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Value-based care: 5 tips to improve the patient experience in health care

Value-based care: 5 tips to improve the patient experience in health care | heaith | Scoop.it

Value-based care is more than a buzz term in health care today—it’s a mandate that has now become a baseline expectation for both patients and regulators. The Affordable Care Act requires health care providers to switch from operating in a service-based mindset to providing value-based care that focuses on the quality of care rather than the quantity of services offered.

But now that this mandate has been in effect for several years, providers can’t just do the bare minimum required. Organizations today need to deeply integrate value-based care into their operations and transform their approaches to stand out in a crowded health care marketplace.

These five tips can help health care organizations add more value to the experience patients can expect at the provider’s clinic or facility.

1. Improve patient engagement

More than ever, patients want to be involved in their own health care. Providers can improve patient engagement by creating email lists, blog posts, videos and social media content that regularly update patients on news and information relevant to their care. To ensure this content is relevant and useful, health care providers can request feedback from patients directly, thereby further engaging patients in their care.

Some forward-thinking providers have embraced online patient portals as a way to securely share information such as test results, physicians’ notes, or other contents of a patient’s file with that patient. Others, like Aurora Health Care, have created online patient communities to engage patients and derive insight to improve their services. By improving patient engagement, providers can inherently boost the value patients feel they are receiving.

2. Create more integrated treatment plans

Thanks to the internet, patients have become more informed about their conditions and treatments. They’re increasingly demanding treatment plans that employ a variety of methods. More patients are considering treatment methods beyond pharmaceuticals, surgery and other Western approaches.

From holistic remedies to Eastern medicine techniques, alternative and complementary treatments are another way to enhance value-based care. To identify and keep up with these changing expectations, health care providers should listen to their patients.

One example comes from OrthoCarolina: When the health care provider was considering adding a PhD-trained acupuncturist to its team, it consulted with patients first to ensure that the idea made sense. Patient feedback confirmed that there was a need for the service, allowing the organization to create a new revenue stream while boosting value for patients.

3. Research competitors’ strategies

While all health care providers may be required to implement a value-based care strategy, clear leaders have emerged across the industry. Providers can identify who those leaders are and watch how they are creating more value for patients in novel and effective ways.

Leading organizations like Horizon Healthcare Services use patient insight to remain ahead in this competitive landscape. Keeping an ear to the ground can offer insight into what has and hasn’t worked for other providers and potentially inspire new ideas that take competitors’ strategies one step further. This might also include looking to other industries beyond health care, such as retail, that can demonstrate other relevant innovations in customer engagement.

4. Elevate market research

To gather insight about competitors’ strategies or what patients value, many health care providers are investing in market research to derive insight directly from patients. Ongoing engagement leads to better patient care by fostering a deeper and more detailed understanding of patients’ attitudes and preferences. This type of research and feedback generation also offers providers a way to test and target new services and marketing strategies, which benefits both patients and providers.

Health care providers are seeing great ROI from investing in research. Cleveland Clinic, for example, recently shared that it uses patient insight to enhance marketing campaigns, increase patient satisfaction and evolve its services to keep up with the evolving needs of the consumers.

5. Understand what patients value now versus what they’ll value in the future

What may be the most critical insights generated from this type of research are not just what patients find valuable today, but rather what patients will value from their health care provider in the future. Providers should pay attention not to what patients feel is valuable in their current health care experience, but identify patient needs that aren’t being met yet. They can also conceptualize what issues patients could have in the future because of current changes in health care or technology. Those insights can keep providers prepared for the future and a step ahead of the competition.

The health care industry’s adoption of a consumer-oriented, retail-driven business model has prompted an increased need for providers to better engage with their patients. Listening to patients and demonstrating that patients’ feedback and insight is truly valuable is critical for providers today as they attempt to differentiate themselves from the competition.

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Rescooped by minuteonlinepharma from EHR and Health IT Consulting

Are Providers Satisfied With Their EHR?

Are Providers Satisfied With Their EHR? | heaith | Scoop.it

Physicians are expected to document encounters with patients. This ensures there is a record of crucial information for decision-making and dispute. A decade ago, around 90% of physicians updated their patient records by hand. By the end of 2014, 83% of physicians had adopted EHR systems. The combination of government incentives, advances in technology, and improved outcomes and operations fueled this growth.

When healthcare providers have access to complete and accurate information, patients receive better care and have better outcomes. Electronic Health Records (EHRs) improve providers’ ability to diagnose disease and reduce medical errors. EHRs further help providers meet patient demands, provide decision support, improve communication, and aid in regulatory reporting.

A national survey of providers highlights their perspective on the benefits of having EHR in their practice:

94% of providers report that their EHR makes records readily available at point of care.88% of providers report that their EHR produces clinical benefits for the practice.75% of providers report that their EHR allows them to deliver better patient care.

As the adoption of EHR grew over the last 10 years, so too did the need to change EHR systems within health systems, hospitals, and private medical practices. Growth in M&A activity fueled many healthcare organizations to combine data through EHR data conversion. Provider dissatisfaction has played a key role in encouraging change in EHR systems, also increasing EHR data conversion activity.

A study completed by Health Affairs showed, by and large, providers recognize the important advances that EHRs enable. Fewer than 20% of all providers said they would return to paper records. That being said, providers also noted negative effects of current EHRs on their professional lives and on patient care.  While excited about the possibilities provided by EHRs, providers have ultimately found poor usability that does not match clinical workflows, time-consuming data entry, interference with patient interaction, and too many electronic messages and alerts.

According to a 2014 survey of physicians conducted by AmericanEHR Partners:

54% indicated their EHR system increased their total operating costs.55% said is was difficult or very difficult to use their EHR to improve efficiency.72% said it was difficult or very difficult to use their EHR to decrease workload.43% said they had not yet overcome productivity challenges associated with their EHR implementation.

These concerns about EHR usability are in alignment with others, including the American Medical Informatics Association, researchers, and practicing physicians. Given the rate at which many healthcare organizations have adopted EHRs, these organizations find themselves unable to wait for the long-run fixes. Healthcare organizations are now looking to change EHR providers in order to fix many of the providers’ concerns.

As healthcare organizations begin the process of changing EHR providers, there is an increased need for solutions to provide access to and maintain the integrity of data stored in the legacy systems. When this need arises, healthcare organizations have the choice to archive the legacy data, run multiple systems simultaneously, or complete an EHR data conversion.

Given the complexity of the data and variety of potential solutions, one might suppose that handling legacy data would be a complex affair. In many ways, that is true. However, it doesn’t have to be. To learn more about the state of EHRs and potential solutions for maintaining access and integrity of legacy data.

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Technical Dr. Inc.'s curator insight, 10 May 2018, 14:00
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Rescooped by minuteonlinepharma from Social Media and Healthcare

Are medical trainees and doctors prepared for the new social media frontier?

Are medical trainees and doctors prepared for the new social media frontier? | heaith | Scoop.it

Instagram and Twitter are turning some doctors into celebrities. Take “Dr. Mike” – also known as Mikhail Varshaski, a family doctor with 2.6 million Instagram followers. That’s more than some Hollywood celebrities such as George Clooney or Meghan Markle. Thanks to the popularity of social media platforms, Dr. Mikes are becoming more common.

As Ali Damji, a resident in the Department of Family and Community Medicine at the University of Toronto, says, “I think that medical education needs to accept that there is a new reality here. So far we have approached social media from a professional and regulatory framework —in other words, what doctors shouldn’t be doing on social media. While this is important, we also now need to be focusing on what doctors should be doing on social media and the most effective ways to use this tool to serve our patients.”

Doctors are using social media to stay informed, discuss issues with other health-care professionals, and promote their own findings and educational materials. It can also be a great tool for advocacy, where physicians can share articles and discuss issues with many beyond their usual geographical areas and outside of their regular circles.

“I use social media—Twitter exclusively—for a few reasons. The most important is to learn, and it’s a tremendous tool for that. By ‘learning’ I mean keeping abreast of medical advances, but also re-learning things I’ve forgotten. Sadly, that list is growing by the year,” says David Juurlink, an internist and clinical pharmacologist at Sunnybrook Health Science Center. “And as a researcher I’ve increasingly used Twitter to help disseminate our findings, as well as to publicize other studies I’ve read that seem worth sharing. For example, last May I tweeted a thread to provide some context for, and increase the reach of, a newly published study. Partly as a result of that thread, the article now has one of New England Journal of Medicine’s highest Altmetric values ever.”

Irfan Dhalla, Vice-President of Evidence Development and Standards at Health Quality Ontario, says he uses it to get feedback. “A current goal [in using social media] is sharing what we are doing at Health Quality Ontario, and interacting with people who have questions or suggestions about our work,” he says.

It can also help physicians educate the public about their health, says Melanie Bechard, a paediatrics resident at The Hospital for Sick Children and President of Resident Doctors of Canada. “These platforms allow us to reach beyond our usual patient rosters to provide health information to patients and families within the comfort of their homes, providing more equitable access to this content in innovative and engaging formats,” she says.

Should medical trainees use social media?

Medical trainees are in a formative stage of both establishing their professional identities in the medical world and as doctors in the social media world. As such, their conduct on social media is usually subject to scrutiny. In a recent extreme case, two medical trainees in Mexico posted an inappropriate picture of them holding an amputated foot on Twitter, an action that brought them to court.

Several associations, universities, departments and divisions have created guidelines for appropriate use of social media by medial trainees. These include the Canadian Federation of Medical Students, the Canadian Medical Association, the Postgraduate Medical Education office and the Division of Plastic and Reconstructive Surgery at the University of Toronto. These guidelines are centered on the basic rules of social media engagement by trainees such as respect of patient confidentiality, appropriate credential use, and promotion of professionalism online.

“We should encourage responsible use by trainees and educate them on how to do this,” says Jamil Ahmad, Plastic Surgery Staff Physician at the Plastic Surgery Clinic in Toronto.

But several areas of concern are not discussed in these guidelines. First, the separation between personal and professional identity remains an area of debate. “Personal and professional boundaries are blurred on social media… Even if you think it is a personal conversation, it represents you professionally as well,” warns Damji.

Another concern is when the respectful exchange of ideas leads to intimidation, harassment and cyberbullying. “While most staff physicians and trainees are conscious of the risks of social media, it has been disheartening to see instances where trainees have been exposed to profane and vitriolic statements from their senior colleagues. This bullying jeopardizes the public perception of the entire profession,” says Bechard.

In February, this became a headline in the Toronto Star after some physicians were targets of cyberbullying over disagreements around physician service agreement negotiations. One disturbing, misogynistic comment from a physician stated: “You are a c—. Crash and burn as you deserve to do!!”

Even without malicious intent, discussions and posts on social media can lead to misunderstandings.

“It’s easy to be misunderstood since you only have 140 characters to make your point. And it’s all in writing, so the tone you intend in a tweet may not be the tone people perceive,” says Alainna Jamal, an MD Candidate at the University of Toronto’s Faculty of Medicine.

Finally, social media can disrupt the traditional hierarchy of learning from staff physician to trainee. Trainees can quickly become powerful influencers online, giving them a “louder” voice on social media than more senior physicians. On social media, years of experience can be replaced by number of followers.

These areas of contention need to be further evaluated, and recommendations should be made to guide trainees in those gray areas.

“Black and white perspectives on social media don’t acknowledge that it’s the new reality for medical trainees,” says Bechard. “Fostering discussions and providing tangible examples of both effective and ineffective social media use throughout medical training would be very helpful.”

As trainees are “doctors-in-training,” their use of social media is one of the spheres in which guidance and education are needed to ensure proper use. As Bechard observes, “Like any tool, social media has its risks and rewards – mastering it is an ongoing process of discovery.”

At the same time, established physicians face many of the same challenges, and would also benefit from more guidance as this becomes increasingly important.

“Social media is a reality,” says Ahmad. “I think it’s an evolving form of communication – just like email was 20 years ago.”

Helene Retrouvey is a third year resident in the Division of Plastic and Reconstructive Surgery at the University of Toronto. Annie Wang is a fourth year medical student at the University of Toronto.

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Researchers turn to AI to flag signs of mental illness online

Researchers turn to AI to flag signs of mental illness online | heaith | Scoop.it

Computer scientists at the University of Ottawa are turning to artificial intelligence, or AI, to search for signs of mental illness among users of social media. 

The researchers are developing AI software that scours platforms including Facebook, Instagram and Twitter. The software is programmed to flag posts for warning signs of mental health issues such as depression, addiction and suicide.

'We are trying to catch early signs [of mental illnesses] and solve them before they become a big problem.'- Diana Inkpen, University of Ottawa


Diana Inkpen, a professor of computer science at the University of Ottawa, is heading up the project. She said the software could become a tool for health care professionals to monitor patients through their social media posts. 

"We are trying to catch early signs [of mental illnesses] and solve them before they become a big problem. That would be a big gain," Inkpen said. 





Key word search

Inkpen collected her initial data by programming the AI software to search for key words on social media — specific words or phrases that could indicate signs of a mental illness including "I'm depressed," "I'm suicidal," or "I can't sleep."

Diana Inkpen, a professor of computer science at the University of Ottawa, is leading the research. (Diana Inkpen/ The University of Ottawa)

The words and phrases were chosen from a list compiled by medical professionals.

The tool has been put to the test during the Bell Let's Talk mental health awareness campaign, when it was able to scan Twitter and extract tweets containing the key words.​

According to Inkpen, each time the software is fed new data it becomes more efficient at gathering specific information and making predictions.

Inkpen is hoping the AI software could be used by public health agencies to gather data on specific areas of mental health, to pinpoint communities that are struggling with mental illness and to help direct funding to where it's most needed. 

Interest from doctors

Although the software is still in the research phase, some health care professionals are already interested in using it.

Dr. Gail Beck, the clinical director of the youth program at The Royal Ottawa Mental Health Centre, said she already uses Twitter to communicate with some patients, and believes the AI software could become a beneficial tool.

Inkpen said a $23,000 grant from the Natural Sciences and Engineering Research Council of Canada will go toward funding the last stage of her research, which she expects to finish with the next year. 

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As Artificial Intelligence makes an uprise in society, its powers are now targeting social media, and has the possibility to spot signs of mental illness across different social media platforms. Researchers think that if they can catch early signs of mental illness through posts on social media, they can better take care of them before they become a bigger issue.

Rescooped by minuteonlinepharma from Social Media and Healthcare

Mixing Social Media With Medicine

Mixing Social Media With Medicine | heaith | Scoop.it

Pediatric oncologist Dr. Justin Baker can usually tell when some new “cure” for cancer is making the rounds on social media. He starts to get desperate questions from parents about a new technique or a new drug or a new surgery. Every time, he tells his patients he will look into it – and he does – knowing all too well the odds are overwhelming that it will end in more heartbreak for the family.

Baker, who is chief of the Division of Quality of Life and Palliative Care at St. Jude Children’s Research Hospital in Memphis, Tennessee, works with some of the most seriously ill children in the country. He tells every new family that he will do whatever it takes to help their child, and that he works on a team with the top science and medicine experts in pediatric cancer to constantly look for cures. But he knows that eventually, there will be a Facebook post or a blog or a tweet claiming to have something better.

“In the context of medicine, social media has, unfortunately, given incredible strength to opinion and a very loud voice to the one,” Baker says. “It’s almost never grounded in data. It’s founded in a personal story or in hope for a cure that does not exist.”

Baker’s experience is played out day after day, appointment after appointment, in hospitals and doctors’ offices everywhere. A patient demands a medication that helped a Facebook friend’s neighbor, or they refuse treatment because a celebrity tweeted about the latest botanical oil to replace medical intervention.

It’s not surprising, considering the reach of social media in everyday life. A 2016 report by the Pew Research Foundation found that 68 percent of all U.S. adults are Facebook users, followed by Instagram (28 percent), Pinterest (25 percent) and Twitter (21 percent). Information is exchanged all day, every day and many times it collides with the facts of medical research.

Social media allows the introduction of these ideas and then they are disseminated as if they’re fact, not speculation.

One of the most public illustrations of this is the anti-vaccine movement on social media. Despite overwhelming scientific evidence of the safety and necessity of vaccinations, a small but growing number of parents are refusing shots for their children – and telling everyone about it across social media. Facebook has dozens of anti-vaccination groups, with anywhere from a few hundred members to tens of thousands.

Parents in these groups often share lengthy stories claiming vaccines cause autism, despite no evidence other than a retracted British study to support that assertion. Others tell of refusing new vaccines on the market because there isn’t enough evidence of their safety. Another common thread in these groups is that vaccines were developed to make money for the health care industry, not to protect the population.

“There is always something being blamed on vaccines in these online groups – autism, neurological problems, even death,” says Dr. Dean Blumberg, chief of pediatric infectious diseases at University of California Davis Children’s Hospital. “Social media allows the introduction of these ideas and then they are disseminated as if they’re fact, not speculation.”

This vast proliferation of misinformation has far-reaching consequences beyond the digital world. A patient may lose trust in a doctor who won’t go along with the latest “cure” being promoted on social media.

Likewise, a physician practice may have a policy against treating unvaccinated children, leaving those families to find care elsewhere. But of course, the most detrimental effect is on patient health.

In the case of vaccinations, that was made clear during a 2015 outbreak of measles that started at Disneyland and eventually sickened 147 people in six states, Mexico and Canada. A study in the journal Pediatrics determined the measles virus was able to spread because of unvaccinated visitors to the park. The whole episode led to a new California law tightening the rules for vaccine exemptions, and Blumberg and other health care providers hoped it also would lead to new faith in immunizations.

“We hoped there would be changing attitudes,” he says. “Instead, from what I saw in some of the anti-vaccination groups, it was people saying ‘So what? A handful of people got a fever and a rash. People are making a big deal of out nothing.’ Unfortunately, you can’t talk to them about how serious measles is worldwide. It’s really sad.”

Speak Up

In the face of so much misinformation on social media, it’s tempting for patients and health care providers to just avoid it altogether. But doing so leaves the power of social media in the hands of the people who promote misinformation, and the people who believe it and spread it.

By now, most hospitals and physician practices have a social media presence. It may be a robust site with new posts several times a day that encourage dialogue, or a small presence that gets updated a few times a month.

The advantage for hospitals that have a social media presence is they can use it to drive the conversation where they want it to go, says Dan Hinmon, community director for the Mayo Clinic Social Media Network. His platform offers resources and interactive communities for health care professionals and communicators.

For Mayo, it’s just one piece of its well-known social media presence, which includes 1 million Facebook likes, 1.7 million Twitter followers, 103,000 LinkedIn followers and 44,000 Instagram followers. It benefits from the brand recognition of a major health care center, and from a strategy that promotes easy-to-digest content about topics that are important to the public. For example, topics posted on a recent afternoon ranged from teething babies to dementia to the use of melatonin.

Hinmon says that in his experience, social and digital media have quickly become the third-biggest influencers of how a patient chooses where to get treatment, behind the best insurance value and where the patient’s physician recommends.

“If I am a patient, I am going to see if my physician is engaged in social media and what the hospital is doing on social media. I am also very interested in what other patients say about him or her on their own social platforms,” Hinmon says. “That’s one of the reasons hospitals got more engaged in social media. It gave physicians and hospitals the chance to be part of those discussions, influence those decisions, and respond to some of the misinformation out there”

In the decade or so since social media became part of the mainstream, Hinmon says the trend has turned toward more community engagement, rather than simply posting events or articles. This gives patients a chance to build a relationship with an organization or a physician, and perhaps choose them for a medical home.

“Social media is the way now to connect in significant ways with patients,” Hinmon says. “It is amazing because of its two-way communication potential. The mindset is shifting from broadcasting messages to connecting with communities in real time, two-way conversation. That has become more and more and more valuable. It is hard to find any hospital not doing Facebook and Twitter. It’s really become embraced as a valuable part of communicating with the patient and the community.”

Putting Guardrails Up

It is relatively easy to engage with social media under the name of a hospital or even a large medical group. They typically have staff to assist with the posting, ensuring it meets brand and professional guidelines. It’s much different doing it as an individual physician. A seemingly innocuous post about a rough night in the ER could quickly become a privacy violation or damage the hospital’s reputation.

In a 2017 study by the Journal of Medical Information Research, 54 percent of 1,628 pediatric residents surveyed reported seeing posts that made derogatory remarks about patients. Additionally, 40 percent said they were unaware of their institution’s policy on social media.

