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Practice Patterns: DC Spine Radiograph Utilization in a Provider Network
André Bussières, DC, PhD, et al.
Objective: Nonspecific back pain is associated with high use of diagnostic imaging in primary care, yet current evidence suggests that routine imaging of the spine is unnecessary. The objective of this study is to describe current practice patterns in spine radiograph utilization among doctors of chiropractic enrolled in an American provider network.
Methods: A cross-sectional analysis of administrative claims data from one of the largest providers of complementary health care networks for health plans in the United States was performed. Survey data containing provider demographics were linked with routinely collected data on spine radiograph utilization and patient characteristics aggregated at the provider level. We calculated rates and variations of spine radiographs over 12 months. Negative binomial regression was performed to identify significant predictors of high radiograph utilization and to estimate the associated incidence risk ratio.
Results: Complete data for 6,946 doctors of chiropractic and 249,193 adult patients were available for analyses. In 2010, claims were paid for a total of 91,542 new patient examinations and 23,369 spine radiographs (including 17,511 ordered within five days of initial patient examination). The rate of spine radiographs within five days of an initial patient visit was 204 per 1,000 new patient examinations. Significant predictors of higher radiograph utilization rates included the following: practicing in the Midwest or South U.S. census regions, practicing in an urban or suburban setting, chiropractic school attended, and being a male provider in full-time practice with more than 20 years of experience.
Conclusion: Chiropractic school attended and practice location were the most influential predictors of spine radiograph utilization among network chiropractors. This information may help to inform the development and evaluation of a tailored intervention to address overuse of radiograph utilization.
Manipulative & Multimodal Therapy for Upper Extremity and TMJ Disorders
James Brantingham, DC, PhD, et al.
Objective: The purpose of this study was to complete a systematic review of manual and manipulative therapy (MMT) for common upper extremity pain and disorders including the temporomandibular joint (TMJ).
Methods: A literature search was conducted using the Cumulative Index of Nursing Allied Health Literature, PubMed, Manual, Alternative, and Natural Therapy Index System (MANTIS), Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, Google Scholar, and hand search inclusive of literature from January 1983 to March 5, 2012. Search limits included the English language and human studies along with MeSH terms such as manipulation, chiropractic, osteopathic, orthopedic, and physical therapies. Inclusion criteria required an extremity peripheral diagnosis (for upper extremity problems including the elbow, wrist, hand, finger and the (upper quadrant) temporomandibular joint) and MMT with or without multimodal therapy. Studies were assessed using the PEDro scale in conjunction with modified guidelines and systems. After synthesis and considered judgment scoring was complete, evidence grades of "A, B, C and I" were applied.
Results: Out of 764 citations reviewed, 129 studies were deemed possibly to probably useful and/or relevant to develop expert consensus. Out of 81 randomized controlled or clinical trials, 35 were included. Five controlled or clinical trials were located and four were included. Fifty case series, reports and/or single-group pre-test post-test prospective case series were located with 32 included. There is Fair (B) level of evidence for MMT to specific joints and the full kinetic chain combined generally with exercise and/or multimodal therapy for lateral epicondylopathy, carpal tunnel syndrome, and temporomandibular joint disorders, in the short term.
Conclusion: The information from this study will help guide practitioners in the use of MMT, soft-tissue technique, exercise, and/or multimodal therapy for the treatment of a variety of upper extremity complaints in the context of the hierarchy of published and available evidence.
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