For many chiropractors, pre-authorization processes are required by Medicare before patients can receive treatment. Doctors who are required to submit more thorough documentation before adjusting their patients must submit their recommended treatment plans for approval.
Every modern healthcare practitioner is surely familiar with David Sackett’s 1996 description of evidence-based medicine as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”1 The intent of evidence-based practice (EBP) was to marry the best and most current quantitative scientific research evidence with the clinical experience of the practitioner, earned through clinical practice with patients, to create optimal decision-making for the treatment of a problem.
Over the years, however, critics of EBP have argued that this approach turns clinicians into technicians who follow a recipe, with individual patient and practitioner values, as well as the circumstances of each patient, being lost in the mix.2 The majority of providers, left to their own devices, would probably not express this tendency. However, the adoption of evidence-based practice guidelines such as the American College of Occupational and Environmental Medicine or Official Disability Guidelines that dominate the third-party pay structure has certainly contributed to the idea that the research component of EBP is what really matters and the other factors are less important. One could make the argument that, over time, EBP became research-focused rather than patient-focused.
Any chiropractor who has been told they have six visits to make significant changes with a patient with low back pain or else their care is the wrong option, for example, understands the frustration that can come with EBP guidelines. It is easy to see how practitioners can have a negative outlook on the evidence when it is used to guide care (or the lack thereof) for patients who depend on third-party pay structures.
Also inherent to evidence-based practice is the type of research that is considered. Practice guidelines like the ACOEM or ODG mentioned previously, systematic reviews and meta-analyses get the highest ranking. However, as with any type of research these can have their own inherent biases and are not without problems, especially when being applied to a patient whose circumstances may not exactly match the research inquiry. In practice, EBP tends to put the highest value on these types of research, assessment and diagnosis, and factors like prevalence.2 Rarely, however, does a patient’s presentation exactly match the inquiries of EBP and the evidence, and so, how does a provider use all of the available research to better serve the patient at hand?
In more recent years the term “evidence-informed practice” (EIP) has found its way into the lexicon of health care providers. While it may seem like mincing words, there is a significant difference between what has become evidence-based practice and this newer approach. Proponents of EIP suggest that the goal of collecting evidence to help inform a provider on a particular case should go further than the singular goal of reducing bias and that a wider range of research information should be used. Estabrooks advocated that providers add “some of our own conventional wisdom and common sense” and give higher value to qualitative studies, case reports, scientific principles and expert opinions.3 Miles and Loughlin have promoted the use of evidence-informed practice to mean the process is person-centered rather than research and evidence-focused4 and this is, perhaps, the most important distinction between evidence-informed and evidence-based practice styles.
To better illustrate the differences in evidence-based and evidence-informed practices, let us consider two therapies gaining popularity among manual therapists and chiropractors: cupping and compression “flossing.” Cupping gained wide popularity in the United States during the 2016 Olympics when U.S. swimmer Michael Phelps was seen with the now-familiar cupping marks on his shoulder and back. The media exploded with curiosity about cupping therapy. Of course, the endless debates about “if it works” or not came with it.
Cupping and compression-band flossing
Cupping has been used for more than 3,000 years throughout Asia, Greece, Egypt and the Saharan region, Iran, and throughout the Muslim world. A medical textbook published in Europe in 1694 shows an illustration of a man having cupping performed on his buttocks. Yet, a 2014 systematic review of cupping concluded that, “because of the unreasonable design and poor research quality, the clinical evidence of cupping is very low,” and a 2011 review found that, “the effectiveness of cupping is currently not well-documented for most conditions.”
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