That’s why it’s essential to develop a strategic plan and enforce guidelines, says Krysta Privoznik, social media specialist for Blue Cross and Blue Shield Plans in Illinois, Montana, New Mexico, Oklahoma and Texas. She counsels medical executives on how to use social media to raise the visibility of their company, drive awareness around important topics, and build an authentic online reputation for themselves while also avoiding some of the many pitfalls.

“I’ve provided training to people who haven’t touched their social media platform out of fear. They were afraid of what to say and how to say it,” she says. “I coach them through a crawl, walk, run approach and provide tips, tricks, guardrails and suggestions. It helps put them at ease when I show my support every step of the way.”

Perhaps most importantly, Privoznik tells them she will be monitoring what people say to them or about them, in addition to everything they post under their personal profile. She advises all organizations to come up with a monitoring plan that suits and protects their organization and its employees.

“Much of an executive’s social media success depends on up-front planning. Have a good strategy in place from an organizational perspective before you start training,” she says. “And prior to anything, have honest conversations with your company’s leadership – ask questions, listen, identify opportunities – to determine whether the executive is a good fit for social media. The fast-paced, cluttered environment is not for everyone and that’s OK too.”

Despite the risks and misinformation, Dr. Baker refuses to let the negative aspects of social media stop him from being a prolific user. He regularly tweets from conferences, or posts interesting articles to Facebook. He does have a few ironclad rules: 1) He will not accept friend requests from active patients and their families, and 2) He always keeps his posts positive. That can be difficult for someone who spends his days working with critically and often terminally ill children.

“I think of my relationship with social media as advocating for those things that are very important to me and to our patient population,” he says. “If there is an important story that is somewhat inspirational, I try to share that. Or if something happens at work that’s remarkable, I try to share that. I see myself as an advocate and promoter of the good in health care. I try to advocate through inspiration, rather than by shining a light on the negative.”

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Where are the lines: Social media and the regulators

Presentation on how social media is impacting the work of organizations regulating the health care professions in Canada

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Saint Clare's Dover Hospital patient receives surprise visit from the NJ Devils.

Through the power of social media and the kindness and passion of the New Jersey Devils organization, Lauren Liff, a patient at Saint Clare’s Health Dover and enthusiastic New Jersey Devils fan, received something better than ‘get well’ flowers or balloons! Liff received a surprise visit from one of her favorite hockey players, New Jersey Devils center Travis Zajac, and the Devils mascot, N.J, Devil!

From the moment Zajac and NJ walked into her room, Liff’s excitement overwhelmed her. “I have been a New Jersey Devils fan all my life and to see them walk through the door was the most unbelievable surprise of my life.”

Surprise video tweet: https://twitter.com/NJDevils/status/992408487056592897

On Monday, April 30, 2018, Liff was sitting in her hospital room using Twitter to rally her fellow hockey fans to retweet a challenge. She tweeted, “So…how many retweets to get the @NJDevils to come and visit me?” After almost 600 retweets, the New Jersey Devils organization jumped to action. The team contacted Saint Clare’s, and working together, made Liff’s challenge a reality. “I am incredibly proud to be a New Jersey Devils fan. For them to come to Saint Clare’s to see me was unbelievable. This visit gave me hope and put a big smile on my face,” expresses Liff.


The kindness and the passion of the New Jersey Devils organization, Zajac and N.J. Devil will not end with this visit. After learning that one of the items on Lauren’s bucket list is to sing the national anthem at Prudential Center, the Devils’ national anthem singer Arlette invited her to come to “The Rock” this offseason to audition with her. Fans can follow along the story here.

Anthem invite tweet: https://twitter.com/NJDevils/status/992482654867116032

About Saint Clare’s Health

Saint Clare’s Health is an award-winning provider of safe, high quality, compassionate care, serving the communities of Morris and Sussex counties. Its network of hospitals and healthcare facilities include Denville Hospital, Dover Hospital, Behavioral Health centers in Boonton, Denville, and Parsippany, Sussex Community Urgent Care Center, and an Imaging Center in Parsippany, among other satellite locations.

About the New Jersey Devils

The New Jersey Devils are part of the 31-team National Hockey League, with teams throughout the United States and Canada. Established in 1982, they are currently in their 35th season in the Garden State. During that time, the team has won three Stanley Cup Championships: 1995, 2000 and 2003. Follow the Devils atwww.newjerseydevils.com, on Facebook, Twitter, and Instagram. The New Jersey Devils organization is a Harris Blitzer Sports & Entertainment property.

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Chiropractic: Americas Exit Strategy To The Opioid Epidemic | El Paso Back Clinic® • 915-850-0900

Chiropractic: Americas Exit Strategy To The Opioid Epidemic | El Paso Back Clinic® • 915-850-0900 | heaith | Scoop.it

The sheer magnitude of America’s prescription opioid abuse epidemic has evoked visceral responses and calls-to-action from public and private sectors. As longtime advocates of drug-free management of acute, subacute and chronic back, neck and neuro-musculoskeletal pain, the chiropractic profession is aligned with these important initiatives and committed to actively participate in solving the prescription opioid addiction crisis.As professionals dedicated to health and well-being, Doctors of Chiropractic (DCs) are educated, trained and positioned to deliver non-pharmacologic pain management and play a leading role in “America’s Opioid Exit Strategy.”

Data released by the Centers for Disease Control and Prevention (CDC) revealed that opioid deaths continued to surge in 2015, surpassing 30,000 for the first time in recent history. CDC Director Tom Frieden said,“The epidemic of deaths involving opioids continues to worsen. Prescription opioid misuse and use of heroin and illicitly manufactured fentanyl are intertwined and deeply troubling problems.”1

The human toll of prescription opioid use, abuse, dependence, overdose and poisoning have rightfully become a national public health concern. Along with the tragic loss of life, it is also creating a monumental burden on our health and related health care costs:


Health care costs for opioid abusers are eight times higher than for nonabusers.2A new retrospective cohort study shows a 72 percent increase in hospitalizations related to opioid abuse/dependence from 2002 to 2012. Not surprisingly, inpatient charges more than quadrupled over that time. Previous estimates of the annual excess costs of opioid abuse to payers range from approximately $10,000 to $20,000 per patient, imposing a substantial economic burden on payers.3A recent government study puts the economic burden to the U.S. economy at $78.5 billion annually. For this study, CDC researchers analyzed the financial impact to include direct health care costs, lost productivity and costs to the criminal justice system.4


As a non-pharmacologic approach to effectively address acute, subacute and chronic non- cancer pain, integrative care management answers the needs of individuals nationwide.

With patient access to opioids becoming more restricted through more responsible clinician prescribing and government-mandated reduced production of opioids — and as those who are addicted become empowered to reduce their utilization — people experiencing pain face new, daunting challenges:


Without the use of drugs, how will they cope with pain?How can they get referrals and access to drug-free care that will be effective for acute, subacute and chronic pain?How can they ensure that their health care plans and insurance will cover the cost of non- pharmacologic care?

While the chiropractic profession lauds many of the noteworthy announcements and strides to overcome opioid addiction, these recommendations fall short in providing meaningful answers and solutions for those who are suffering from pain.

It is encouraging to see the July 22, 2016 enactment of the Comprehensive Addiction and Recovery Act (P.L. 114-198), the first major federal addiction legislation in 40 years, and the most comprehensive effort undertaken to address the opioid epidemic. It encompasses all six pillars necessary for such a coordinated response – prevention, treatment, recovery, law enforcement, criminal justice reform and overdose reversal.5 The recent passage of the 21st Century Cures Act included $1 billion for states to use to fight opioid abuse.6 Unfortunately, this legislation has drawn critics who say it is simply a huge de-regulatory giveaway to the pharmaceutical and medical device industry.7

Closer examination of these legislative initiatives points to the absence of programs that address non-pharmacologic options for those fighting drug addiction, notably chiropractic care. When paired with the U.S. Surgeon General’s declaration of war on addiction,8 the government’s designation of “Prescription Opioid and Heroin Epidemic Awareness Week,” 9 and the commitment from 40 prescriber groups to ensure that 540,000 health care providers would complete training on appropriate opioid prescribing within two years,10 these “solutions” appear woefully inadequate to address the challenges of those who need effective, drug- free pain management.

This follow-up discussion to “Chiropractic: A Safer Strategy than Opioids” (June 2016), examines the positive steps as well as the shortcomings of initiatives undertaken from July 2016 – March 2017 to address the opioid crisis. It also assesses the current landscape of opportunities to offer patients, doctors and payers meaningful programs to effectively address acute, subacute and chronic neck, low back and neuro-musculoskeletal pain without the use of painkillers.

The chiropractic profession contends this should be a top priority, and it appears that a growing number of stakeholders are in agreement. In fact, the world’s second-largest pharmaceutical company has agreed to disclose in its marketing material that opioid painkillers might carry a serious risk of addiction, and promised not to promote prescription opioids for unapproved uses, such as long-term back pain.11

Based upon the evidence articulated in this document, it becomes clear that chiropractic care is a key component of “America’s Opioid Exit Strategy” on several levels:


 Perform first-line assessment and care for neck, back and neuro-musculoskeletal pain to avoid opiate prescribing from the first onset of pain. Provide care throughout treatment to mitigate the introduction of drugs. Offer an effective approach to acute, subacute and chronic pain management that helps addicts achieve a wellness focused, pain-free lifestyle as they reduce their utilization of opioids.

It’s also a compelling opportunity for our health system, commercial and government payers, employers — and most importantly patients — to resolve the issues surrounding pain at lower costs, with improved outcomes and without drugs or surgery.

Further complicating the situation: escalating prices of the opioid OD drug naloxone may threaten efforts to reduce opioid-related deaths across America, warn teams at
Yale University and the Mayo Clinic.13

Naloxone is a drug given to people who overdose on prescription opioids and heroin. If administered in time, it can reverse the toxic and potentially deadly effects of “opioid intoxication.”

The research team called attention to skyrocketing prices for the lifesaving antidote, noting:


Hospira (a Pfizer Inc. company) charges $142 for a 10-pack of naloxone — up 129 percent since 2012.Amphastar’s 1 milligram version of naloxone is used off-label as a nasal spray. It’s priced around $40 — a 95 percent increase since September 2014.Newer,easier-to-use formulations are even more expensive — a two-dose package of Evzio (naloxone) costs $4,500, an increase of more than 500 percent over two years.“The challenge is as the price goes up for naloxone, it becomes less accessible for patients,” said Ravi Gupta, the study’s lead author.

Government & Regulators Restrict Access To Opioids

In the wake of this firestorm surrounding opioid abuse, and following the dissemination of prescribing guidelines introduced by the CDC, it becomes evident that certain market forces are influencing the battle against opioid addiction and the availability of drugs.

Among the most egregious stakeholders are those in the pharmaceutical sector.There are numerous instances which document their role attempting to thwart many legislative initiatives throughout the country to combat drug abuse.They impose exorbitant costs for life-saving antidotes, and aggressively develop and market the use of more drugs to fight opioid-induced side effects such as constipation. It becomes apparent that many of their answers to opioid addiction are simply more pills.14

The opioid market is worth nearly $10 billion in annual sales, and has expanded to include an unlimited universe of medications aimed at treating secondary effects rather than controlling pain.15 Given the financial incentives to produce, sell and distribute drugs, it’s no wonder that pharmaceutical companies (pharmcos) have a material interest in promoting drug utilization.

This set of behaviors has drawn extensive criticism.

“The root cause of our opiate epidemic has been the over-prescribing of prescription pain medications. Physicians get little to no training related to addiction in general, but particularly around opiate prescriptions. Over the past year, however, you hear more and more physicians admitting ‘we are part of the problem and can be part of the solution’.”16

—- Michael Botticelli, former White House drug policy director, commonly called the nation’s drug czar.

While physicians have been responding to calls for more responsible prescribing, the drug industry has historically been accused of providing physicians with misleading information regarding the addictive qualities of certain drugs.Appropriate education of prescribers is a key component of necessary change.

For example, when semisynthetic opioids like oxycodone and hydrocodone — found in Percocet and Vicodin respectively — were first approved in the mid–20th century, they were recommended only for managing pain during terminal illnesses such as cancer, or for acute short-term pain, like recovery from surgery, to ensure patients wouldn’t get addicted. But in the 1990s, doctors came under increasing pressure to use opioids to treat the millions of Americans suffering from chronic non-malignant conditions, like back pain and osteoarthritis.

A physician pain specialist helped lead the campaign, claiming prescription opioids were a “gift from nature,” with assurances to his fellow doctors — based on a 1986 study of only 38 patients — that fewer than one percent of long-term users became addicted.17

Today, drug makers may be getting their ‘wings clipped’ with the introduction of new government directives slashing production of popular prescription painkillers. In 2016, the U.S. Drug Enforcement Administration (DEA) finalized a previous order on 2017 production quotas for a variety of Schedule I and II drugs, including addictive narcotics like oxycodone, hydromorphone, codeine and fentanyl. The agency has the authority to set limits on manufacturing under the Controlled Substances Act. The DEA said it is reducing “the amount of almost every Schedule II opiate and opioid medication” by at least 25 percent.18 Some, like hydrocodone, commonly known by brand names like Vicodin or Lortab, will be cut by one-third.

Despite these setbacks, the drug industry continues to launch strong initiatives that fight state- mandated opioid limits. Amid the crisis and regardless of the pressures urging a shift away from opioid use, the makers of prescription painkillers recently adopted a 50-state strategy that includes hundreds of lobbyists and millions in campaign contributions to help kill or weaken measures aimed at stemming the tide of prescription opioids.19

While the drug makers vow they’re combating the addiction problem,The Associated Press and the Center for Public Integrity found that these manufacturers often employ a statehouse playbook of delay and defend tactics.This includes funding advocacy groups that use the veneer of independence to fight limits on the drugs, such as OxyContin, Vicodin and Fentanyl, a potent, synthetic opioid pain medication with a rapid onset and short duration of action that is estimated to be between 50 and 100 times as potent as morphine.20

In its national update released Dec. 16, 2016 in the Morbidity and Mortality Weekly Report, the CDC reported that more than 300,000 Americans have lost their lives to an opioid overdose since 2000.

As enforcement restricts the availability of prescription opioids, people addicted to painkillers — such as oxycodone (OxyContin) and morphine — have increasingly turned to — street drugs like heroin.21

These independent sources also found that the drug makers and allied advocacy groups employed an annual average of 1,350 lobbyists in legislative hubs from 2006 through 2015, when opioids’ addictive nature came under increasing scrutiny.

“The opioid lobby has been doing everything it can to preserve the status quo of aggressive prescribing.They are reaping enormous profits from aggressive prescribing.”22

Andrew Kolodny, MD, founder, Physicians for Responsible Opioid Prescribing

Undaunted by these interferences, and buoyed by a thirst for profits, pharmcos are now fueling other creative solutions to drive even greater revenues from the sale and distribution of drugs.

It now appears that pharmcos are directing their activities toward medicines known as abuse-deterrent formulations: opioids with physical and/or chemical barriers have built-in properties that make the pills difficult to crush,chew or dissolve.This aims to deter abuse through intranasal and intravenous routes of administration.These drugs ultimately are more lucrative, since they’re protected by patent and do not yet have generic competitors.They cost insurers more than generic opioids without the tamper-resistant technology.23

Skeptics warn that they carry the same risks of addiction as other opioid versions, and the U.S. FDA noted that they don’t prevent the most common form of abuse — swallowing pills whole.

“This is a way that the pharmaceutical industry can evade responsibility, get new patents and continue to pump pills into the system,” said Dr. Anna Lembke, Chief of Addiction Medicine at the Stanford University School of Medicine.24

Drug makers have discovered yet another way to profit from addicts taking high doses of prescription opioid painkillers – the new billion-dollar drug to treat opioid-induced constipation (OIC) rather than controlling pain.

Studies show that constipation afflicts 40-90 percent of opioid patients.Traditionally,doctors advised people to cut down the dosage of their pain meds, take them less often or try non-drug interventions. By promoting OIC as a condition in need of more targeted treatment, the drug industry is creating incentives to maintain painkillers at full strength and add another pill instead.25

Collectively, the subsets of new pharmaceutical submarkets to treat opioid addiction, overdoses, and side effects such as OIC are estimated to be worth at least $1 billion a year in sales.These economics, some experts say, work against efforts to end the epidemic.26

While there is continued pressure to limit the number and scope of opiates for patients, new government statistics reveal that drug overdose deaths continue to surge in the United States, now exceeding the number of deaths caused by motor vehicle accidents.27 Although it is reported that the number of opioid prescriptions has fallen across the U.S. over the past three years, with intermittent data on this decline in states such as West Virginia and Ohio, they still kill more Americans each year than any other drug.

Just over 33,000 (63 percent) of the more than 52,000 fatalities reported in 2015 are linked to the illicit use of prescription painkillers.28 States including Massachusetts, and most recently Virginia, have declared public health emergencies as the number of deaths has escalated.29

Regardless of whether these issues are viewed from the perspective of patients, clinician prescribers, or government regulators, the status quo is clearly not acceptable.

Responsible Prescribing

“My new patient didn’t mention his back pain until the very end of the visit.As he was rising to leave, he asked casually if I could refill his Percocet. I told him I am not a pain or a back specialist and that I generally prescribe muscle relaxants or anti-inflammatory medications for back pain — not opioids, which are addictive and do not really treat the underlying problem.

The patient persisted. He said his prior internist always prescribed it, and the medication also helped his mood. He promised he had its use under control and did not feel he needed to take more and more to achieve the same effect.

I didn’t relent. I offered to refer him to a back specialist instead. It was an uncomfortable end to an otherwise positive visit.

Unfortunately, we doctors are enablers.Too many of us fill those prescriptions for chronic pain. And when we don’t, too many of our patients leave us for other doctors who will. Or worse, they turn to buying heroin on the street.”30

Marc Siegel, MD, FOX NEWS

Clinical prescribers of pain medications are beginning to recognize their responsibilities for increased prescribing vigilance, and are expected to become important advocates for drug-free pain care. More than half of doctors across America are curtailing opioid prescriptions, and nearly 1 in 10 have stopped prescribing the drugs, according to a new nationwide online survey. More than one-third of the respondents said the reduction in prescribing has hurt patients with chronic pain.

The survey, conducted for The Boston Globe by the SERMO physicians social network, offers fresh evidence of the changes in prescribing practices in response to the opioid crisis that has killed thousands in New England and elsewhere around the country.The deaths awakened fears of addiction and accidental overdose, and led to state and federal regulations aimed at reining in excessive prescribing.

Doctors face myriad pressures as they struggle to treat addiction and chronic pain, two complex conditions in which most physicians receive little training.Those responding to the survey gave two main reasons for cutting back: the risks and hassles involved in prescribing opioids, and a better understanding of the drugs’ hazards.31

In Wisconsin, the Medical Society says the state’s effort to fight the opioid epidemic is showing results.A new report found about eight million fewer opioids were dispensed between July and September 2016 compared to the same time during the previous year.The Medical Society says it’s doing more to help physicians monitor patients’ use of opioids by supporting the release of an enhanced prescription drug monitoring program – or PDMP. Starting in April 2017, doctors will have to access the program while pharmacists will only have 24 hours to enter information instead of seven days.This gives doctors an update in case patients are going from doctor to doctor for more prescriptions.32

Prescription drug monitoring programs (PDMPs), launched in 2013, are state-run electronic databases used to track the prescribing and dispensing of controlled prescription drugs to patients.They are designed to monitor this information for suspected abuse or diversion (i.e., channeling drugs into illegal use), and can give a prescriber or pharmacist critical information regarding a patient’s controlled substance prescription history.This information can help prescribers and pharmacists identify patients at high-risk who would benefit from early interventions.

PDMPs continue to be among the most promising state-level interventions to improve opioid prescribing, inform clinical practice and protect patients at risk.33

Hospital Admissions Due To Heroin, Painkillers Rose 64% 2005-2014

Researchers found misuse of prescription painkillers and street opioids climbed nationwide, related hospital stays jumped from 137 per 100,000 people to 225 per 100,000 in that decade.

States where overdoses required at least 70 percent more hospital beds between 2009 and 2014 were North Carolina, Oregon, South Dakota and Washington.

