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Thursday, August 17, 2017

Choosing Wisely X-ray Recommendations Reflect Evolving Evidence, Accepted Standards

By Christine Goertz, DC, PhD 

 

The goal of the Choosing Wisely® campaign is to promote conversations between doctors and their patients about utilizing the most appropriate tests and treatments. The campaign is an initiative of the American Board of Internal Medicine Foundation and Consumer Reports. As part of the campaign, an organization creates an evidence-based list of 5 tests and/or procedures that may be common…but often should not be part of routine care. The program encourages an evidence-based approach to patient care and shared decision-making between doctors and patients. The American Chiropractic Association (ACA) joined the Choosing Wisely® campaign recently because these are principles that ACA strongly supports.  

 

The first ACA Choosing Wisely® recommendation states: In the absence of red flags, do not obtain spinal imaging (X-rays) for patients with acute low-back pain during the six weeks after the onset of pain. This recommendation is not only on ACA’s Choosing Wisely® lista similar item is also included on the lists of seven other organizations. This includes, among others, the American College of Emergency Physicians, the North American Spine Society and the American College of Physicians. It's also one of the performance measures established by the Centers for Medicare and Medicaid (CMS) under the MIPS Program. Thus, it is a widely accepted standard.  

 

It's important to clarify that ACA's recommendation refers to imaging patients with acute low back pain, not those with chronic pain or acute pain caused by trauma sufficient to suspect pathology that may be identified by imaging, such as compression fracture.  

 

Some doctors of chiropractic may be surprised that ACA included this recommendation. There are many DCs who are committed to delivery of high-quality patient care that currently take or order X-rays on a majority of their patients because they believe that X-rays are a necessary component of the examination process. There are a number of reasons why this is the case. First, many of us were taught to do so in chiropractic school, with the intent to either rule out underlying pathology and/or contraindications to spinal manipulation or to deliver a chiropractic technique that is based upon X-ray findings. 

 

As Evidence Expands, Our Practice Must Evolve  

Clinical practice for all health professions continues to evolve after we graduate from our educational institutions. This is the reason why continuing education is required. We would not want our child’s pediatrician to recommend a medication that was popular when he graduated from medical school 20 years ago rather than the one that was recently shown in clinical trials to be the safest and most effective. Further, there is no evidence that those chiropractic techniques based primarily on X-ray findings lead to better outcomes than those techniques that do not. To be clear, there is no evidence against either. There is simply very little evidence at all. While one must always be cognizant of the fact that lack of evidence does not equate to evidence against, it is now the national standard across all health professions to take an evidence-informed approach to patient care. The onus is on those practicing chiropractic techniques that have not yet been evaluated to support research to determine if the risk of x-rays is outweighed by any additional benefit when compared to techniques such as HVLA and flexion-distractionChoosing Wisely® recommendations are not set in stone. Rather, they are updated as new high-quality evidence becomes available.   

 

Letting Go of “Defensive” Practice  

As with many of our colleagues in the health care professions, we have learned from experience to practice “defensive medicine.”  This perspective may be even more deeply ingrained within the chiropractic profession based on our prior experiences with bias and/or lack of understanding regarding chiropractic care. As an example, just look how long it took before Choosing Wisely® was even willing to consider a chiropractic list!  

 

Always Weighing Benefits vs. Risks 

Every chiropractor in practice for more than a few weeks has run across a patient with sub-pathological findings that could potentially impact treatment decisions. For instance, one really wants to avoid putting a dynamic thrust into a transitional segment with an accessory joint. We know there are contraindications that can be identified using X-rays in the absence of red flags that are identified through the history and examination process. However, X-rays do not identify all contraindications. For instance, Syringomyelia is a relative contraindication to spinal manipulationYet it is not standard practice to order an MRI on every patient to rule out this possibilityWhy? Because it is simply not possible or advisable to do every test on every patient every timeGood clinical practice involves constant juxtapositioning between benefits and the risks of progressively more advanced and invasive diagnostic procedures as we assess each individual patient. While there may be some benefit to a limited number of patients in conducting routine X-ray examinations (similar to routine mammograms in patients under the age of 50), research has shown that for the majority, imaging tests do not ensure a speedy recovery, are expensive and involve some risk to the patient in terms of radiation and increased likelihood of receiving surgical treatment.   

 

More frequently than not, clinical decisions need to be made with imperfect information. Fortunately, the majority of absolute contraindications to spinal manipulation are relatively rare, those that are discovered on X-rays in the absence of red flags are even more so.   

 

Dr. Goertz is senior scientific advisor for the ACA and chairperson of association’s Committee on Quality Assurance and Accountability, which developed the Choosing Wisely® recommendations for the association.  

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6 comments on article "Choosing Wisely X-ray Recommendations Reflect Evolving Evidence, Accepted Standards"

James Smith

8/24/2017 6:45 AM

Nice explanation, Christine, but the main reason we classic chiropractors take images is not only to detect pathoanatomical problems, but more so, to detect vertebral subluxations to know where to adjust. By restricting x-rays, you've taken our best scientific tool out of our hands. Without the ability to see the structure of the spine, our hands are tied to guessing where to adjust--how unscientific is that?

