Chiropractors' protocols vary greatly from DC to DC depending on training, client base, experience, and perspective. With the likelihood that reimbursement will eventually be tied to more standardized processes for diagnosis and treatment, should doctors of chiropractic follow clinical care pathways or clinical care guidelines?
"Guidelines are typically put together via consensus, using the best information available," says Randy J. Ferrance, DC, MD, who practices with Riverside Medical Group in Tappahannock, Virginia. "Pathways tend to incorporate the interventions that have been found to provide the most benefit at different stages of treatment for various conditions."
According to Dagenais, et al., clinical practice guidelines (CPGs) "endeavor to locate, evaluate, and summarize the scientific evidence on particular topics and are considered important tools in the implementation of evidence-based medicine. However, methods for developing CPGs are not yet standardized, which may impact the perceived validity of their recommendations." (1)
"CPGs are often formatted into an algorithm or flowchart," says John M. Ventura, a DC who practices with Rochester Chiropractic Group in Rochester, New York. Dr. Ventura co-owns Spine Care Partners, LLC, in Falmouth, Massachusetts. "The flowchart defines a process with key decision points. Evidence supports the use of CPGs at both improving quality of care and reducing costs; however, adherence to CPGs has generally been lacking among clinicians. This may be due to disagreement with the findings of the CPG, or the lack of incentives to follow the CPG."
Clinical care pathways, on the other hand, are "complex interventions for the mutual decision-making and organization of care processes for a well-defined group of patients during a well-defined period." Pathways also require:
* Clear description of the objectives and key components of care based on best evidence and patient expectations
* Facilitation of communication among practitioners and with patients
* Inclusion of all key stakeholders with focus on the patient (rather than on a system or a provider type)
* Coordination of care through a sequence of activities with the ability to incorporate multidisciplinary care
* Continued monitoring of the pathway with processes and outcomes, including patient satisfaction
* Appropriate allocation of resources for the pathway to function
* Electronic health records (EHR) to facilitate communication
* A classification system that can be used as a common language
* Focus on the point of entry for the patient into the health care system
"Care pathways are basically the application of the principles of evidence-based practice (EBP)," adds Michael Schneider, DC, PhD, assistant professor at the School of Health and Rehabilitation Sciences, University of Pittsburgh. "These include clinician experience, patient preference, and the best current evidence. All three components of the EBP model are important, although care pathways focus on the best current evidence component."
Meeting Quality Objectives
Guidelines describe best evidence. Pathways provide a framework to bridge the gap between best available evidence and actual clinical practice.
"Available clinical guidelines serve as the clinical basis for the development of clinical care pathways," states Ian C. Paskowski, DC, and medical director for the medical back pain program at Jordan Hospital in Plymouth, Massachusetts. "Over...