In 2014, the District of Columbia, Maryland, Massachusetts, New York, Rhode Island and West Virginia each reported rates above 300 per 100,000 people — far above the national average.34

Health Plans Report Limited Prescribing Is Paying Off

According to IMS Health, a global health information and technology firm, the rate of opioid prescribing in the U.S. has dropped since its peak in 2012.The drop is the first that has been reported since the early 1990s, when OxyContin first hit the market and pain became “the fifth vital sign” doctors were encouraged to more aggressively treat.35

However, continued pressure on physician prescribing patterns and opportunities for therapies other than opioids may be paying off. Prescriptions for powerful painkillers dropped significantly among patients covered by Massachusetts’ largest insurer after measures were introduced to reduce opioid use.36 The Blue Cross Blue Shield of Massachusetts program serves as an example of a private health insurer collaborating on a public health goal.

In 2012, the insurer — the state’s largest, with 2.8 million members — instituted a program intended to induce doctors and patients to weigh the risks of opioids and consider alternatives.As part of that initiative, first-time opioid prescriptions are limited to 15 days, with a refill allowed for 15 more days. Blue Cross must approve in advance any prescription for longer than a month or for any long-acting opioid such as OxyContin. Pharmacy mail orders for opioids are prohibited.

Doctors and others who prescribe must assess the patient’s risk of abusing drugs and develop a treatment plan that considers options other than opioids. And patients with chronic pain are referred to case managers who advise on therapies other than opioids.

By the end of 2015, the average monthly prescribing rate for opioids decreased almost 15 percent, from 34 per 1,000 members to 29. About 21 million fewer opioid doses were dispensed during the three years covered in the study.37

In another example, Highmark (Pennsylvania) shared data in December 2016 showing that the number of prescriptions for opioids it reimbursed in each of the past three months was lower than in any of the prior nine months. One leading health plan in the state reported that 16 percent of its insured population received at least one opioid prescription in 2016, down from 20 percent in 2015.38 UPMC Health Plan indicated it is using “an algorithm to identify patients who may be at risk for opioid addiction,” and training doctors to use other pain management tools.

Mounting Evidence & Support For Non-Pharmacologic Care For Acute, Subacute & Chronic Back, Neck & Neuro-Musculoskeletal Pain

The earlier sections of this white paper have focused on the continuing and growing problem of opioid use, abuse and addiction. It is essential that this information is understood and appreciated as it clearly calls for a wholesale change in the approach American health care providers and patients bring to the care and management of pain.

No matter what is done to address the use, abuse and addiction associated with opioids it is a fact of life that opioid containing products will continue to be required by individuals suffering severe, intractable and unrelenting pain.This issue is not about the cessation of all opioid use, rather it is about not turning to opioids before they are required, and not until all less onerous approaches to pain management have been exhausted.

We began this discussion with three questions in mind:


Without the use of drugs, how will they cope with pain?How can they get referrals and access to drug-free care that will be effective for both acute, subacute and chronic pain?How can they ensure that their health care plans and insurance will cover the cost of non- pharmacologic care?

According to new guidelines developed by the American College of Physicians,39 conservative non-drug treatments should be favored over drugs for most back pain. The guidelines are an update that include a review of more than 150 recent studies and conclude that,“For acute and subacute pain, the guidelines recommend non-drug therapies first, such as applying heat, massage, acupuncture, or spinal manipulation, which is often done by a chiropractor.”

The Wall Street Journal

As we have previously noted the CDC, FDA and IOM have all called for the early use of non- pharmacologic approaches to pain and pain management. Unfortunately, beyond asserting the need to move in this direction, little, if any, guidance has been offered to providers, patients and payors on how to accomplish this important transition.

It is a fact that a chasm exists between the worlds of pharmacologic based management of pain, and the non-pharmacologic based management of pain. Medical physicians are not going to suddenly attain knowledge and understanding of practices, procedures and management options that they have never been trained in or exposed to. Similarly, the non-pharmacologic providers addressing pain management do not encounter or understand the barriers that prevent prescribers from directing patients toward non-pharma approaches.These two spheres of healthcare are distinct and separate, and demonstrate little, if any, knowledge about the other.

The first step is to provide resources to prescribers that will detail the indications, effectiveness, efficiency and safety of non-pharmacologic approaches. In particular, the chiropractic profession, through its 70,000 practitioners in the United States, represents a significant and proven non- pharmacologic approach for reducing the need for opioids, opioid-related products and non- opioid pain medications.

Chiropractic, like other complementary health care approaches, suffers from a lack of awareness about its high level of education, credentialing and regulation. In addition, a substantial awareness gap exists among frontline providers in terms of referring patients to chiropractors as part of patient care.

The chiropractic profession and the health care consumer are equally supported by a robust oversight infrastructure.This infrastructure ranges from institutional and programmatic accreditation of chiropractic education by agencies recognized by the U.S. Department of Education to standardize national credentialing examinations and licensure by state agencies and ongoing professional development as a requirement for continued practice in many states.

Typically, after earning a Bachelor of Science, chiropractors follow a four-year curriculum to earn a Doctor of Chiropractic (DC) as a prerequisite to earning the right to independent practice. Chiropractic, medical, osteopathic, dental, optometric and naturopathic education share a similar foundation in the basic sciences, followed by discipline-specific content that focuses on the unique contribution of each provider type. For example, a medical student pursues the study of pharmacology and surgery, while a chiropractic student studies the intricacies of manual approaches to health care and the acquisition of the skills needed to perform spinal adjusting or manipulation.

Chiropractors also pursue specialization in specific areas, such as radiology, through structured residency programs, similar to other disciplines. DCs also pursue focus areas related to various methods of spinal adjusting and related patient management.

For over a century, DCs have studied the relationship between structure, primarily the spine, and function, primarily of the nervous system, and how this interrelationship impacts health and well- being. Due to this emphasis on the spine, chiropractors have become associated with spinal and skeletal pain syndromes, and bring their non-surgical, non-drug rationale to the management of these problems.

DCs are the quintessential example of non-pharmacologic providers of health care with particular expertise in neuro-musculoskeletal conditions.

A Look At The Evidence

While the United States is attempting to deal with its opioid epidemic, our nation is making only limited headway in providing non-pharmacologic approaches to patients with pain.

Over 100 million Americans suffer with chronic pain,40 and an estimated 75 to 85 percent of all Americans will experience some form of back pain during their lifetime. However, 50 percent of all patients who suffer from an episode of low back pain will have a recurrent episode within one year.41 Surgery has a very limited role in the management of spinal pain, and is only considered appropriate in a handful of cases per hundred patients. Likewise, opioids have very limited utility in the spinal pain environment with the recommended use of these drugs being limited to three days.

Of special relevance, this data relates to the most commonly-reported pain conditions:42


When asked about four common types of pain, respondents of a National Institute of Health Statistics survey indicated that low back pain was the most common (27 percent), followed by severe headache or migraine pain (15 percent), neck pain (15 percent) and facial ache or pain (4 percent).Back pain is the leading cause of disability in Americans under 45 years old. More than 26 million Americans between the ages of 20-64 experience frequent back pain.Adults with low back pain are often in worse physical and mental health than people who do not have low back pain: 28 percent of adults with low back pain report limited activity due to a chronic condition, as compared to 10 percent of adults who do not have low back pain. Also, adults reporting low back pain were three times as likely to be in fair or poor health and more than four times as likely to experience serious psychological distress as people without low back pain.

Results of a 2010 study indicate that DCs provide approximately 94 percent of the manipulation services performed in the U.S.,43 with a number of published studies documenting manipulation, along with other drug-free interventions, as effective for the management of neck44 and back pain.45 Most high-quality guidelines target the noninvasive management of nonspecific low back pain and recommend education, staying active/exercising, manual therapy, and paracetamol or NSAIDs as first-line treatments.46

Action Needed

Care pathways and clinical guidelines need to be modified to bring greater attention to the use of non-pharmacologic approaches to pain management. Primary medical care providers must be encouraged to make recommendations or referrals to drug-free resources and appropriate providers, such as DCs, rather than turning to the prescription pad when managing patients who have pain, particularly those with spinal pain. Patients should be educated about non- pharmacologic options for dealing with pain first and foremost, and the dangers of opioids.

For these good intentions to be effective, drug-free pathways will need to be funded by payers in the private sector and government. Government leadership and policy support for introducing innovative reimbursement initiatives by the CMS is a critical step toward allowing health providers to acquire familiarity with non-pharmaceutical approaches.These could frame and stimulate use of evidence-based care options and promote referrals, access to care and reimbursement. By re- engineering these approaches to care to fit the current health care landscape, rather than simply reacting to the opioid crisis by de-emphasizing pain treatment, CMS can better serve patients.

One example: CMS should consider a chronic pain shared-savings program targeting accountable care organizations (ACOs), where success is tied explicitly to patient functional outcomes. Benchmarking against ACO performance measures to determine if care results in savings or losses would allow these organizations to work towards meeting or exceeding quality performance standards – leading to receiving a portion of the savings generated. By incorporating incentives, this type of model would be consistent for more effective integrative intervention for pain.47

Fortunately, progressive thinking is gaining traction in this area. In a January 5, 2017 posting on the CMS Blog, authors wrote that the CMS is focusing on significant programs, including increased use of evidence-based practices for acute and chronic pain management.

“We are working with Medicare and Medicaid beneficiaries, their families and caregivers, health care providers, health insurance plans and states to improve how opioids are prescribed by providers and used by beneficiaries, how opioid use disorder is identified and managed, and how alternative approaches to pain management can be promoted.”48

While we applaud CMS, we feel it is important to point out that this approach begins with a focus on how opioids are prescribed.The focus needs to shift to early applications of non-pharmacologic approaches first and not as a follow-on after the drug path has been established.

Documented Results & Cost Savings

Back pain is the most common occupational injury in the United States and Canada,49 and represents the most common non-fatal occupational injury, according to the U.S. Bureau of Labor Statistics. Musculoskeletal disorders (MSDs), such as sprains or strains resulting from overexertion in lifting, accounted for 31 percent (356,910 cases) of the total cases for all workers.50

Most recently, Maine Department of Labor data showed injuries to a person’s lumbar region represented 14.3 percent of all injuries reported in 2014, up from 10.7 percent just five years earlier.51 Health care employees have among the highest rates of musculoskeletal injuries for workers, second only to those working in the transportation and warehousing sectors.52

Opiates are not a safe alternative especially when operating heavy machinery, transportation or caring for patients because side effects can alter performance and have tragic outcomes.

Take for example, a 56-year-old nurse at the Maine Medical Center in Portland. She relies on a comprehensive strategy to address her chronic back pain, which originates from having to wear heavy lead aprons when giving radiation treatments, and moving patients and equipment. Her regimen, which includes regularly seeing a chiropractor, exercises, stretches and building up her core muscles, has helped her to control her pain.53

In terms of the value of a “gatekeeper” health care provider for insured workers like this nurse, a study published in Journal of Occupation Rehabilitation (September 17, 2016) cites this factor as a significant predictor of the duration of the first episode of a worker’s compensation claim. They analyzed a cohort of 5,511 workers, comparing the duration of financial compensation and the occurrence of a second episode of compensation for back pain among patients seen by three types of first health care providers: physicians, chiropractors and physical therapists in the context of workers’ compensation.54

When compared with medical doctors, chiropractors were associated with shorter duration of compensation and physical therapists (PT) with longer ones.There was also greater likelihood that PT patients were more likely to seek additional types of care that incurred longer compensation duration.

Additionally, earlier research confirms that on a case adjusted basis 42.7 percent of workers who initially visited a surgeon underwent surgery compared with only 1.5 percent of those who first consulted a chiropractor.55


The National Academy for State Health Policy (NASHP), an independent academy of state health policymakers dedicated to helping states achieve excellence in health policy and practice, recently studied chronic pain management therapies in Medicaid, including policy considerations for non-pharmacological alternatives to opioids. A non-profit and non-partisan organization, NASHP provides a forum for constructive work across branches and agencies of state government on critical health issues.56


“Has your Medicaid agency implemented specific policies or programs to encourage or require alternative pain management strategies in lieu of opioids for acute or chronic non-cancer pain?”

A September 2016 NASHP report states that although most Medicaid agencies cover services that can be used as alternatives to opioids for pain management, significantly fewer states have policies or procedures in place to encourage their use.

Between March and June 2016, NASHP conducted a survey of all 51 Medicaid agencies to determine the extent to which states have implemented specific programs or policies to encourage or require non-opioid therapies for acute or chronic non-cancer pain.They contacted each Medicaid director via email and, in cases of non-response, followed up with Medicaid medical directors. Ultimately, they received responses from 41 states and the District of Columbia.

Because reimbursement is a key incentive to access alternative care, they also note the most recent results of Medicaid agency reimbursement data from The Henry J. Kaiser Family Foundation (KFF):57

• 27 reimbursed chiropractic services;
• 36 reimbursed occupational therapy services;
• 38 reimbursed psychologist services;
• 39 reimbursed physical therapy services.

Among the key findings, researchers found most Medicaid agencies cover services that can be used to treat pain in lieu of opioids, but less than half have taken steps to specifically encourage or require their use. Non-pharmacological therapies commonly used to address pain include physical therapy, cognitive behavioral therapy, and exercise, as well as other services, commonly known as Complementary and Alternative Medicine (CAM), including chiropractic manipulation, acupuncture and massage.

They point out that while the current literature on non-pharmacological alternatives is mixed, there is a growing body of evidence to support the use of alternative services to treat chronic pain. For example, a systematic review suggests lower costs for patients experiencing spine pain who received chiropractic care.58

This finding is substantiated in Rhode Island, where the state’s Section 1115 Demonstration authorizes certain individuals enrolled in Medicaid managed care delivery systems to receive CAM services for chronic pain.59 Rhode Island Medicaid has implemented this benefit through its Communities of Care program, a state initiative designed to reduce unnecessary emergency room utilization. Medicaid managed care enrollees with four or more emergency room visits within a 12-month period are eligible to receive acupuncture, chiropractic or massage therapy services.

The state’s two managed care plans, Neighborhood Health Plan of Rhode Island (NHPRI) and United HealthCare of New England, were responsible for developing participation criteria for their enrollees. For example, NPRHI published clinical practice guidelines for its Ease the Pain program, which specified when CAM services referrals were appropriate. Under NHPRI’s guidelines, qualifying individuals diagnosed with back pain, neck pain, and fibromyalgia can be referred for chiropractic services, acupuncture and massage.

Substantiating the results for CAM, Advanced Medicine Integration Group, L.P. in Rhode Island contracted with the two health plans to identify and manage their Medicaid eligible members suffering from chronic pain through its Integrated Chronic Pain Program (ICPP).The target Medicaid population for this program was the Community of Care (CoC) segment — high utilizers of ER visits and opioids/pharmaceuticals.

The objectives of the ICPP are to reduce pain levels (and opioid use), improve function and overall health outcomes, reduce emergency room costs and, through a holistic approach and behavioral change models, educate members in self-care and accountability.

The design of the program for this patient population features holistic nurse case management with directed use of patient education, community services and CAM modalities, including chiropractic care, acupuncture and massage.

Individuals with chronic pain conditions were identified using proprietary predictive modeling algorithms applied to paid claims data to determine opportunities for reducing chronic pain-related utilization and costs.

Results for enrolled CoC Medicaid members with chronic pain conditions document:


Reduced per member per year (PMPY) total average medical costs by 27 percentDecreased the average number of ER visits by 61 percentLowered the number of average total prescriptions by 63 percentReduced the average number of opioid scripts by 86 percent

These reductions exceeded by two to three times those reported for a non-enrolled control group of conventionally managed CoC chronic pain patients. Every $1 spent on CAM services and program fees resulted in $2.41 of medical expense savings.


At the time of publication, a study entitled: Assessment of Chiropractic Treatment for Low Back Pain and Smoking Cessation in Military Active Duty Personnel, has completed its clinical trial activities and is currently in the analysis phase. Funded by a four-year grant from the Department of Defense, it is the largest multi-site clinical trial on chiropractic to date, with a total sample size of 750 active- duty military personnel.60

The purpose of this study is to evaluate the effectiveness of chiropractic manipulative therapy for pain management and improved function in active duty service members with low back pain that do not require surgery.The study also measures the impact of a tobacco cessation program delivered to participants allocated to the chiropractic arm.

Low back pain (LBP) is the most common cause of disability worldwide, but it is even more prevalent in active duty military personnel. More than 50 percent of all diagnoses resulting in disability discharges from the military across all branches are due to musculoskeletal conditions. LBP has been characterized as “The Silent Military Threat” because of its negative impact on mission readiness and the degree to which it compromises a fit fighting force. For these reasons, military personnel with LBP need a practical and effective treatment that relieves their pain and allows them to return to duty quickly. It must preserve function and military readiness, address the underlying causes of the episode and protect against re-injury.

This multisite Phase II Clinical Comparative Effectiveness Trial is designed to rigorously compare the outcomes of chiropractic manipulative therapy (CMT) and conventional medical care (CMC) to CMC alone. Chiropractic treatment will include CMT plus ancillary physiotherapeutic interventions. CMC will be delivered following current standards of medical practice at each site. At each of the four participating sites, active military personnel, ages 18 to 50, who present with acute, sub-acute or chronic LBP that does not require surgery will be randomized to one of the two treatment groups.

Outcome measures include the Numerical Rating Scale for pain, the Roland-Morris Low Back Pain and Disability questionnaire, the Back Pain Functional Scale for assessing function, and the Global Improvement questionnaire for patient perception regarding improvement in function. Patient Expectation and Patient Satisfaction questionnaires will be used to examine volunteer expectations toward care and perceptions of that care. Pharmaceutical use and duty status data will also be collected.The Patient Reported Outcomes Measurement Information System (PROMIS-29) will be utilized to compare the general health component and quality of life of the sample at baseline.

Also, because DCs are well positioned to provide information to support tobacco cessation, this clinical trial includes a nested study designed to measure the impact of a tobacco cessation program delivered by a DC.The results will provide critical information regarding the health and mission-support benefits of chiropractic health care delivery for active duty service members in the military.61

This current research was preceded by a pilot study on LBP, conducted at an Army Medical Center in El Paso,Texas, with 91 active-duty military personnel between the ages of 18 and
35.62 Results reported in the journal SPINE showed that 73 percent of those who received standard medical care and chiropractic care rated their improvement as pain “completely gone,”“much better” or “moderately better.” In comparison, 17 percent of participants who received only standard medical care rated their improvement this way.These results, as well as other measures of pain and function between the two groups, are considered both clinically and statistically significant.

Recommendations & Next Steps

The opioid crisis has provided a wake-up call for regulators, policy experts, clinicians and payers nationwide. As the support for complementary health techniques builds, interdisciplinary and integrative approaches to chronic pain management are considered best practices.

While the Centers for Disease Control and Prevention’s Guideline validates the need for a shift away from the utilization of opioid prescription painkillers as a frontline treatment option for pain relief, the mention of chiropractic care as a safe, effective and drug-free alternative is omitted.

Instead, CDC recommendations encourage utilization of physical therapy, exercise and over- the-counter (OTC) pain medications prior to prescription opioids for chronic pain.63

“Though the guidelines are voluntary, they could be widely adopted by hospitals, insurers and state and federal health systems.”

CBS News64

The CDC rarely advises physicians on how to prescribe medication — which further adds to the significance of their pronouncements. Many payers and state legislators have already added these findings to their coverage on the use of opioids.

With the likelihood of major players in the industry adopting the well-respected guidelines, it is critical that chiropractic care receives the consideration it deserves.

Chiropractic care has earned a leading role as a pain relief option and is regarded as an important element of the nation’s Opioid Exit Strategy: a drug-free, non-invasive and cost-effective alternative for acute or chronic neck, back and musculoskeletal pain management.

For individuals who may be suddenly “cut-off” from painkillers, chiropractic offers a solution. But access to care will depend upon several important factors:


Pharmaceutical Industry “Re-engineering”: A change toward responsible marketing and physician education.Physician Referrals to Ensure Access to Chiropractic Care: Physician prescribing of chiropractic care rather than opioids.Benefit Coverage and Reimbursement for Chiropractic Care: Government and commercial payers as well as plan sponsors have a responsibility to offer patients the option of chiropractic care – and reimburse DCs as participating providers.Access to Chiropractic Care for Active Military and Veteran Populations: Chiropractic care should be expanded in the Department of Defense and veterans’ health care systems.

