objective: This study evaluates the actual or potential contribution of the chiropractic profession in meeting U.S. health care workforce needs.
Methods: The authors performed a descriptive cross-sectional mail survey of U.S. chiropractors in 2002 to 2003.
Results: The amount of charity care provided by chiropractors closely approximates that of medical physicians; on a weekly basis, approximately 2 weekly hours of chiropractic care are provided for free and 4 weekly hours are provided at a reduced fee.
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