I understand the goal is to reduce excessive radiation exposure since most MDs only look to detect "incidentalomas" to convince the patient to seek surgery for a 'bad disc', but without the ability to see the abnormal structure of the spine, we DCs are left blindfolded.

Another reason to restrict x-rays is so insurance payers can reduce their costs, such as the greedy ASHN that refuses to discuss this issue with me as they chant "squeeze care to increase profits."

In the end, this is not a wise choice to restrict x-rays for DCs -- it opens us up to malpractice as well as greatly limits our ability to detect subluxations.

Thanks for all you do!

JCS


John Ventura

8/25/2017 7:26 PM

Hi JC,

I guess your comments were not 'tongue-in-cheek'.

I assure you it was best research evidence which guided the selection of items for inclusion in the ACA Choosing Wisely campaign.

And currently best evidence strongly suggests that plain film X-Rays in the first 6 weeks of acute LBP do NOT improve outcomes, nor does their lack increase the risk to the patient, barring red flags, no matter the degree of the health care practitioner, including the chiropractic profession.

Were evidence to exist which demonstrated that utilizing X-Rays in the first 6 weeks of acute LBP improved outcomes or reduced patient risks for seeing a chiropractor, we would not have included this item. But as already stated, the evidence just simply does not exist.

Choosing Wisely is an effort to initiate dialogue between a patient and their health care practitioner by educating the public on some commonly utilized practices which are over utilized or unnecessary, as determined by best available research evidence. A partner in this effort is Consumer Reports, whose mission as we know, is to educate the public, whether they are buying a refrigerator or a health care service.

wishing you all the best,

John M Ventura DC


Stephen Perle

8/26/2017 8:33 PM

I think ACA's contribution to the ChoosingWisely initiative is outstanding. It has been said that If You Don’t Stand for Something, You’ll Fall for Anything. ACA has courageously decided to stand for patients and using the best evidence.

I understand that some in our profession use methods that ACA has said are inappropriate. This may be hard for those doctors to hear that what they are doing is not best for their patients. I'm sure it was what they were told when they were students or heard from someone in the profession they respected. However time changes and the evidence is quite clear that these practices are not in the patient's best interest. Like all sciences the past is destroyed as knowledge grows as time marches forward. It can be hard and unsettling to find that knowledge has march past one but it is time to change so that we do provide the best possible care for our patients.

Stephen M. Perle, DC, MS

Professor of Clinical Sciences

University of Bridgeport College of Chiropractic


Jay Greenstein

8/27/2017 2:44 PM

I certainly understand perspectives of those used to taking x-rays. I for one resisted moving away from x-rays as a regular part of my exam when the clinical practice guidelines came out. Here's what I learned...Even though I couldn't "see" the spine, patients still got better, and sometimes, more rapidly. I found myself able to explain their condition on a more functional level, as opposed to just anatomical,and because of that, when I explained my treatment plan, it was easier for the patient to understand the connection between diagnosis and treatment. Further, I found that there was greater compliance and less fear avoidance because the patient didn't fear they had something "terrible". As it related to concerns about malpractice, it's really hard to get sued when the evidence supports choosing wisely. If you watch your red flags, and make appropriate decisions for patients who don't respond to care, you're certainly at less risk. A great resource on the standard of care can be found here. http://www.jmptonline.org/article/S0161-4754(15)00184-0/abstract

Good luck!


James Kravis

9/18/2017 11:49 AM

Since when does the the American Board of Internal Medicine Foundation and Consumer Reports know what is best for Chiropractic patients? Have they made guidelines for dental patients and stated that dental patrients should not get x-rays? Of course not. I have been a chiropractor for 31 years, I have seen cancer, fractues and other pathologies that the patients did not know about. I would have caused detrimental harm to my patients health and my reputation without taking x-rays of the affected areas. We are specialists of joint function, and therefore must know how the joint is functioning by using the tools of our science. I find it insulting when our own association sides with an entity that has no knowledge of our profession. The ACA wants us to use an evidence based plan on taking care of our patients, that is exactly what I am doing with 30 years of experience and will continue to doalong with teaching all of my associates to do the same. I task the ACA to stop kissing the ass of Meical Associations, they know not of what and who we are, nor what we do for our patients. It is time we made true guidelines for the diagnosis of SUBLUXATION and reveled in our distinction and difference from allopaths.

James Kravis DC, CCWP


James Lehman

3/4/2018 3:46 PM

The ACA's decision to recommend that members "Choose Wisely" demonstrates an ethical responsibility to improve care chiropractic patients and educate chiropractors regarding necessary changes that will reduce costs and reduce exposure to unnecessary radiation. I commend the ACA leaders for stepping forth in spite of the objections of some in the profession. Dr. James Edwards recently wrote an article in Dynamic Chiropractic opposing the use of "Choosing Wisely." I wrote a letter to the letter expressing my opinion. Thought maybe others might want to read the letter. James J. Lehman, DC, FACO www.dynamicchiropractic.com/digital/index.php?i=1238&s=41074&l=13&a_id=58137&pn=70&r=t&Page=70

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