As a nation, we have all come to recognize that pain is a complex, multifaceted condition that impacts millions of Americans, their families and caregivers. Unfortunately, the lessons learned about long-term opioid therapy for non-cancer pain have been deadly and heartbreaking.We now understand that there is little to no evidence to support their effectiveness for ongoing chronic pain management.

It is now incumbent upon all stakeholders to increasingly explore the appropriateness, efficacy and cost-effectiveness of alternative pain management therapies and embrace these solutions as a realistic opportunity for America’s Opioid Exit Strategy.

End Notes

1 Ingraham, Christopher; Heroin deaths surpass gun homicides for the first time, CDC data shows. Washington Post, December
8, 2016. https://www.washingtonpost.com/news/wonk/wp/2016/12/08/heroin-deaths-surpass-gun-homicides-for-thefirst-time-cdc-data-show/?utm_term=.38c3d6096d4d;
accessed December 8, 2016.
2 Ronan, M. V., & Herzig, S. J. (2016). Hospitalizations Related To Opioid Abuse/Dependence And Associated Serious Infections
Increased Sharply, 2002–12. Health Affairs, 35(5), 832-837. doi:10.1377/hlthaff.2015.1424.
3 J Manag Care Spec Pharm. [Published online January 3, 2017].Academy of Managed Care Pharmacy.
4 Dallas, Mary Elizabeth; Opoid Epidemic Costs U.S. $78.5 Billion Annually; HealthDay, September 21, 2016.
5 Comprehensive Addiction and Recovery Act (CARA);
6 DeBonis, Mike; 21st Century Cures Act, boosting research and easing drug approvals; Washington Post, December 8, 2016;
7 Hiltzik, Michael; The 21st Century Cures Act; LA Times, January 5, 2017. http://www.latimes.com/business/hiltzik/la-fi-hiltzik-
8 U.S. Surgeon General Declares War on Addiction; Medline Plus, November 17, 2016;
https://medlineplus.gov/news/fullstory_162081.html; accessed December 7, 2016.
9 Obama Administration announces Prescription Opioid and Heroin Epidemic Awareness Week; Proclamation by
President Obama, September 16, 2016. https://www.whitehouse.gov/the-press-office/2016/09/19/fact-sheet-obama-administration-announces-prescription-opioid-and-heroin
10 Obama Administration announces Prescription Opioid and Heroin Epidemic Awareness Week, 2016
11 Shedrofsky, Karma; Drug czar: Doctors, drugmakers share blame for opioid epidemic; USA Today, July 7, 2016; http://
accessed January 1, 2017.
12 Pallarito, Karen; Rising Price of Opioid OD Antidote Could Cost Lives: Study; Health Day News, December 8, 2016. https://
accessed December 8, 2016.
13 Gupta, R., Shah, N. D., & Ross, J. S. (2016). The Rising Price of Naloxone — Risks to Efforts to Stem Overdose Deaths. New
England Journal of Medicine, 375(23), 2213-2215. doi:10.1056/nejmp1609578
14 Cha, Ariana Eunjung; The drug industry’s answer to opioid addiction: More pills, October 16, 2016;
accessed December 8, 2016.
15 Cha, Ariana Eunjung, 2016.
16 Shedrrofsky, Karma, 2016.
17 America’s Painkiller Epidemic, Explained; The Week, February 13, 2016;
18 Wing, Nick; DEA Is Cutting Production Of Prescription Opioids By 25 Percent In 2017; Huffington Post, October 5, 2016;
19 Mulvihill, Geoff, Whyte, Liz Essley, Wieder, Ben; Politics of pain: Drugmakers fought state opioid limits amid crisis; The Center
for Public Inegrity, December 15, 2016. https://www.publicintegrity.org/2016/09/18/20200/politics-pain-drugmakersfought-state-opioid-limits-amid-crisis;
accessed December 20, 2016.
ADJUVANT TO BUPIVACAINE, Journal of Evolution of Medical and Dental Sciences;
https://jemds.com/latest-articles.php?at_id=7552; accessed December 31, 2016.
21 CDC: 10 Most Dangerous Drugs Linked to Overdose Deaths, Health Day, December 22, 2016. http://www.empr.com/
news/cdc-10-most-dangerous-drugs-linked-to-overdose-deaths/article/580540/; accessed January 1, 2017.
22 Mulvihill et.al.., 2016.
23 Mulvihill et.al.., 2016.
24 Mulvihill, et. al., 2016.
25 Cha, Ariana Eunjung, 2016.
26 Cha, Ariana Eunjung, 2016.
©2017 Foundation for Chiropractic Progress PAGE 27
27 Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS). 2014
28 Thompson, Dennis; Drug Overdose Deaths Climb Dramatically in U.S.; HealthDay News, December 20, 2016;
accessed December 23, 2016.
29 Bernstein, Lenny; Crites, Alice, Higham, Scott, and Rich, Steven; Drug industry hired dozens of officials from the DEA as
the agency tried to curb opioid abuse; The Washington Post, December 22, 2016; https://www.washingtonpost.com/
30 Siegel, Marc, MD; We doctors are enablers: A physician’s take on the opioid epidemic; FOXNews, December 21, 2016;
accessed January 4, 2017.
31 Freyer, Felice J.; Doctors are cutting opioids, even if it harms patients; Boston Globe, January 3, 2017;
32 Blair, Nolan; Doctors prescribing less opioids; ABC WBAY.com, November 2, 2016.
33 Centers for Disease Control; https://www.cdc.gov/drugoverdose/pdmp/; accessed January 5, 2017.
34 Lord, Rich; Attention to opioids may be curbing doctors prescriptions; Pittsburgh Post-Gazette, December 26, 2016; http://
35 Nuzum, Lydia; Opioid prescriptions in US, WV down for first time in two decades; The Charleston Gazette-Mail, June 6, 2016.
36 Freyer, Felice J.; Opioid prescriptions drop among patients covered by state’s biggest insurer; Boston Globe, October 20,
2016; https://www.bostonglobe.com/metro/2016/10/20/opioid-prescriptions-drop-significantly-among-patients-covered-state-biggest-insurer/06jIYorfogaG2o8Wrhr8ZN/story.html
37 Freyer, Felice J., 2016.
38 U.S. Agency for Healthcare Research and Quality, Opioid Overdoses Burden U.S. Hospitals: Report, HealthDay News, December
15, 2016. https://consumer.healthday.com/public-health-information-30/heroin-news-755/opioid-overdoses-taketoll-on-u-s-hospitals-717872.html;
accessed December 16, 2016.
39 Reddy, S. (2017, February 13). No Drugs for Back Pain, New Guidelines Say. Retrieved from
40 Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in
America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011.
41 American Association of Neurological Surgeons; Low Back Pain, May 2016. http://www.aans.org/Patientpercent20Information/Conditionspercent20andpercent20Treatments/Lowpercent20Backpercent20Pain.aspx
42 American Academy of Pain Medicine; Facts and Figures About Pain;
http://www.painmed.org/PatientCenter/Facts_on_Pain.aspx#refer; accessed January 7, 2017.
43 Daniel C. Cherkin, Robert D. Mootz; Chiropractic in the United States: Training, Practice, and Research, 2010.
Chiropractic in the United States: Training, Practice, and Research”; accessed January 17, 2017.
44 Wong, J. J., Shearer, H. M., Mior, S., Jacobs, C., Côté, P., Randhawa, K., . . . Taylor-Vaisey, A. (2016). Are manual therapies, passive
physical modalities, or acupuncture effective for the management of patients with whiplash-associated disorders or
neck pain and associated disorders? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated
Disorders by the OPTIMa collaboration. The Spine Journal, 16(12), 1598-1630. doi:10.1016/j.spinee.2015.08.024.
45 Spinal Manipulation for Low-Back Pain. (2016, April 20). Retrieved January 17, 2017, from
46 Wong, J., Côté, P., Sutton, D., Randhawa, K., Yu, H., Varatharajan, S., . . . Taylor-Vaisey, A. (2016). Clinical practice guidelines for
the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management
(OPTIMa) Collaboration. European Journal of Pain, 21(2), 201-216. doi:10.1002/ejp.931
47 Doctor, Jason, October 4, 2016.
48 Goodrich, Kate, MD; Agrawal, Shantanu, MD; The CMS Blog; Addressing the Opioid Epidemic: Keeping Medicare and Medicaid
Beneficiaries Healthy, January 5, 2017; https://blog.cms.gov/2017/01/05/addressing-the-opioid-epidemic/
49 Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine.
2006;31(23):2724–7. doi:10.1097/01.brs.0000244618.06877.cd
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50 Bureau of Labor Statistics; Nonfatal Occupational Injuries and Illnesses Requiring Days Away From Work, 2015,
November 10, 2016; https://www.bls.gov/news.release/osh2.nr0.htm; accessed January 8, 2017.
51 Lawlor, Joe; Back injuries most common type of injuries for workers; Portland Press Herald, October 16, 2016; http://www.
pressherald.com/2016/10/16/back-injuries-most-common-type-of-injuries-for-workers/; accessed 1.8.2017.
52 La

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Vertebrobasilar Stroke, Chiropractic Care & Risks | El Paso Back Clinic® • 915-850-0900

Vertebrobasilar Stroke, Chiropractic Care & Risks | El Paso Back Clinic® • 915-850-0900 | heaith | Scoop.it
Results Of A Population-Based Case-Control & Case-Crossover Study

J. David Cassidy, DC, PhD, DrMedSc,*†‡ Eleanor Boyle, PhD,* Pierre Coˆte ́, DC, PhD,*†‡§ Yaohua He, MD, PhD,* Sheilah Hogg-Johnson, PhD,†§ Frank L. Silver, MD, FRCPC, and Susan J. Bondy, PhD†


SPINE Volume 33, Number 4S, pp S176 –S183 ©2008, Lippincott Williams & Wilkins


Neck pain is a common problem associated with consid- erable comorbidity, disability, and cost to society.1–5 In North America, the clinical management of back pain is provided mainly by medical physicians, physi- cal therapists and chiropractors.6 Approximately 12% of American and Canadian adults seek chiropractic care annually and 80% of these visits result in spinal manipulation.7,8 When compared to those seeking medical care for back pain, Canadian chiropractic pa- tients tend to be younger and have higher socioeco- nomic status and fewer health problems.6,8 In On- tario, the average number of chiropractic visits per episode of care was 10 (median 6) in 1985 through 1991.7 Several systematic reviews and our best- evidence synthesis suggest that manual therapy can benefit neck pain, but the trials are too small to eval- uate the risk of rare complications.9 –13


Two deaths in Canada from vertebral artery dissection and stroke following chiropractic care in the 1990s attracted much media attention and a call by some neurologists to avoid neck manipulation for acute neck pain.14 There have been many published case reports linking neck manipulation to vertebral artery dissection15 and stroke. The prevailing theory is that extension and/or rotation of the neck can damage the vertebral artery, particularly within the foramen transversarium at the C1–C2 level. Activities leading to sudden or sustained rotation and extension of the neck have been implicated, included motor vehicle collision, shoulder checking while driving, sports, lifting, working over- head, falls, sneezing, and coughing.16 However, most cases of extracranial vertebral arterial dissection are thought to occur spontaneously, and other factors such as connective tissue disorders, migraine, hyper- tension, infection, levels of plasma homocysteine, vessel abnormalities, atherosclerosis, central venous catherization, cervical spine surgery, cervical percutaneous nerve blocks, radiation therapy and diagnostic cerebral angiography have been identified as possible risk factors.17–21


The true incidence of vertebrobasilar dissection is un- known, since many cases are probably asymptomatic, or the dissection produces mild symptoms.22 Confirming the diagnosis requires a high index of suspicion and good vascular imaging. The cases that are most likely to be diagnosed are those that result in stroke.19,22 Ischemic stroke occurs when a thrombus develops intraluminally and embolizes to more distal arteries, or less commonly, when the dissection extends distally into the intracranial vertebral artery, obliterating branching vessels.22 The best incidence estimate comes from Olmstead county, where vertebral artery dissection causing stroke affected 0.97 residents per 100,000 population between 1987 and 2003.23


To date there have been two case-control studies of stroke following neck manipulation. Rothwell et al used Ontario health data to compare 582 cases of VBA stroke to 2328 age and sex-matched controls.24 For those aged 45 years, cases were five times more likely than con- trols to have visited a chiropractor within 1 week of VBA stroke. Smith et al studied 51 patients with cervical ar- tery dissection and ischemic stroke or transient ischemic attack (TIA) and compared them to 100 control patients suffering from other strokes not caused by dissections.25 Cases and controls came from two academic stroke cen- ters in the United States and were matched on age and sex. They found no significant association between neck manipulation and ischemic stroke or TIA. However, a subgroup analysis showed that the 25 cases with verte- bral artery dissection were six times more likely to have consulted a chiropractor within 30 days before their stroke than the controls.


Finally, because patients with vertebrobasilar artery dissection commonly present with headache and neck pain,23 it is possible that patients seek chiropractic care for these symptoms and that the subsequent VBA stroke occurs spontaneously, implying that the associ- ation between chiropractic care and VBA stroke is not causal.23,26 Since patients also seek medical care for headache and neck pain, any association between pri- mary care physician (PCP) visits and VBA stroke could be attributed to seeking care for the symptoms of verte- bral artery dissection.


The purpose of this study is to investigate the association between chiropractic care and VBA stroke and compare it to the association between recent PCP care and VBA stroke using two epidemiological designs. Evidence that chiropractic care increases the risk of VBA stroke would be present if the measured association between chiropractic visits and VBA stroke exceeds the association between PCP visits and VBA strokes.

Study Design

We undertook population-based case-control and case- crossover studies. Both designs use the same cases. In the case- control design, we sampled independent control subjects from the same source population as the cases. In the case-crossover design, cases served as their own controls, by sampling control periods before the study exposures.27 This design is most appropriate when a brief exposure (e.g., chiropractic care) causes a transient change in risk (i.e., hazard period) of a rare-onset disease (e.g., VBA stroke). It is well suited to our research questions, since within person comparisons control for unmeasured risk factors by design, rather than by statistical modeling.28 –30 Thus the advantage over the case control design is better control of confounding.

Source Population

The source population included all residents of Ontario (109,020,875 person-years of observation over 9 years) covered by the publicly funded Ontario Health Insurance Plan (OHIP). Available utilization data included hospitalizations with diagnostic coding, and practitioner (physician and chiropractic) utilization as documented by fee-for-service billings accompanied by diagnostic coding. We used two data sources: (1) the Discharge Abstract Database (DAD) from the Canadian Institute for Health Information, which captures hospital separations and ICD codes, and (2) the OHIP Databases for services provided by physicians and chiropractors. These data- bases can be linked from April 1992 onward.


We included all incident vertebrobasilar occlusion and stenosis strokes (ICD-9433.0 and 433.2) resulting in an acute care hospital admission from April 1, 1993 to March 31, 2002. Codes were chosen in consultation with stroke experts and an epidemiologist who participated in a similar past study (SB).24 Cases that had an acute care hospital admission for any type of stroke (ICD-9433.0, 433.2, 434, 436, 433.1, 433.3, 433.8, 433.9, 430, 431, 432, and 437.1), transient cerebral ischemia (ICD- 9435) or late effects of cerebrovascular diseases (ICD-9438) before their VBA stroke admission or since April 1, 1991 were excluded. Cases residing in long-term care facilities were also excluded. The index date was defined as the hospital admission date for the VBA stroke.


For the case-control study, four age and sex-matched controls were randomly selected from the Registered Persons Database, which contains a listing of all health card numbers for Ontario. Controls were excluded if they previously had a stroke or were residing in a long-term care facility.


For the case crossover study, four control periods were randomly chosen from the year before the VBA stroke date, using a time-stratified approach.31 The year was divided into disjoint strata with 2 week periods between the strata. For the 1 month hazard period, the disjoint strata were separated by 1 month periods and the five remaining control periods were used in the analyses. We randomly sampled disjoint strata because chiropractic care is often delivered in episodes, and this strategy eliminates overlap bias and bias associated with time trends in the exposure.32


All reimbursed ambulatory encounters with chiropractors and PCPs were extracted for the one-year period before the index date from the OHIP database. Neck-related chiropractic visits were identified using diagnostic codes: C01–C06, cervical and cervicothoracic subluxation; C13–C15, multiple site subluxation; C30, cervical sprain/strain; C40, cervical neuritis/ neuralgia; C44, arm neuritis/neuralgia; C50, brachial radiculitis; C51, cervical radiculitis; and C60, headache. For PCP visits, we included community medicine physicians if they submitted ambulatory fee codes to OHIP. Fee codes for group therapy and signing forms were excluded. Headache or neck pain- related PCP visits were identified using the diagnostic codes: ICD-9307, tension headaches; 346, migraine headaches; 722, intervertebral disc disorders; 780, headache, except tension headache and migraine; 729, fibrositis, myositis and muscular rheumatism; and 847, whiplash, sprain/strain and other traumas associated with neck (These codes include other diagnoses, and we list only those relevant to neck pain or headache). There is no limit on the number of reimbursed PCP visits per year. However, there are limits chiropractors, but less than 15% of patients surpass them.24

Statistical Analysis

Conditional logistic regression was used to estimate the asso- ciation between VBA stroke after chiropractor and PCP visits. Separate models were built using different a priori specified hazard periods, stratified by age ( 45 years and 45 years) and by visits with or without head and neck pain related diag- nostic codes. For the chiropractic analysis, the index date was included in the hazard period, since chiropractic treatment might cause immediate stroke and patients would not normally consult a chiropractor after having a stroke. However, the in- dex day was excluded from the PCP analysis, since patients might consult these physicians after experiencing a stroke. We tested different hazard periods, including 1 day, 3 days, 1 week, 2 weeks, and 1 month before the index date. Exposure occurred if any chiropractic or PCP visits were recorded during the des- ignated hazard periods.


We also measured the effect of cumulative numbers of chiropractic and PCP visits in the month before the index date by computing the odds ratio for each incremental visit. These estimates were similarly stratified by age and by diagnostic codes related to headache and/or neck pain. Finally, we conducted analyses to determine if our results were sensitive to chiropractic and PCP visits related to neck complaints and headaches. We report our results as odds ratios (OR) and 95% confidence intervals. Confidence intervals were estimated by accelerated bias corrected bootstraps with 2000 replications using the variance co-variance method.33 All statistical analyses were per- formed using STATA/SE version 9.2.34


A total of 818 VBA strokes met our inclusion/exclusion criteria over the 9 year inception period. Of the 3272 matched control subjects, 31 were excluded because of prior stroke, one had died before the index date and 76 were receiving long-term care. Thus, 3164 control subjects were matched to the cases. The mean age of cases and controls was 63 years at the index date and 63% were male. Cases had a higher proportion of comorbid conditions (Table 1). Of the 818 stroke cases, 337 (41.2%) were coded as basilar occlusion and stenosis, 443 (54.2%) as vertebral occlusion and stenosis and 38 (4.7%) had both codes.


Overall, 4% of cases and controls had visited a chiropractor within 30 days of the index date, while 53% of cases and 30% of controls had visited a PCP within that time (Table 2). For those under 45 years of age, 8 cases (7.8%) had consulted a chiropractor within 7 days of the index date, compared to 14 (3.4%) of controls. For PCPs, 25 cases (24.5%) under 45 years of age had a consultation within 7 days of the index date, com- pared to 27 (6.6%) of controls. With respect to the number of visits within 1 month of the index date, 7.8% of cases under the age of 45 years had three or more chiropractic visits, whereas 5.9% had three or more PCP visits (Table 2).


The case control and case crossover analyses gave similar results. (Tables 3–7) Age modified the effect of chiropractic visits on the risk of VBA stroke. For those under 45 years of age, there was an increased association between chiropractic visits and VBA stroke regardless of the hazard period. For those 45 years of age and older, there was no association. Each chiropractic visit in the month before the index date was associated with an in- creased risk of VBA stroke in those under 45 years of age (OR 1.37; 95% CI 1.04–1.91 from the case crossover analysis) (Table 7). We were not able to estimate boot- strap confidence intervals in some cases because of sparse data.


Similarly, we found that visiting a PCP in the month before the index date was associated with an increased risk of VBA stroke regardless of the hazard period, or the age of the subject. Each PCP visit in the month before the stroke was associated with an increased risk of VBA stroke both in those under 45 years of age (OR 1.34; 95% CI 0.94 –1.87 from the case crossover analysis) and 45 years and older (OR 1.52; 95% CI 1.36–1.67 from the case crossover analysis) (Table 7).


Our results were sensitive to chiropractic and PCP visits related to neck complaints and headaches, and we observed sharp increases in the associations when restricting the analyses to these visits (Tables 3–7). Overall, these associations were more pronounced in the PCP analyses. However, the data are sparse, and we were unable to compute bootstrap confidence intervals in many cases.


Our study advances knowledge about the association between chiropractic care and VBA stroke in two respects. First, our case control results agree with past case control studies that found an association between chiropractic care and vertebral artery dissection and VBA stroke.24,25 Second, our case crossover results confirm these findings using a stronger research design with better control of confounding variables. The case-crossover design controls for time independent confounding factors, both known and unknown, which could affect the risk of VBA stroke. This is important since smoking, obesity, undiagnosed hypertension, some connective tis- sue disorders and other important risk factors for dissection and VBA stroke are unlikely to be recorded in ad- ministrative databases.


We also found strong associations between PCP visits and subsequent VBA stroke. A plausible explanation for this is that patients with head and neck pain due to vertebral artery dissection seek care for these symptoms, which precede more than 80% of VBA strokes.23 Since it is unlikely that PCPs cause stroke while caring for these patients, we can assume that the observed association between recent PCP care and VBA stroke represents the background risk associated with patients seeking care for dissection-related symptoms leading to VBA stroke. Be- cause the association between chiropractic visits and VBA stroke is not greater than the association between PCP visits and VBA stroke, there is no excess risk of VBA stroke from chiropractic care.


Our study has several strengths and limitations. The study base includes an entire population over a 9-year period representing 109,020,875 person-years of observation. Despite this, we found only 818 VBA strokes, which limited our ability to compute some estimates and bootstrap confidence intervals. In particular, our age stratified analyses are based on small numbers of ex- posed cases and controls (Table 2). Further stratification by diagnostic codes for headache and neck pain related visits imposed even greater difficulty with these estimates. However, there are few databases that can link incident VBA strokes with chiropractic and PCP visits in a large enough population to undertake a study of such a rare event.


A major limitation of using health administrative data are misclassification bias, and the possibility of bias in assignment of VBA-related diagnoses, which has previously been raised in this context.24 Liu et al have shown that ICD-9 hospital discharge codes for stroke have a poor positive predictive value when compared to chart review.35 Furthermore, not all VBA strokes are secondary to vertebral artery dissection and administrative databases do not provide the clinical detail to determine the specific cause. To investigate this bias, we did a sensitivity analysis using different positive predictive values for stroke diagnosis (ranging from 0.2 to 0.8). Assuming non differential misclassification of chiropractic and PCP cases, our analysis showed attenuation of the estimates towards the null with lower positive predictive values, but the conclusions did not change (i.e., associations remained positive and significant—data not shown).

The reliability and validity of the codes to classify headache and cervical visits to chiropractors and PCPs is not known.


It is also possible that patients presenting to hospital with neurologic symptoms who have recently seen a chiropractor might be subjected to a more vigorous diagnostic workup focused on VBA stroke (i.e., differential misclassification).36 In this case, the predictive values of the stroke codes would be greater for cases that had seen a chiropractor and our results would underestimate the association between PCP care and VBA stroke.


A major strength of our study is that exposures were measured independently of case definition and handled identically across cases and controls. However, there was some overlap between chiropractic care and PCP care. In the month before their stroke, only 16 (2.0%) of our cases had seen only a chiropractor, while 20 (2.4%) had seen both a chiropractor and PCP, and 417 (51.0%) had just seen only a PCP. We were not able to run a subgroup analysis on the small number of cases that just saw a chiropractor. However, subgroup analysis on the PCP cases (n 782) that did not visit a chiropractors during the 1 month before their stroke did not change the conclusions (data not shown).


Our results should be interpreted cautiously and placed into clinical perspective. We have not ruled out neck manipulation as a potential cause of some VBA strokes. On the other hand, it is unlikely to be a major cause of these rare events. Our results suggest that the association between chiropractic care and VBA stroke found in previous studies is likely explained by present- ing symptoms attributable to vertebral artery dissection. It might also be possible that chiropractic manipulation, or even simple range of motion examination by any practitioner, could result in a thromboembolic event in a patient with a pre-existing vertebral dissection. Unfortunately, there is no acceptable screening procedure to identify patients with neck pain at risk of VBA stroke.37 These events are so rare and difficult to diagnose that future studies would need to be multi-centered and have unbiased ascertainment of all potential exposures. Given our current state of knowledge, the decision of how to treat patients with neck pain and/or headache should be driven by effectiveness and patient preference.38


Our population-based case-control and case-crossover study shows an association between chiropractic visits and VBA strokes. However, we found a similar association between primary care physician visits and VBA stroke. This suggests that patients with undiagnosed vertebral artery dissection are seeking clinical care for head- ache and neck pain before having a VBA stroke.


The authors acknowledge the members of the Decade of the Bone and Joint 2000 –2010 Task Force on Neck Pain and its Associate Disorders for advice about de- signing this study. In particular, they acknowledge the help of Drs. Hal Morgenstern, Eric Hurwitz, Scott Haldeman, Linda Carroll, Gabrielle van der Velde, Lena Holm, Paul Peloso, Margareta Nordin, Jaime Guzman, Eugene Carragee, Rachid Salmi, Alexander Grier, and Mr. Jon Schubert.


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9. Aker PD, Gross AR, Goldsmith CH, et al. Conservative management of mechanical neck pain: systematic overview and meta-analysis. BMJ 1996; 313:1291–6.
10. Gross AR, Kay T, Hondras M, et al. Manual therapy for mechanical neckdisorders: a systematic review. Man Ther 2002;7:131–49.
11. Hurwitz EL, Aker PD, Adams AH, et al. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Spine 1996;21:1746–59.
12. McClune T, Burton AK, Waddell G. Whiplash associated disorders: a review of the literature to guide patient information and advice. Emerg Med J 2002;19:499–506.
13. Peeters GG, Verhagen AP, de Bie RA, et al. The efficacy of conservative treatment in patients with whiplash injury: a systematic review of clinical trials. Spine 2001;26:E64–E73.
14. Norris JW, Beletsky V, Nadareishvili ZG. Sudden neck movement and cervical artery dissection. The Canadian Stroke Consortium. CMAJ 2000;163:38–40.
15. Ernst E. Manipulation of the cervical spine: a systematic review of case reports of serious adverse events, 1995–2001. Med J Aust 2002;176:376–80.
16. Haldeman S, Kohlbeck FJ, McGregor M. Risk factors and precipitating neckmovements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine 1999;24:785–94.
17. Rubinstein SM, Peerdeman SM, van Tulder MW, et al. A systematic reviewof the risk factors for cervical artery dissection. Stroke 2005;36:1575–80.
18. Inamasu J, Guiot BH. Iatrogenic vertebral artery injury. Acta Neurol Scand 2005;112:349–57.
19. Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 2001;344:898–906.
20. D’Anglejan-Chatillon J, Ribeiro V, Mas JL, et al. Migraine—a risk factor for dissection of cervical arteries. Headache 1989;29:560–1.
21. Pezzini A, Caso V, Zanferrari C, et al. Arterial hypertension as risk factor for spontaneous cervical artery dissection. A case-control study. J Neurol Neurosurg Psychiatry 2006;77:95–7.
22. Savitz SI, Caplan LR. Vertebrobasilar disease. N Engl J Med 2005;352: 2618–26.
23. Lee VH, Brown RD Jr, Mandrekar JN, et al. Incidence and outcome of cervical artery dissection: a population-based study. Neurology 2006;67: 1809–12.
24. Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case-control study. Stroke 2001;32:1054–60.
25. Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology 2003;60: 1424–8.
26. Arnold M, Bousser MG, Fahrni G, et al. Vertebral artery dissection: presenting findings and predictors of outcome. Stroke 2006;37:2499–503.
27. Maclure M. The case-crossover design: a method for studying transient effects on the risk of acute events. Am J Epidemiol 1991;133:144–53.
28. Kelman CW, Kortt MA, Becker NG, et al. Deep vein thrombosis and air travel: record linkage study. BMJ 2003;327:1072.
29. Mittleman MA, Maclure M, Tofler GH, et al. Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exertion. Determinants of Myocardial Infarction Onset Study Investigators.
N Engl J Med 1993;329:1677–83.
30. Redelmeier DA, Tibshirani RJ. Association between cellular-telephone calls and motor vehicle collisions. N Engl J Med 1997;336:453–8.
31. Janes H, Sheppard L, Lumley T. Overlap bias in the case-crossover design, with application to air pollution exposures. Stat Med 2005;24:285–300.
32. Janes H, Sheppard L, Lumley T. Case-crossover analyses of air pollution exposure data: referent selection strategies and their implications for bias. Epidemiology 2005;16:717–26.
33. Efron B, Tibshirani RJ. An Introduction to the Bootstrap. New York: Chapmanand Hall/CRC, 1993.
34. STATA/SE [computer program]. College Station, Tex: Stata Corp, 2006.
35. Liu L, Reeder B, Shuaib A, et al. Validity of stroke diagnosis on hospitaldischarge records in Saskatchewan, Canada: implications for stroke surveillance. Cerebrovasc Dis 1999;9:224–30.
36. Boyle E, Coˆte´ P, Grier AR, et al. Examining vertebrobasilar artery stroke in two Canadian provinces. Spine, in press.
37. Coˆte´ P, Kreitz BG, Cassidy JD, et al. The validity of the extension-rotation test as a clinical screening procedure before neck manipulation: a secondary analysis. J Manip Physiol Therap 1996;159–64.
38. van der Velde G, Hogg-Johnson S, Bayoumi A, et al. Identifying the best treatment among common non-surgical neck pain treatments: a decision analysis. Spine 2008;33(Suppl):S184–S191.

Key words: vertebrobasilar stroke, case control stud- ies, case crossover studies, chiropractic, primary care, complications, neck pain. Spine 2008;33:S176–S183

From the *Centre of Research Expertise for Improved Disability Outcomes (CREIDO), University Health Network Rehabilitation Solutions, Toronto Western Hospital, and the Division of Heath Care and Outcomes Research, Toronto Western Research Institute, Toronto, ON, Canada; †Department of Public Health Sciences, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ‡Department of Health Policy, Management and Evalua- tion, University of Toronto, Toronto, ON, Canada; §Institute for Work & Health, Toronto, ON, Canada; ¶University Health Net- work Stroke Program, Toronto Western Hospital, Toronto, ON, Canada; and Division of Neurology, Department of Medicine, Fac- ulty of Medicine, University of Toronto, Toronto, ON, Canada. Supported by Ontario Ministry of Health and Long-term Care. P.C. is supported by the Canadian Institute of Health Research through a New Investigator Award. S.H.-J. is supported by the Institute for Work & Health and the Workplace Safety and Insurance Board of Ontario. The opinions, results, and conclusions are those of the authors and no endorsement by the Ministry is intended or should be inferred.

The manuscript submitted does not contain information about medical device(s)/drug(s).
University Health Network Research Ethics Board Approval number 05-0533-AE.

Address correspondence and reprint requests to J. David Cassidy, DC, PhD, DrMedSc, Toronto Western Hospital, Fell 4-114, 399 Bathurst Street, Toronto, ON, Canada M5T 2S8; E-mail: dcassidy@uhnresearch.ca

Via Dr. Alex Jimenez D.C.,C.C.S.T
minuteonlinepharma's insight:
Dr. Alex Jimenez D.C.,C.C.S.T's curator insight, 22 June 2017, 01:12

Strokes, vertebrobasilar injury and risks with chiropractic care have always been a question many scholars have sought to correlate. For Answers to any questions you may have please call Dr. Jimenez at 915-850-0900

pharma's curator insight, 5 July, 00:56
Rescooped by minuteonlinepharma from Social Media and Healthcare

Medicine slow to recognize social media as window into the patient experience 

Medicine slow to recognize social media as window into the patient experience  | heaith | Scoop.it

Patients are increasingly turning to social media to vent their frustrations about health care, in some cases provoking backlash from doctors who feel attacked and unappreciated. But for those able to look past controversial hashtags, patients’ angry tweets may hold crucial data for improving health care.


Recent trending hashtags, including #DoctorsAreDickheads, #MyDoctorSaid and #HealthcareWhileColored, triggered an outpouring of stories on Twitter about doctors dismissing, misdiagnosing and mistreating patients. Many of the stories came from women, people with chronic or rare conditions, and others who felt their care had been compromised by prejudice.

One woman with multiple conditions wrote that doctors often assumed she was a drug addict when she complained about pain. “Doctors do not listen to me, 3 times over, for being a woman, black, disabled. I’m ignored, criminalized, infantilized.”

Another wrote that she suffered from chronic and acute pain for two decades before she was diagnosed with a group of connective tissue disorders. “My right hip and shoulder dislocate on a daily basis. I have a dozen comorbidities. I was told it was my weight, anxiety or all in my head. It was undiagnosed Ehlers-Danlos Syndrome.”

Social media has given stories like these new reach and impact, says Dr. Matt Hawkins, an associate professor of pediatric radiology at Emory University in Atlanta. In the past, patients had few opportunities to connect and share their experiences, and limited recourse when unhappy with their care. But the balance of power has shifted as social media has enabled conversations and comparisons across social and geographic divides.

Social media is also drawing new attention to blind spots in health care. “If you’re seeing an area where patients seem to consistently express frustration, you can at least start to have something to guide what your next steps are if you want to continue to be a patient-centred organization,” says Hawkins.

Other industries already use natural language processing and sentiment analysis technology to extract insights from social media about their products and services. Many major consumer brands use social media to crowdsource innovations and respond to customers’ questions and complaints.

According to Dr. Ronen Rozenblum, an assistant professor at Harvard Medical School, health organizations have been slow to recognize the potential of social media as a window into the patient experience. However, that’s starting to change. Most hospitals in the US have some presence on social media, and some have “crisis teams” that respond to online complaints and other threats to their reputations. In Canada, many hospitals use social media for branding and communication, but only “lead adopters” use it for patient engagement. The National Health Service in England has gone a step further and actively monitors social media for trends in its performance.

Research on using social media data to measure patient satisfaction is still in its early stages. The “big question” is whether online comments reflect real-world quality of care, says Rozenblum. One study he coauthored found a weak link between positive tweets and lower hospital readmission rates but no link between the sentiment of tweets and hospitals’ performance in a nationally required patient satisfaction survey. Because many of the tweets discussed issues that were not covered by the survey, Rozenblum and his coauthors concluded that Twitter is a source of “potentially untapped feedback.”

Patient satisfaction surveys have many strengths, says Rozenblum, but they only provide feedback on an aggregate level “months after the fact.” Social media may not supplant surveys as a source of data on the patient experience, but it can add nuance and help organizations pinpoint and react to problems in real-time.

Rozenblum says both approaches have limitations. Surveys miss anyone who doesn’t participate. Social media users tend to be younger and wealthier, although that’s changing. Most people in the US who use the Internet use social media, including up to a third of seniors, according to Rozenblum.

Extracting useable data from social media remains difficult but will become easier as technology improves, he adds. And because social media is open to anyone, there’s always a risk that people or organizations will game the conversation for their own interests.

There is also some resistance from health providers who see the growing empowerment of patients as a threat, says Rozenblum. Many doctors protested the blanket criticism of #DoctorsAreDickheads and defended their profession under tags like #DoctorsAreNotDickheads and #DoctorsAreHuman. Some described the flood of patient complaints as an attack or bullying.

Doctors have traditionally had some control over their performance data, says Rozenblum. “We control the information that we’re providing and reporting.” But online, no punches are pulled.

“It’s really exposed them, but they have to play the game,” says Rozenblum. Ultimately, “this is where we’re going, this is where patients and families are going, and this is where the health system is going.”

Via Plus91
minuteonlinepharma's insight:
Bảo Bảo's comment, 2 January, 03:31
HEALTH CARE's curator insight, 14 January, 16:25
Rescooped by minuteonlinepharma from Chiropractic + Wellness

Chiropractic: A Brief History Of Its Origin

Chiropractic: A Brief History Of Its Origin | heaith | Scoop.it

The history of chiropractic dates all the way back to 1895 when Daniel David (DD) Palmer, founder of chiropractic, did his first spinal adjustment on a janitor – restoring his hearing in the process. Palmer moved from what is now Ontario, Canada to the United States in 1865 and started practicing magnetic healing and other natural health practices in Davenport, Iowa in 1880. His interest in a more organic, less invasive approach to healing opened the door for the natural, whole body wellness that chiropractic provides.


In 1895, Palmer encountered a janitor who claimed that he had lost his hearing when he moved and heard a “pop” in his back. Upon inspection, Palmer noted that the janitor had a vertebra out of place. He had the man lie on the floor, face down, while he manipulated the man’s spine, gently coaxing it into alignment. The next day the janitor claimed that he could hear again.


Two years later, after extensive research and development of the practice of what he called “chiropractic,” he opened the Palmer School of Cure where he began teaching others his techniques. After that first adjustment, word spread and this new, mysterious practice piqued the interest of the public, many who became students, including Palmer’s own son, Bartlett Joshua. Quite a few early students were practitioners of the healing arts of osteopathy and medicine. The school is still operational today as the Palmer School of Chiropractic.


The term was first coined by DD Palmer and is derived from two Greek words, the first cheir which means “hand” and praktos which means “done.” A literal translation is “done by hand” which is an apt moniker for this very hands on practice.


The first state to create laws licensing chiropractors was Kansas in 1913. By 1931, 39 states were on board, giving legal recognition to chiropractors. The last state was Louisiana in 1974.


There are more than 60,000 active licenses in the U.S. alone. Several U.S. territories, including the U.S. Virgin Islands and Puerto Rico officially recognize the practice as a legitimate health care profession. Switzerland, Japan, Australia, Great Britain, Mexico, and Canada, as well as other countries, also recognize chiropractic and have created laws to regulate it.


Over the years, chiropractic has evolved and grown beyond the sole use of spinal adjustments as treatment. Other treatments and philosophies have been developed and introduced. Research was initiated in 1975 at a conference hosted by the National Institutes of Health.


Over the years, chiropractic was not met with much acceptance by many medical associations - initially anyway. Eventually, many have come on board once that have seen chiropractic’s benefits. In 1987, the American Medical Association filed and lost an antitrust case against chiropractic. Until that time, the AMA had been boycotting the practice. That ended when they lost their case.


Chiropractic successfully changed the landscape of health care and health care practitioners. By providing a whole body approach, it has been used to treat a variety of conditions from back pain to knee injuries to colic in infants. Research backing it as a legitimate medical practice is steadily mounting. Chiropractic is proving to be beneficial for a wide variety of health ailments that extend far beyond a painful back.


As chiropractic continues to develop and grow, even more doors are opened, allowing the practice to grow and evolve. Every year researchers are finding more uses for chiropractic treatment and discovering just how beneficial it can be for a myriad of health conditions. As fast as it has grown since its discovery, it is easy to envision continued, rapid advancement in the years to come.

Injury Medical Clinic: Chiropractor
Via Dr. Alex Jimenez D.C.,C.C.S.T
minuteonlinepharma's insight:
Dr. Alex Jimenez D.C.,C.C.S.T's curator insight, 29 June 2018, 01:40

1895 Daniel David (DD) Palmer, founder of chiropractic, did his first spinal adjustment on a janitor, restoring his hearing in the process. For Answers to any questions you may have please call Dr. Jimenez at 915-850-0900

Rescooped by minuteonlinepharma from Social Media and Healthcare

Medicine slow to recognize social media as window into the patient experience

Medicine slow to recognize social media as window into the patient experience | heaith | Scoop.it

Patients are increasingly turning to social media to vent their frustrations about health care, in some cases provoking backlash from doctors who feel attacked and unappreciated. But for those able to look past controversial hashtags, patients’ angry tweets may hold crucial data for improving health care.

Recent trending hashtags, including #DoctorsAreDickheads, #MyDoctorSaid and #HealthcareWhileColored, triggered an outpouring of stories on Twitter about doctors dismissing, misdiagnosing and mistreating patients. Many of the stories came from women, people with chronic or rare conditions, and others who felt their care had been compromised by prejudice.

One woman with multiple conditions wrote that doctors often assumed she was a drug addict when she complained about pain. “Doctors do not listen to me, 3 times over, for being a woman, black, disabled. I’m ignored, criminalized, infantilized.”

Another wrote that she suffered from chronic and acute pain for two decades before she was diagnosed with a group of connective tissue disorders. “My right hip and shoulder dislocate on a daily basis. I have a dozen comorbidities. I was told it was my weight, anxiety or all in my head. It was undiagnosed Ehlers–Danlos syndrome.”

Doctors may not like it when patients complain about them on social media, but it could be viewed as valuable data on the patient experience.

Image courtesy of alvarez/iStock

Social media has given stories like these new reach and impact, says Dr. Matt Hawkins, an associate professor of pediatric radiology at Emory University in Atlanta. In the past, patients had few opportunities to connect and share their experiences, and limited recourse when unhappy with their care. But the balance of power has shifted as social media has enabled conversations and comparisons across social and geographic divides.

Social media is also drawing new attention to blind spots in health care. “If you’re seeing an area where patients seem to consistently express frustration, you can at least start to have something to guide what your next steps are if you want to continue to be a patient-centred organization,” says Hawkins.

Other industries already use natural language processing and sentiment analysis technology to extract insights from social media about their products and services. Many major consumer brands use social media to crowdsource innovations and respond to customers’ questions and complaints.

According to Dr. Ronen Rozenblum, an assistant professor at Harvard Medical School, health organizations have been slow to recognize the potential of social media as a window into the patient experience. However, that’s starting to change. Most hospitals in the US have some presence on social media, and some have “crisis teams” that respond to online complaints and other threats to their reputations. In Canada, many hospitals use social media for branding and communication, but only lead adopters use it for patient engagement. The National Health Service in England has gone a step further and actively monitors social media for trends in its performance.

Research on using social media data to measure patient satisfaction is still in its early stages. The big question is whether online comments reflect real-world quality of care, says Rozenblum. One American study he coauthored found a weak link between positive tweets and lower hospital readmission rates but no link between the sentiment of tweets and hospitals’ performance in a nationally required patient satisfaction survey. Because many of the tweets discussed issues that were not covered by the survey, Rozenblum and his coauthors concluded that Twitter is a source of “potentially untapped feedback.”

Patient satisfaction surveys have many strengths, says Rozenblum, but they only provide feedback on an aggregate level “months after the fact.” Social media may not supplant surveys as a source of data on the patient experience, but it can add nuance and help organizations pinpoint and react to problems in real-time.

Rozenblum says both approaches have limitations. Surveys miss anyone who doesn’t participate. Social media users tend to be younger and wealthier, although that’s changing. Most people in the US who use the Internet use social media, including up to a third of seniors, according to Rozenblum.

Extracting useable data from social media remains difficult but will become easier as technology improves, he adds. And because social media is open to anyone, there’s always a risk that people or organizations will game the conversation for their own interests.

There is also some resistance from health providers who see the growing empowerment of patients as a threat, says Rozenblum. Many doctors protested the blanket criticism of #DoctorsAreDickheads and defended their profession under tags like #DoctorsAreNotDickheads and #DoctorsAreHuman. Some described the flood of patient complaints as an attack or bullying.

Doctors have traditionally had some control over their performance data, says Rozenblum. “We control the information that we’re providing and reporting.” But online, no punches are pulled.

“It’s really exposed them, but they have to play the game,” says Rozenblum. Ultimately, “this is where we’re going, this is where patients and families are going, and this is where the health system is going.”

Via Plus91
minuteonlinepharma's insight:
No comment yet.
Rescooped by minuteonlinepharma from Social Media and Healthcare

How to Build a Community in the Healthcare Industry

How to Build a Community in the Healthcare Industry | heaith | Scoop.it

When you think about how to build a community in the healthcare industry, and reduce the divide between medical and social circles, healthcare is the obvious connector.

Social engagement happens in medical circles of health care providers, researchers, and patients just as medical talks also happen in social circles.

This interplay happens because healthcare affects everyone.

Doctors don’t just talk among themselves in medical abstracts: they tweet, tag, and like or comment on each other’s posts.

Additionally, medical opinions and health perspectives are not confined to journals – they, too, are built around hashtag campaigns. Patient or public partnerships are now the way forward for medical research and cohort studies.

A study on “The Emerging World of Online Health Communities,” showed that:

…social outcomes sit alongside and sometimes above clinical ones. Where health care has a low tolerance of failure due to the consequences that can follow, online health communities thrive on stories of what went wrong and how people battled the system.

So how do you begin those conversations online, let alone build communities to converge in those conversations?

Here are 5 ways:

Listen and Engage with Your Audience

Health talk is everywhere, and the vast majority is online where they seek solutions and community support for health-related concerns:

online forums health blogs educational platforms social media

To stay relevant and reach these audiences, the healthcare industry needs to meet consumers where they are: social media.

Use the communicative power on social networks to raise awareness and counter misinformation, provide patient support, for public health monitoring.

As you listen in, engage to understand your audience, what they are talking about, so you can use the insights in developing your strategy.

A good example of an online health community that made health-related feedback and shared stories the core of its existence is Care Opinion. Formerly Patient Opinion, it’s a UK-based online platform to share experiences of health and care services in the UK, good or bad.

It also bridges those shared experiences to the right people who can help. Health and care providers have used this channel to connect with patients, address their concerns and improve their services for a better patient experience.

Use Healthcare Influencers

Healthcare Influencers offer unique insights, led by their own experience, and lend credibility with their name.

They have the ability to reach your target audience, engage them for you, and spread your message.

Influencers have a community of followers to help you build your community from within. There is the macro-influencer with a huge social following. But there are also micro-influencers with a niche audience, not a fan base. Therefore, they are closest to the prospective customers and impact their decision-making process.

But there is a caveat – endorsements should adhere to the Food and Drug Administration (FDA) rules on advertising and comply to Health Insurance Portability and Accountability (HIPAA).

Influencers are not exempt from rules even when they operate in the free-wheeling space of social media, especially on health information, and should pay particularly close attention to messaging for any drug advertising via social media.

This is a lesson Diclegis (Diclectin in Canada), an anti-nausea pregnancy (NVP) drug, learned when they used a celebrity macro-influencer to promote the medicine without communicating any risk information associated.

This resulted in an FDA warning to the maker of the drug, Duchesnay USA.

Celebrity and reality-star Kim Kardashian had to delete her original Instagram post endorsing the anti-morning sickness pill. The paid endorsement received 464,000 likes.

Kardashian had to post an updated message, including the side effects and links to the FDA website.

Source: Daily Mail

Building a Community Through Thought Leadership

One of the problems of the open-source web is the abundance of misleading and dangerous content.

Healthcare companies can rise above this noise by being a thought leader providing insights, sharing medical information, and answering patient questions.

By building trust with your target audience, you can raise awareness, counter misinformation, and clarify misconceptions.

Claiming to be the “Authentic Voice of Healthcare” is the founder of a primary care clinic in Downtown Las Vegas, Internist Dr. Zubin Damania, or ZDoggMD. He has a bolder take on thought leadership, but in a lighter way.

He takes strong positions on relevant medical and health-related issues in video commentaries, using medical humour, healthcare satire, parody music videos, and witty and amusing social media posts.

He has 1.4M followers on Facebook, 44.8K on Twitter, 147,981 YouTube subscribers, and 234K Instagram followers.

His music videos are always a hit. Taking on the opioid crisis issue, for example, he made a parody music video of Justin Bieber’s “Love Yourself”, with his version, “Treat Yourself”, an ode to those who are suffering due to the opioid epidemic.

Create Useful Content

To patients, clinicians, researchers, academicians,  the internet is one of the first go-to information resource. Build your community around valuable, digestible content that educates your audience.

Well-timed informational posts, and patient stories through video or other creative formats, are easy magnets for followers. Multimedia content helps reach a wider audience.

Infographics, “how-tos,” interactive quizzes, health tips, and “did you know?”-type trivia are content styles that can attract a large audience.

Inspirational content also motivates and sparks much-needed hope, especially content related to malignant diseases. Success stories that inspire usually get shared most, increasing awareness of your brand and your name.

Cleveland Clinic knows how to attract followers, by pulling at heartstrings with inspiring stories about real patients on Instagram.

They also features posts with shocking facts about health, fat-freezing tips, motivation to exercise, posture, weight loss, and more.

Bridge and Connect Them to Resources

Referrals are very much part of the dynamics in the healthcare and medical industry. When you bridge your audience to resources of information or service, this will build your reputation as a go-to source of information.

But the work doesn’t end with a helpful recommendation – you need to engage your audience, make suggestions, initiate productive conversations between patients, doctors, industry leaders, health technologists, innovators, or policymakers.

Sensei client LifeWIRE, a health technology platform for patient engagement, shares curated content related to anesthesiology, Post-Traumatic Stress Disorder (PTSD), and the opioid crisis.

It uses and cites multiple scholarly articles, medical journals, and has quoted and featured doctors in its blog posts and white paper. 

The U.S. Department of Health & Human Services (HHS) thanked @LifeWIREGroup for sharing their infographic on the government’s efforts in combating the opioid crisis.

Via nrip
minuteonlinepharma's insight:
Rescooped by minuteonlinepharma from Alcohol & other drug issues in the media

Morrison government promises $1.25 billion for health care (Aus)

Morrison government promises $1.25 billion for health care (Aus) | heaith | Scoop.it
The health program was unveiled as the federal, state and territories meet in Adelaide on Wednesday for the Council of Australian Governments with health one of the items on the agenda.

Via ReGenUC
minuteonlinepharma's insight:
ReGenUC's curator insight, 13 December 2018, 23:18

There isn't much detail available about the Govt's proposed funding but the four priority areas are:

  • specialist hospital services such as cancer treatment, rural health and hospital infrastructure

  • drug and alcohol treatment

  • preventive, primary and chronic disease management

  • mental health.

Rescooped by minuteonlinepharma from Social Media and Healthcare

 Paul Buchanan: Social media and the patient experience

 Paul Buchanan: Social media and the patient experience | heaith | Scoop.it

Previously a stranger to the “health” world there was now an imperative to learn, and learn quickly, how to live with and manage a life-long chronic condition. The team of doctors and nurses who initially diagnosed and treated me did everything by the book and by the accepted wisdom of the day. To be able to learn about diabetes as a condition, with the aid of Professor Google, was a matter of application and long days and nights reading medical texts, scouring the websites of the charities involved in the condition area, and spending hours on the phone with a spectacular diabetes specialist nurse.

However, learning to live with diabetes—well that was a completely different story. Here in the UK, I discovered a gaping hole in the provision of day to day life lessons for a person newly diagnosed, whereas in the USA I discovered they have such things as Certified Diabetes Educators—essentially private ”consultants” who you can pay to teach you what you want to learn. Perhaps this is something that needs to be aired and discussed more widely in the UK, after all, we pay for “personal coaches” in almost every other aspect of our lives, from executive coaching, to diet and exercise coaches. Whilst pushing service delivery may be the trend and the general direction our government wish to take our NHS, there are not as yet plans for this type of “life-coaching” to become a private sector service paid for by patients, is it just a matter of time?

It also struck me that I couldn’t be the only person in the UK with a need, so I took to social media to see if there was anything “out there” that could help. The short answer was no. Thus the #gbdoc was created.

15 August 2012 and @theGBdoc posted its first tweet, inviting any and all people with diabetes (#pwd) to join in a #tweetchat on the topic of hypoglycaemia. That first week’s #tweetchat was a success, much to my amazement! It grew. In the first four weeks it made over 2.5m impressions in twitter. By the end of the first three months there were participants from 24 countries, and in its first year it reached over 13m people. Initially there was considerable scepticism, especially from within the word of the healthcare professionals—was this any more than a random collection of emotive rants about our own condition? What about safety?

Critics cited the lack of accountability and oversight, perhaps even lack of identity because of the anonymity that twitter offers, as justification to claim the posts could be potentially causing harm. Let us not forget though, within the online community is perhaps the greatest level of scrutiny available, the best possible form of peer-review, people with whole lives of experience of living with a condition, to balance, mediate, moderate, and make suggestions.

Now, some four years later and with social media (SocMe) acceptable to the establishment (thanks to people like @weNurses), #gbdoc is a resource that healthcare professionals use. They let their patients know about it so they can learn from it, and engage with and be supported by their peers. And many healthcare professionals use it as a resource for their own use—to dip into the daily lived experience, to ask questions about specific issues that may have no answer in the journals or academic papers, and to help frame the very questions you want to ask us as patients about how we are coping with our condition, to ask us about the things that we talk about.

If you look through SocMe, you will find a rich, deep, and peer-supported world of care that you as a professional can use to help your patients. For every condition there is a group out there. For every issue there is patient that has lived through it and come up with an answer that worked for them, a “life-hack” to fix a problem. For every patient there is support from their peers. It’s not perfect, there are always ”personalities,” squabbles and fallings out, but—and it’s a big but—there are thousands of people giving their time, effort, and care to help the next person along have an easier time of it than they did.

On a personal note, a big thank you to the many thousands of individuals who make up the #gbdoc and for the care, support, help, and friendship that you have shown me over the last four years. Peer support at its very best. Over and above the excellent care I get from my healthcare team, I can honestly say that without peer support I would not be able to manage my condition as I do.

Via Plus91
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Will Social Media Revolutionize Healthcare? -

Will Social Media Revolutionize Healthcare? - | heaith | Scoop.it

Without a doubt. In fact, several medical providers and IT vendors are plowing ahead already.


"For healthcare, this represents a veritable social revolution."

That bold statement about the value of social networking sites, wikis, blogs, and other online forums in patient care comes from Katherine Chretien, MD, of Washington DC VA Medical Center, and Terry Kind, MD, of The George Washington University School of Medicine.

It's uncommon for reserved academics to speak of revolutions, but their enthusiasm is warranted. The list of potential healthcare applications for social media and collaboration platforms is almost limitless.

As I mentioned in my last column, IT-enhanced care coordination is already having an impact, making care safer and more effective. But the tools used by Dr. Matthew Press that were highlighted in that article -- email, phone calls, and EHRs -- are child's play compared with the sophisticated collaboration platforms coming online now. At least four application types come to mind:

Second-generation patient portals and secure messaging systems that engage patients in their own care. Intuit Health and Medseek are prime examples.Applications that track patients' movements as they transition from hospital to home to doctor visit to nursing home, making sure all the right data travels with them and all the right providers follow through on their care. Siemens' CareXcell comes to mind. This software, packed with a variety of collaboration tools, lets clinicians exchange clinical data easily and keep tabs on patients and specific staff responsibilities as patients move from place to place.Social tools that provide doctors with ready online access to specialists to help manage tough cases and make complicated diagnoses. Doximity, Sermo, and QuantiaMD, for example, are basically Facebooks for doctors, letting them share their thoughts along with lab data, images, and other intelligence.Tools that market and polish the reputations of provider organizations. Mayo Clinic, for instance, has drawn attention to itself and created a lot of good will by offering patients a variety of educational resources and a symptom checker to help them determine whether they need medical attention. It also gives patients access to their records and lets them make appointments and refill prescriptions online. Mayo's smartphone app encourages two-way communication with the Clinic.

Granted, most EHR systems have the capacity to do many of the things detailed above, but clinicians complain that they're difficult to use and often don't interoperate across healthcare providers.

[Here's why healthcare providers should support investment in IT: IT-Enhanced Care Coordination Really Works.]

In a recent interview with the Huffington Post, David Chou, CIO at the University of Mississippi Medical Center, opined that social media "is rapidly becoming a preferred medium for patient-to-physician, patient-to-patient, and physician-to-physician communication."

For example, some large medical centers now have online support programs that let patients with the same disease share experiences and coping skills with one another. Mayo Clinic, Massachusetts General Hospital, Henry Ford Hospital, and Geisinger Health Systems encourage clinicians to use social media tools to engage patients and build loyalty, says Will Reese, chief innovation officer at Cadient Group, a marketing agency near Philadelphia. They also have dedicated communications teams to send consistent messages to the public, he says.

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Of course, there's a downside to using social networking in healthcare. Some patients get carried away once they realize their doctor is available online, pestering the doctor with every minor ache and pain. It's why providers must set clear guidelines on patient-doctor communication. Clinicians also complain that they're not adequately compensated for the time they spend responding to patient messages. And the Chretien/Kind commentary referenced above cautions against establishing new patient-doctor relationships online rather than in person.

Those issues notwithstanding, the industry needs to join this revolution. And to do that will require the powers that be to give up their risk-averse mindset. It needs to be open to new possibilities.

If the world wasn't changing, we might continue to view IT purely as a service organization, and ITSM might be the most important focus for IT leaders. But it's not, it isn't and it won't be -- at least not in its present form. Get the Research: Beyond IT Service Management report today. (Free registration required.)

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Bringing the geriatric medicine community online, one tweet at a time

Bringing the geriatric medicine community online, one tweet at a time | heaith | Scoop.it

Dr. Camilla Wong, a geriatrician at St. Michael’s Hospital is encouraging the geriatric medicine community to expand its horizons and embrace social media.

When the geriatric medicine journal club at the University of Toronto holds its monthly meetings, Dr. Wong and her team simultaneously live-tweet the proceedings through the handle @GeriMedJC and hashtag #GeriMedJC. This offers people who are not able to attend the in-person meeting an option to participate online.

“We’ve been able to connect thought leaders and allied experts in the small, geriatric space, that may never have connected in the physical world,” said Dr. Wong.

What began as an informal project grew into a formal part of the club, explained Dr. Wong.

“We noticed increased engagement levels from participants internationally which led us to formalize the use of Twitter and publicize it ahead of time, personally inviting featured journal club authors to join in,” she said. “We even created how-to-guides for colleagues and allied organizations interested in joining the platform.”

Beyond the journal club, the #GeriMedJC hashtag has engaged multiple audiences interested in geriatric health, explained Dr. Wong.

Did you know?
The team behind the @GeriMedJC Twitter handle built a following of more than 1,300 users from six continents including physicians, health advocacy organizations, trainees and allied health practitioners.

“This has forced us to think more creatively and has infused an interdisciplinary way of thinking,” she said. “It also highlights there are multiple ways to solve the same geriatric health problem.”

The conversations on Twitter have also translated to real-world connections for geriatricians across Canada and abroad, said Dr. Amanda Gardhouse, a geriatrician at the Leacock Care Centre in Orillia, Ont.

“Twitter has helped break the ice for geriatric professionals,” she said. “For example, just recently at the 37th Canadian Geriatric Society Annual Scientific Meeting, we connected with other geriatric professionals because of discussions we’d had on social media.”

Both Drs. Gardhouse and Wong are avid users of social media and said it’s important for the broader scientific community to embrace platforms such as Twitter.

“There’s a lot of misinformation that occupies the social media space,” said Dr. Wong. “I truly feel as a scientist I have an academic and moral obligation to promote the integrity of science online.”

About St. Michael's Hospital

St. Michael’s Hospital provides compassionate care to all who enter its doors. The hospital also provides outstanding medical education to future health care professionals in more than 29 academic disciplines. Critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, care of the homeless and global health are among the Hospital’s recognized areas of expertise. Through the Keenan Research Centre and the Li Ka Shing International Healthcare Education Centre, which make up the Li Ka Shing Knowledge Institute, research and education at St. Michael’s Hospital are recognized and make an impact around the world. Founded in 1892, the hospital is fully affiliated with the University of Toronto.

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 Can hashtags improve diversity in medicine?

 Can hashtags improve diversity in medicine? | heaith | Scoop.it

An interesting phenomenon has emerged on Twitter lately, and I am not talking about the constant barrage of insults coming from the account of the U.S. president. What I am referring to is the growing online chorus of a medical community that seems to be waking from its long off-line slumber.

Physicians in general have been loath to use social media as a means of communicating with the public. Most of their reluctance stems from the possible medical-legal implications of sharing information on the internet. By shying away from social media, physicians have unfortunately ceded much of the health-care narrative to non-medical groups. Recently, however, doctors and medical organizations are beginning to understand the value of their voice in the online conversation. Indeed, many are using the platform to bring attention to an issue that has long plagued the profession: diversity.

One of the pioneers in using Twitter to bring awareness to diversity issues in medicine is Dr. Julie Silver from Harvard Medical School. Dr. Silver, a rehabilitation physician and colleague, has been extremely active in promoting gender equity in medicine. While she has published in academic journals about the lack of recognition female physicians receive, perhaps her most significant contributions in this area are the hashtag campaigns she has helped popularize. Dr. Silver is responsible for promoting hashtags like #WomeninMedicine and #HeforShe, while also starting #QuoteHer, an initiative aiming to increase the number of women experts in medical and health-care stories.

This week, the hashtag #BlackMeninMedicine has been trending among the wider medical community. Within the first 24 hours of the campaign, it had accumulated nearly 1.5 million impressions, and that number continues to grow. Started in the U.S., this campaign was borne out of the shocking statistic that there are fewer Black men enrolled in American medical schools in 2017 compared to 1978. That number is even smaller for Black women. Importantly, this is demographic data that has been collected annually by the medical community in the United States for decades. This contrasts dramatically with Canada, where similar data is simply non-existent.

The real question, however, is will these hashtag campaigns really help to improve diversity in medicine? One worry, of course, is that these initiatives are just flashes in the pan that disappear as quickly as they appear online. Staying power for online movements can be difficult in an era that is dominated by a 24 hour news cycle with the next trending hashtag a moment away. Additionally, for a profession that has been driven by evidence, there is currently little data to suggest that online activity has created real, meaningful and statistically significant improvements in diversity.

On the other hand, it is likely that outcome data in this field is lacking because it is a relatively new experience for the medical community. There are also reasons to be optimistic. As reported previously in the Star, the University of Toronto is actively engaged in recruiting visible minorities, and specifically Black students. Led by chief diversity officer Dr. Lisa Robinson, the medical school has started a diversity mentorship program and a Black student application program. This is a cue that other medical schools should take to improve diversity in their own ranks.

Still, there are ways to use social media to improve representation in medicine. Many online advocates primarily focus on their own campaigns. However, imagine the strength of alliances that could be realized across advocacy groups. This would not only broaden impression numbers, retweets and likes, but would also reach a far wider audience than the simple silos we currently operate within. Because, ultimately, when it comes to diversity in medicine, we are all on the same team.

Dr. Adam Kassam is a resident physician in the department of physical medicine and rehabilitation at Western University.

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There's an epidemic of bogus health claims online, and no easy cure 

There's an epidemic of bogus health claims online, and no easy cure  | heaith | Scoop.it

Can turmeric really cure cancer? Is the HIV virus actually a conspiracy concocted by the Illuminati? Are vaccines responsible for food allergies in children?

All the scientific evidence points to no, but these ideas are spreading, thanks in part to social media and a growing distrust of medical experts and government.

"There is so much misleading information out there that it's a real challenge for us," said Jay Robinson, president of the B.C. Chiropractic Association.

"We're constantly faced with the battle of getting accurate, verifiable and true information out to our members."

In the last two months, CBC reporting has revealed a number of healthcare workers who've spread some of this misinformation, including chiropractors suggesting vaccines are dangerous or ineffective, and naturopaths claiming to eliminate autism with homeopathy.

And the experts suggest some of those unscientific claims are creeping into the more conventional medical professions.

Chiropractors forced to remove anti-vaccine posts
'You feel like you're being listened to'

But when it comes to human health, there doesn't seem to be an easy answer for preventing the spread of bogus claims, and there's evidence some attempts to counter false information can backfire, as Facebook is learning as it tries to crack down on hoaxes and fake news.

An emergency preparedness pamphlet issued by Sweden's government warns of the increasing risk of misleading information and offers tips for sorting out truth from rumour. (Swedish Civil Contingencies Agency)

Health professionals told CBC they're frustrated by the role of social media. It's not only used to spread false information, but it also allows like-minded people to reinforce each other's unsubstantiated beliefs.

At the same time, people who share phoney health claims on social media often have legitimate reasons for being skeptical of conventional medicine, according to Timothy Caulfield, Canada research chair in health law and policy at the University of Alberta.

Naturopath college outlaws therapy that promises 'complete elimination' of autism

They're often concerned about the outsized role that pharmaceutical companies play in health research, he said, or disillusioned by doctors who only have time for brief visits with each patient.

Caulfield has tried just about every unscientific therapy out there, and he understands the appeal of the more personal approach.

"You feel like you're being listened to, you feel like they're providing you with an answer that's tailored to your needs. It's just a really pleasant experience," he said.

He wants to see more qualified medical professionals and government officials speaking out on social media and engaging with the public to understand why they're distrustful of proven treatments.

Dr. Bonnie Henry has addressed several dubious health claims in recent CBC stories. (Jonathan Hayward/Canadian Press)


But that's a delicate thing to do. A recent editorial in the Canadian Medical Association Journalpoints out that when experts talk down to people, that can further alienate folks who already have their doubts about science and conventional medicine.

B.C.'s provincial health officer, Dr. Bonnie Henry, recently watched this phenomenon unfold in her email inbox.

B.C.'s top doctor warns of naturopaths misleading parents about cause of autism

The messages came after she spoke out against the use of a homeopathic remedy made from the saliva of a rabid dog and called for sanctions on the vice-chair of the College of Chiropractors for suggesting fruit smoothies are more effective than the flu vaccine.

 "Some people accused me of being in cahoots with Big Pharma," she said. 

Still, she tries to respond to every email. She says the key is to be respectful of people's beliefs and transparent — both about conflicts of interest and the limitations of what science can tell us.

Calls for stricter regulations

UBC nursing professor Bernie Garrett has studied internet health scams extensively, and he argues what's needed is stronger government legislation and better enforcement from professional colleges to limit the spread of claims that aren't based in scientific evidence.

This approach has its limits, too. As Henry's experience suggests, from the perspective of someone who already distrusts institutions, well-meaning government intervention might look like censorship.

Vancouver chiropractor resigns from college board over anti-vaccine video

On a professional level, Garrett says unscientific practices aren't just an issue in the alternative and complementary health worlds.

He takes issue with his own regulator, the College of Registered Nurses of B.C., for allowing RNs to provide what he describes as "faith-based" remedies on a private basis.

"As a nurse, I can, for example, sell services such as beer spas … using my RN title to do that," Garrett alleged.

Yes, there are spas that advertise health benefits from bathing in beer. (Shutterstock / Rades)

A few years back, Garrett complained to the college about an RN who was offering "therapeutic touch," which involves someone placing their hands near or lightly on a patient, supposedly healing the body by bringing "energy fields" into harmony.

But the college said it considers therapeutic touch to be acceptable, a decision that was upheld by the Health Professions Review Board.

For its part, the college describes regulating alternative health practices as a "complex issue" and says its regulations are constantly under review. College spokesperson Johanna Ward said nurses are obliged to adhere to the same professional standards when offering alternative therapies as they do when providing mainstream care.

Cracking down isn't simple

There are some who argue it may be necessary to take the fight against misinformation straight to the source — the private tech companies like Facebook and YouTube whose platforms allow myths and scams to proliferate.

In a recent column for the science publication Undark, writer Michael Schulson contends that the commercial interests and algorithms for those websites feed into a cycle of misinformation. Someone who watches one video from an AIDS denialist, for example, will suddenly find YouTube suggesting a bunch more in the same vein — and many of those videos are monetized with ads from major corporations.

B.C. health official voices 'grave concerns' after child given homeopathic remedy using rabid-dog saliva

But as Facebook has discovered, cracking down on "fake news" can be extremely tricky.

In the fallout from the 2016 U.S. election, the social media giant tried putting little red flags on false stories. But the flags actually fired up some users who desperately wanted to believe, and they became even more likely to share those hoaxes.

In the end, Garrett believes there are some people who just can't be reached. The key, he believes, is to contain the spread of misinformation.

"These are generally people who won't change their mind, whatever the evidence is," he said. "What we do need to do is protect the public from the implications of people who believe those sorts of things."

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Paria Harirsaz's curator insight, 19 November 2018, 03:28
Think about the impact this can have on a person! When someone researches a way to heal themselves and gets a result that sounds simple and right, they may find it logical to try it. However, if what is posted is inaccurate, this could be very unhealthy and even fatal.
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Nurse Disciplined For Unprofessional Posts On Social Media Loses Appeal

Nurse Disciplined For Unprofessional Posts On Social Media Loses Appeal | heaith | Scoop.it

In 2015, Strom posted comments on Facebook and Twitter relating to the end-of-life care that her grandfather received at St. Joseph's Health facility in Saskatchewan. In her comments, Strom criticized the competence and professionalism of staff — including other nurses — who worked at the facility.

The Discipline Committee of the Saskatchewan Registered Nurses' Association (the "Discipline Committee") ruled that in publicly posting the comments, Strom engaged in professional misconduct, imposing a $1,000 fine and ordering Strom to pay $25,000 for the costs of the proceedings.

View Strom's Online Comments ↓

Ms. Strom initially posted the following comments on Facebook:

My Grandfather spent a week in "Palliative Care" before he died and after hearing about his and my family's experience there (@ St. Joseph's Health Facility in Macklin, SK) it is evident that Not Everyone is "up to speed" on how to approach end of life care ... Or how to help maintain an Aging (SIC) Senior's Dignity (among other things!)

So ... I challenge the people involved in decision making with that facility, to please get All Your Staff a refresher on the topic AND More.

Don't get me wrong, "some" people have provided excellent care so I thank you so very much for YOUR efforts, but to those who made Grandpa's last years less than desirable, Please Do Better Next Time! My Grandmother has chosen to stay in your facility, so here is your chance to treat her "like you would want your own family member to be treated".

That's All I Ask!

And a caution to anyone that has loved ones at the facility mentioned above: keep an eye on things and report anything you Do Not Like! That's the only way to get some things to change.
(I'm glad the column reference below surfaced, because it has given me a way to segway (sic) into this topic.)

The fact that I have to ask people, who work in health care, to take a step back and be more compassionate, saddens me more than you know!

In response to an entry on Strom's Facebook page by another person, who had concluded her comments with "Isn't it unfortunate that we have to have this discussion at all?", Strom posted the following:

It is VERY UNFORTUNATE Alex. And this has been an ongoing struggle with the often subpar care given to my [surname] Grandparents (especially Grandpa) for many years now....Hence my effort to bring more public attention to it (As not much else seems to be working).

As an RN and avid health care advocate myself, I just HAVE to speak up! Whatever reasons/excuses people give for not giving quality care, I Do Not Care. It. Just. Needs. To. Be. Fixed. And NOW!

And in response to another comment that concluded with "... we all deserve to be treated with respect," Strom posted :

Absolutely, and that's why I am also now asking people to just rethink... "Why do you do your job?" "Do you actually care about the people you WORK FOR/Care For?" "Or is it JUST A JOB, WITH A PAYCHEQUE?" .. If so, maybe it's time to take a step back.

Either way I just want my Grandmother (and everyone else in that facility) to be treated well, ALWAYS!

Strom tweeted a link to her Facebook discussion to both the provincial Minister of Health and the Leader of the Opposition. and changed her Facebook settings so that the discussion, which to that point had been accessible only by her Facebook friends, became accessible by anyone who accessed the link.

Discipline Committee Decision

The Discipline Committee concluded that Strom's off-duty conduct was subject to discipline because she identified herself as a registered nurse when making comments on Facebook and Twitter with the purpose of adding credibility and legitimacy to them. Strom herself admitted that, being an advocate nurse, she had been motivated to make the comments online and had also made them known to both the provincial Minister of Health and Leader of Opposition.

The Discipline Committee's primary concern related to Strom criticizing the care provided by other nurses without knowing or endeavoring to know all the facts. Strom had attended the facility only a handful of times each year and had little direct knowledge of the care her grandfather received there — her online comments were based on information provided by her relatives.

The Discipline Committee accepted that Strom had not been motivated by malice, but perhaps by grief and anger but found that nonetheless she was bound to act professionally. Further, as the comments on social media needlessly harmed the reputation of the nursing staff at St. Joseph's and undermined the public confidence in them, they amounted to professional misconduct. The Discipline Committee relied, in part, on various publications that remind nurses that their online content and behaviour are subject to the same ethical and professional standards that have always applied to the profession.

The Discipline Committee also took into account Strom's right to freedom of expression as guaranteed by the Canadian Charter of Rights and Freedoms, making it clear that it does not seek to "muzzle" nurses from using social media but to ensure they conduct themselves professionally when communicating online.

In balancing the conflicting interests at stake, the Discipline Committee was sensitive to the nature and extent of the harm caused by Ms. Strom's online comments, and to the right to express concerns. It concluded that Strom should have used other available avenues to voice her criticisms and avoid harming the reputation of other nurses.


On appeal, the Saskatchewan Court of Queen's Bench upheld the decision of the Discipline Committee. The court determined that the Discipline Committee's decision is reasonable and falls within the acceptable range of possible outcomes. Strom's lawyer has said they will be appealing to the Saskatchewan Court of Appeal.

The Discipline Committee and court decisions in Strom have attracted a lot of attention. Strom's legal proceedings have been closely followed by nurses across the country, many of whom have now signed an open letter saying that the Disciplinary Committee's decision will silence nurses who speak up about patient care. In addition, hundreds of people across Canada and the United States signed an online petition calling for the decision to be reversed and an online fundraiser has raised more than $27,000 to cover the penalty and costs levied against Strom.

Some commentators say the case reflects an undue restriction of a nurse's right to freedom of expression. This concern is the reason why the Saskatchewan Union of Nurses and the British Columbia Civil Liberties Association intervened before the Saskatchewan Court of Queen's Bench.

Whether or not the decision in Strom will be overturned on appeal is difficult to predict. But in the age of social media, the intersection of (and boundaries between) professional responsibility and personal freedom of expression is an eminently relevant social question, which we expect different administrative tribunals and courts will continue to try to answer in a variety of ways.

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U.S. Case Study: Chiropractic & Vertebrobasilar Stroke | El Paso Back Clinic® • 915-850-0900

U.S. Case Study: Chiropractic & Vertebrobasilar Stroke | El Paso Back Clinic® • 915-850-0900 | heaith | Scoop.it

Thomas M Kosloff1*†, David Elton1†, Jiang Tao2† and Wade M Bannister2†



Background: There is controversy surrounding the risk of manipulation, which is often used by chiropractors, with respect to its association with vertebrobasilar artery system (VBA) stroke. The objective of this study was to compare the associations between chiropractic care and VBA stroke with recent primary care physician (PCP) care and VBA stroke.


Methods: The study design was a case–control study of commercially insured and Medicare Advantage (MA) health plan members in the U.S. population between January 1, 2011 and December 31, 2013. Administrative data were used to identify exposures to chiropractic and PCP care. Separate analyses using conditional logistic regression were conducted for the commercially insured and the MA populations. The analysis of the commercial population was further stratified by age (<45 years; ≥45 years). Odds ratios were calculated to measure associations for different hazard periods. A secondary descriptive analysis was conducted to determine the relevance of using chiropractic visits as a proxy for exposure to manipulative treatment.


Results: There were a total of 1,829 VBA stroke cases (1,159 – commercial; 670 – MA). The findings showed no significant association between chiropractic visits and VBA stroke for either population or for samples stratified by age. In both commercial and MA populations, there was a significant association between PCP visits and VBA stroke incidence regardless of length of hazard period. The results were similar for age-stratified samples. The findings of the secondary analysis showed that chiropractic visits did not report the inclusion of manipulation in almost one third of stroke cases in the commercial population and in only 1 of 2 cases of the MA cohort.


Conclusions: We found no significant association between exposure to chiropractic care and the risk of VBA stroke. We conclude that manipulation is an unlikely cause of VBA stroke. The positive association between PCP visits and VBA stroke is most likely due to patient decisions to seek care for the symptoms (headache and neck pain) of arterial dissection. We further conclude that using chiropractic visits as a measure of exposure to manipulation may result in unreliable estimates of the strength of association with the occurrence of VBA stroke.


Keywords: Chiropractic, Primary care, Cervical manipulation, Vertebrobasilar stroke, Adverse events


The burden of neck pain and headache or migraine among adults in the United States is significant. Survey data indicate 13% of adults reported neck pain in the past 3 months [1]. In any given year, neck pain affects 30% to 50% of adults in the general population [2]. Prevalence rates were reportedly greater in more eco- nomically advantaged countries, such as the USA, with a higher incidence of neck pain noted in office and com- puter workers [3]. Similar to neck pain, the prevalence of headache is substantial. During any 3-month time- frame, severe headaches or migraines reportedly affect one in eight adults [1].


Neck pain is a very common reason for seeking health care services. “In 2004, 16.4 million patient visits or 1.5% of all health care visits to hospitals and physician offices, were for neck pain” [4]. Eighty percent (80%) of visits occurred as outpatient care in a physician’s office [4]. The utilization of health care resources for the treatment of headache is also significant. “In 2006, adults made nearly 11 million physician visits with a headache diagno- sis, over 1 million outpatient hospital visits, 3.3 million emergency department visits, and 445 thousand inpatient hospitalizations” [1].


In the United States, chiropractic care is frequently utilized by individuals with neck and/or headache com- plaints. A national survey of chiropractors in 2003 re- ported that neck conditions and headache/facial pain accounted respectively for 18.7% and 12% of the patient chief complaints [5]. Chiropractors routinely employ spinal manipulative treatment (SMT) in the management of patients presenting with neck and/or headache [6], either alone or combined with other treatment approaches [7-10].


While evidence syntheses suggest the benefits of SMT for neck pain [7-9,11-13] and various types of headaches [10,12,14-16], the potential for rare but serious adverse events (AE) following cervical SMT is a concern for researchers [17,18], practitioners [19,20], professional organizations [21-23], policymakers [24,25] and the public [26,27]. In particular, the occurrence of stroke affecting the vertebrobasilar artery system (VBA stroke) has been associated with cervical manipulation. A recent publication [28] assessing the safety of chiropractic care reported, “...the frequency of serious adverse events varied between 5 strokes/ 100,000 manipulations to 1.46 serious adverse events/ 10,000,000 manipulations and 2.68 deaths/10,000,000 manipulations”. These estimates were, however, derived from retrospective anecdotal reports and liability claims data, and do not permit confident conclusions about the actual frequency of neurological complications following spinal manipulation.


Several systematic reviews investigating the association between stroke and chiropractic cervical manipulation have reported the data are insufficient to produce definitive conclusions about its safety [28-31]. Two case–control studies [32,33] used visits to a chiropractor as a proxy for SMT in their analyses of standardized health system databases for the population of Ontario (Canada). The more recent of these studies [32] also included a case-crossover methodology, which reduced the risk of bias from confounding variables. Both case–control studies reported an increased risk of VBA stroke in association with chiropractic visits for the population under age 45 years old. Cassidy, et al. [32] found, how- ever, the association was similar to visits to a primary care physician (PCP). Consequently, the results of this study suggested the association between chiropractic care and stroke was non-causal. In contrast to these studies, which found a significant association between chiropractic visits and VBA stroke in younger patients (<45 yrs.), the analysis of a population-based case-series suggested that VBA stroke patients who consulted a chiropractor the year before their stroke were older (mean age 57.6 yrs.) than previously documented [34].


The work by Cassidy, et al. [32] has been qualitatively appraised as one of the most robustly designed investigations of the association between chiropractic manipulative treatment and VBA stroke [31]. To the best of our knowledge, this work has not been reproduced in the U.S. population. Thus, the main purpose of this study is to replicate the case–control epidemiological design published by Cassidy, et al. [32] to investigate the association between chiropractic care and VBA stroke; and compare it to the association between recent PCP care and VBA stroke in samples of the U.S. commercial and Medicare Advantage (MA) populations. A secondary aim of this study is to assess the utility of employing chiropractic visits as a proxy measure for exposure to spinal manipulation.

MethodsStudy design and population

We developed a case–control study based on the experience of commercially insured and MA health plan members between January 1, 2011 and December 31, 2013. General criteria for membership in a commercial or MA health plan included either residing or working in a region where health care coverage was offered by the in- surer. Individuals must have Medicare Part A and Part B to join a MA plan. The data set included health plan members located in 49 of 50 states. North Dakota was the only State not represented.


Both case and control data were extracted from the same source population, which encompassed national health plan data for 35,726,224 unique commercial and 3,188,825 unique MA members. Since members might be enrolled for more than one year, the average annual commercial membership was 14.7 million members and the average annual MA membership was 1.4 million members over the three year study period, which is comparable to ~5% of the total US population based on the data available from US Census Bureau [35]. Administrative claims data were used to identify cases, as well as patient characteristics and health service utilization.


The stroke cases included all patients admitted to an acute care hospital with vertebrobasilar (VBA) occlusion and stenosis strokes as defined by ICD-9 codes of 433.0, 433.01, 433.20, and 433.21 during the study period. Pa- tients with more than one admission for a VBA stroke were excluded from the study. For each stroke case, four age and gender matched controls were randomly se- lected from sampled qualified members. Both cases and controls were randomly sorted prior to the matching using a greedy matching algorithm [36].


The index date was defined as the date of admission for the VBA stroke. Any encounters with a chiropractor or a primary care physician (PCP) prior to the index date were considered as exposures. To evaluate the impact of chiropractic and PCP treatment, the designated hazard period in this study was zero to 30 days prior to the index date. For the PCP analysis, the index date was excluded from the hazard period since patients might consult PCPs after having a stroke. The standard health plan coverage included a limit of 20 chiropractic visits. In rare circumstances a small employer may have selected a 12-visit limit. An internal analysis (data not shown) revealed that 5% of the combined (commercial and MA) populations reached their chiropractic visit limits. Instances of an employer not covering chiropractic care were estimated to be so rare that it would have had no measurable impact on the analysis. There were no limits on the number of reimbursed PCP visits per year.


Two sets of similar analyses were performed, one for the commercially insured population and one for the MA population. In each set of analyses, conditional logistic regression models were used to examine the association between the exposures and VBA strokes. To measure the association, we estimated the odds ratio of having the VBA stroke and the effect of total number of chiropractic visits and PCP visits within the hazard period. The analyses were applied to different hazard periods, including one day, three days, seven days, 14 days and 30 days for both chiropractic and PCP visits. The results of the chiropractic and PCP visit analyses were then compared to find evidence of excess risk of having stroke for patients with chiropractic visits during the

hazard period. Previous research has indicated that most patients who experience a vertebral artery dissection are under the age of 45. Therefore, in order to investigate the impact of exposure on the population at different ages, separate analyses were performed on patients stratified by age (under 45 years and 45 years and up) for the study of the commercial population. The number of visits within the hazard period was entered as a con- tinuous variable in the logistic model. The chi square test was used to analyze the proportion of co-morbidities in cases as compared to controls.


A secondary analysis was performed to evaluate the relevance of using chiropractic visits as a proxy for spinal manipulation. The commercial and MA databases were queried to identify the proportions of cases of VBA stroke and matched controls for which at least one chiropractic spinal manipulative treatment procedural code (CPT 98940 – 98942) was or was not recorded. The analysis also calculated the use of another manual therapy code (CPT 97140), which may be employed by chiropractors as an alternative means of reporting spinal manipulation.


The New England Institutional Review Board (NEIRB) determined that this study was exempt from ethics review.


The commercial study sample included 1,159 VBA stroke cases over the three year period and 4,633 age and gender matched controls. The average age of the patients was 65.1 years and 64.8% of the patients were male (Table 1). The prevalence rate of VBA stroke in the commercial population was 0.0032%.


There were a total of 670 stroke cases and 2,680 matched controls included in the MA study. The aver- age patient age was 76.1 years and 58.6% of the patients were male (Table 2). For the MA population, the prevalence rate of VBA stroke was 0.021%.


Claims during a one year period prior to the index date were extracted to identify comorbid disorders. Both the commercial and MA cases had a high percentage of comorbidities, with 71.5% of cases in the commercial study and 88.5% of the cases in the MA study reporting at least one of the comorbid conditions (Table 3). Six comorbid conditions of particular interest were identified, including hypertensive disease (ICD-9 401–404), ischemic heart disease (ICD-9 410–414), disease of pulmonary circulation (ICD-9 415–417), other forms of heart disease (ICD-9 420–429), pure hypercholesterolemia (ICD-9 272.0) and diseases of other endocrine glands (ICD-9 249–250). There were statistically significant differences (p = <0.05) between groups for most comorbidities. Greater proportions of comorbid disorders (p = <0.0001) were reported in the commercial and MA cases for hyper- tensive disease, heart disease and endocrine disorders (Table 3). The commercial cases also showed a larger proportion of diseases of pulmonary circulation, which was statistically significant (p = 0.0008). There were no significance differences in pure hypercholesterolemia for either the commercial or MA populations. Overall, cases in both the commercial and MA populations were more likely (p = <0.0001) to have at least one co- morbid condition.


Among the commercially insured, 1.6% of stroke cases had visited chiropractors within 30 days of being admit- ted to the hospital, as compared to 1.3% of controls visit- ing chiropractors within 30 days prior to their index date. Of the stroke cases, 18.9% had visited a PCP within 30 days prior to their index date, while only 6.8% of controls had visited a PCP (Table 4). The proportion of exposures for chiropractic visits was lower in the MA sample within the 30-day hazard period (cases = 0.3%; controls = 0.9%). However, the proportion of exposures for PCP visits was higher, with 21.3% of cases having PCP visits as compared to12.9% for controls (Table 5).


The results from the analyses of both the commercial population and the MA population were similar (Tables 6, 7 and 8). There was no association between chiropractic visits and VBA stroke found for the overall sample, or for samples stratified by age. No estimated odds ratio was significant at the 95% confidence level. MA data were insufficient to calculate statistical measures of association for hazard periods less than 0–14 days for chiropractic visits. When stratified by age, the data were too sparse to calculate measures of association for hazard periods less than 0–30 days in the commercial population. The data were too few to analyze associative risk by headache and/or neck pain diagnoses (data not shown).


These results showed there is an association existing between PCP visits and VBA stroke incidence regardless of age or length of hazard period. A strong association was found for those visits close to the index date (OR 11.56; 95% CI 6.32-21.21) for all patients with a PCP visit within 0–1 day hazard period in the commercial sample. There was an increased risk of VBA stroke associated with each PCP visit within 30-days prior to the index date for MA patients (OR 1.51; 95% CI 1.32-1.73) and commercial patients (OR 2.01; 95% CI 1.77-2.29).


The findings of the secondary analysis showed – that of 1159 stroke cases from commercial population – there were a total of 19 stroke cases associated with chiropractic visits for which 13 (68%) had claims documentation indicating chiropractic SMT was performed. For the control group of the commercial cohort, 62 of 4633 controls had claims of any kind of chiropractic visits and 47 of 4633 controls had claims of SMT. In the commercial control group, 47 of 62 DC visits (76%) included SMT in the claims data. Only 1 of 2 stroke cases in the MA population included SMT in the claims data. For the MA cohort, 21 of 24 control chiropractic visits (88%) included SMT in the claims data (Table 9).


None of the stroke cases in either population included CPT 97140 as a substitute for the more conventionally re- ported chiropractic manipulative treatment procedural codes (98940 – 98942). For the control groups, there were three instances where CPT 97140 was reported without CPT 98940 – 98942 in the commercial population. The CPT code 97140 was not reported in MA control cohort.


The primary aim of the present study was to investigate the association between chiropractic manipulative treatment and VBA stroke in a sample of the U.S. population. This study was modeled after a case–control design previously conducted for a Canadian population [32]. Administrative data for enrollees in a large national health care insurer were analyzed to explore the occurrence of VBA stroke across different time periods of exposure to chiropractic care in comparison with PCP care.


Unlike Cassidy et al. [32] and most other case–control studies [33,37,38], our results showed there was no significant association between VBA stroke and chiropractic visits. This was the case for both the commercial and MA populations. In contrast to two earlier case–control studies [32,33], this lack of association was found to be irrespective of age. Although, our results (Table 8) did lend credence to previous reports that VBA stroke occurs more frequently in patients under the age of 45 years. Additionally, the results from the present study did not identify a relevant temporal impact. There was no significant association, when the data were sufficient to calculate estimates, between chiropractic visits and stroke regardless of the hazard period (timing of most recent visit to a chiropractor and the occurrence of stroke).


There are several possible reasons for the variation in results with previous similar case–control studies. The younger (<45 yrs.) commercial cohort that received chiropractic care in our study had noticeably fewer cases. The 0–30 days hazard period included only 2 VBA stroke cases. There were no stroke cases for other hazard periods in this population. In contrast, earlier studies reported sufficient cases to calculate risk estimates for most hazard periods [32,33].


Another factor that potentially influenced the difference in results concerns the accuracy of hospital claims data in the U.S. vs. Ontario, Canada. The source population in the Province of Ontario was identified, in part, from the Discharge Abstract Database (DAD). The DAD includes hospital discharge and emergency visit diagnoses that have undergone a standardized assessment by a medical records coder [39]. To the best of our know- ledge, similar quality management practices were not routinely applied to hospital claims data used in sourcing the population for our study.


An additional reason for the disparity in results may be due to differences in the proportions of chiropractic visits where SMT was reportedly performed. Our study showed that SMT was not reported by chiropractors in more than 30% of commercial cases. It is plausible that a number of the cases in earlier studies also did not include SMT as an intervention. Differences between studies in the proportion of cases reporting SMT may have affected the calculation of risk estimates.


Also, there were an insufficient number of cases having cervical and/or headache diagnoses in our study. Therefore, our sample population may have included proportionally less cases where cervical manipulation was performed.


Our results were consistent with previous findings [32,33] in showing a significant association between PCP visits and VBA stroke. The odds ratios for any PCP visit increase dramatically from 1–30 days to 1–1 day (Tables 6 and 7). This finding is consistent with the hypothesis that patients are more likely to see a PCP for symptoms related to vertebral artery dissection closer to the index date of their actual stroke. Since it is unlikely that the services provided by PCPs cause VBA strokes, the association between recent PCP visits and VBA stroke is more likely attributable to the background risk related to the natural history of the condition [32].


A secondary goal of our study was to assess the utility of employing chiropractic visits as a surrogate for SMT. Our findings indicate there is a high risk of bias associated with using this approach, which likely overestimated the strength of association. Less than 70% of stroke cases (commercial and MA) associated with chiropractic care included SMT. A somewhat higher proportion of chiropractic visits included SMT for the control groups (commercial = 76%; MA = 88%).


There are plausible reasons that support these findings. Internal analyses of claims data (not shown) consistently demonstrate that one visit is the most common number associated with a chiropractic episode of care. The single visit may consist of an evaluation without treatment such as SMT. Further; SMT may have been viewed as contraindicated due to signs and symptoms of vertebral artery dissection (VAD) and/or stroke. This might explain the greater proportion of SMT provided to control groups in both the commercial and MA populations.


Overall, our results increase confidence in the findings of a previous study [32], which concluded there was no excess risk of VBA stroke associated chiropractic care compared to primary care. Further, our results indicate there is no significant risk of VBA stroke associated with chiropractic care. Additionally, our findings highlight the potential flaws in using a surrogate variable (chiropractic visits) to estimate the risk of VBA stroke in association with a specific intervention (manipulation).


Our study had a number of strengths and limitations. Both case and control data were extracted from the same source population, which encompassed national health plan data for approximately 36 million commercial and 3 million MA members. A total of 1,829 cases were identified, making this the largest case– control study to investigate the association between chiropractic manipulation and VBA stroke. Due to the nationwide setting and large sample size, our study likely reduced the risk of bias related to geographic factors. However, there was a risk of selection bias – owing to the data set being from a single health insurer – including income status, workforce participation, and links to health care providers and hospitals.


Our study closely followed a methodological approach that had previously been described [32], thus allowing for more confident comparisons.


The current investigation analyzed data for a number of comorbid conditions that have been identified as potentially modifiable risk factors for a first ischemic stroke [40]. The differences between groups were statistically significant for most comorbidities. Information was not obtainable about behavioral comorbid factors e.g., smoking and body mass. With the exception of hypertensive disease, there are reasons to question the clinical significance of these conditions in the occurrence of ischemic stroke due to vertebral artery dissection. A large multinational case-referent study investigated the association between vascular risk factors (history of vascular disease, hypertension, smoking, hypercholesterolemia, diabetes mellitus, and obesity/overweight) for ischemic stroke and the occurrence of cervical artery dissection [41]. Only hypertension had a positive association (odds ratio 1.67; 95% confidence interval, 1.32 to 2.1; P <0.0001) with cervical artery dissection.


While the effect of other unmeasured confounders cannot be discounted, there is reason to suspect the absence of these data was not deleterious to the results. Cassidy, et al. found no significant differences in the results their case-crossover design, which affords better control of unknown confounding variables, and the findings of their case–control study [32].


Our results highlight just how unusual VBA stroke is in the MA cohort (prevalence = 0.021%) and – even more so – for the commercial population (prevalence = 0.0032%). As a result, some limitations of this study re- lated to the rarity of reporting VBA stroke events. Despite the larger number of cases, data were insufficient to calculate estimates and confidence intervals for seven measures of exposure (4 commercial and 3 MA) for chiropractic visits. Additionally, we were not able to compute estimates specifically for headache and neck pain diagnoses due to small numbers. Confidence intervals associated with estimates tended to be wide making the results imprecise [42].


There were limitations related to the use of administrative claims data. “Disadvantages of using secondary data for research purposes include: variations in coding from hospital to hospital or from department to department, errors in coding and incomplete coding, for example in the presence of comorbidities. Random errors in coding and registration of discharge diagnoses may dilute and attenuate estimates of statistical association” [43]. The recordings of unvalidated hospital discharge diagnostic codes for stroke have been shown to be less precise when compared to chart review [44,45] and validated patient registries [43,46]. Cassidy, et al. [32] conducted a sensitivity analysis to determine the effect of diagnostic misclassification bias. Their conclusions did not change when the effects of misclassification were assumed to be similarly distributed between chiropractic and PCP cases.


A particular limitation in using administrative claims data is the paucity of contextual information surround- ing the clinical encounters between chiropractors/PCPs and their patients. Historical elements describing the occurrence/absence of recent trauma or activities reported in case studies [47-51] as potential risk factors for VBA stroke were not available in claims data. Confidence was low concerning the ability of claims data to provide accurate and complete reporting of other health disorders, which have been described in case–control designs as being associated with the occurrence of VBA stroke e.g., migraine [52] or recent infection [53]. Symptoms and physical examination findings that would have permitted further stratification of cases were not reported in the claims data.


The reporting of clinical procedures using current pro- cedural terminology (CPT) codes presented additional shortcomings concerning the accuracy and interpretation of administrative data. One inherent constraint was the lack of anatomic specificity associated with the use of standardized procedural codes in claims data. Chiropractic manipulative treatment codes (CPT 98940 – 98942) have been formatted to describe the number of spinal regions receiving manipulation. They do not identify the particular spinal regions manipulated.


Also, treatment information describing the type(s) of manipulation was not available. When SMT was re- ported, claims data could not discriminate among the range of techniques including thrust or rotational manipulation, various non-thrust interventions e.g., mechanical instruments, soft tissue mobilizations, muscle energy techniques, manual cervical traction, etc. Many of these techniques do not incorporate the same bio- mechanical stressors associated with the type of manipulation (high velocity low amplitude) that has been investigated as a putative risk factor for VBA stroke [54-56]. It seems plausible that the utility of future VBA stroke research would benefit from explicit descriptions of the particular type of manipulation performed.


Moreover, patient responses to care – including any adverse events suggestive of vertebral artery dissection or stroke-like symptoms – were not obtainable in the data set used for the current study.


In the absence of performing comprehensive clinical chart audits, it is not possible to know from claims data what actually transpired in the clinical encounter. Further, chart notes may themselves be incomplete or otherwise fail to precisely describe the nature of interventions [57]. Therefore, manipulation codes represent surrogate measures, albeit more direct surrogate measures, than simply using the exposure to chiropractic visits.


Our study was also limited to replication of the case– control design described by Cassidy, et al. [32]. For pragmatic reasons, we did not attempt to conduct a case-crossover design. While the addition of a case- crossover design would have provided better control of confounding variables, Cassidy, et al. [32] showed the results were similar for both the case control and case crossover studies.


The findings of this case–control study and previous retrospective research underscore the need to rethink how to better conduct future investigations. Researchers should seek to avoid the use of surrogate measures or use the least indirect measures available. Instead, the focus should be on capturing data about the types of services and not the type of health care provider.


In alignment with this approach, it is also important for investigators to access contextual data (e.g., from electronic health records), which can be enabled by qualitative data analysis computer programs [58]. The acquisition of the elements of clinical encounters – including history, diagnosis, intervention, and adverse events – can provide the infrastructure for more action- able research. Because of the rarity of VBA stroke, large data sets (e.g., registries) containing these elements will be necessary to achieve adequate statistical power for making confident conclusions.


Until research efforts produce more definitive results, health care policy and clinical practice judgments are best informed by the evidence about the effectiveness of manipulation, plausible treatment options (including non-thrust manual techniques) and individual patient values [20].


Our findings should be viewed in the context of the body of knowledge concerning the risk of VBA stroke. In contrast to several other case–control studies, we found no significant association between exposure to chiropractic care and the risk of VBA stroke. Our secondary analysis clearly showed that manipulation may or may not have been reported at every chiropractic visit. Therefore, the use of chiropractic visits as a proxy for manipulation may not be reliable. Our results add weight to the view that chiropractic care is an unlikely cause of VBA strokes. However, the current study does not exclude cervical manipulation as a possible cause or contributory factor in the occurrence of VBA stroke.

Authors' Contributions

DE conceived of the study, and participated in its design and coordination. JT participated in the design of the study, performed the statistical analysis and helped to draft the manuscript. TMK participated in the design and coordination of the study, and wrote the initial draft and revisions of the manuscript. WMB participated in the coordination of the study and the statistical analysis, and helped to draft the manuscript. All authors contributed to the interpretation of the data. All authors read and approved the final manuscript.

Author Details

1Optum Health – Clinical Programs at United Health Group, 11000 Optum Circle, Eden Prairie MN 55344, USA. 2Optum Health – Clinical Analytics at United Health Group, 11000 Optum Circle, Eden Prairie MN 55344, USA.


Received: 14 October 2014 Accepted: 28 April 2015

Published Online: 16 June 2015


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53. Guillon B, Berthet K, Benslamia L, Bertrand M, Bousser M, Tzourio C. Infection and the risk of cervical artery dissection: a case–control study. Stroke. 2003;34(7):e79–81.
54. Symons B, Leonard TR, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. J Manip Physiol Ther.2002;25(8):504–10.
55. Wuest S, Symons B, Leonard T, Herzog W. Preliminary report: biomechanics of vertebral artery segments C1-C6 during cervical spinal manipulation. J Manip Physiol Ther. 2010;33(4):273–8.
56. Herzog W, Leonard TR, Symons B, Tang C, Wuest S. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. J Electromyogr Kinesiol. 2012;22(5):747–51.
57. Centers for Medicare & Medicaid: Comprehensive error rate testing (CERT). 2015 (Jan. 15). [http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/index.html?redirect=/cert] Accessed February 4, 2015.
58. Welsh E: Dealing with data: using NVivo in the qualitative data analysis process. Forum: Qualitative Social Research 2002, 3(2): Art. 26 [http://nbnresolving.de/urn:nbn:de:0114-fqs0202260] Accessed February 4, 2015.

Via Dr. Alex Jimenez D.C.,C.C.S.T
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There is controversy surrounding the risk of manipulation, often used by chiropractors, with association to vertebrobasilar (VBA) stroke. For Answers to any questions you may have please call Dr. Jimenez at 915-850-0900

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How devices are letting people take control of their own healthcare

How devices are letting people take control of their own healthcare | heaith | Scoop.it

It's 6am in the yoga room when my Apple Watch beeps three times. It's not helping the mediative mood but I have to look. I've been wearing the watch for two weeks and I'm tracking everything I can about my body. Right now my heart rate is 68 beats per minute. The readout tells me I've stood for a minute each hour for 10 consecutive hours. Through the My Fitness Pal app, I've logged exactly what I've eaten today and learned a glass of Bonsoy is nearly as calorific as a banana. Where my doctor's advice and own self-interest failed to get me doing my 30 minutes of exercise a day, the watch has succeeded.

I now have data about how much I weigh, what I eat, how well I sleep, how much I've walk and how hard my heart is working. If I am prepared to share some of this information with my insurance company I could get a discount on my life cover. But what I am doing is just the start when it comes to monitoring my wellbeing. Already, there's a wristband that scans whatever you put into your shopping basket to find out whether it's a good match for your genetic make-up, an app that alerts your doctor when you haven't taken your antipsychotic medication and a box in your bedroom that can sense your heart beat in the living room.

Across the world, healthcare is undergoing a fundamental transformation. As we all live longer, health systems are increasingly dealing with chronic conditions as opposed to the old model of acute care lasting days or weeks. And the promotion and management of healthy lifestyles, to combat the rise of lifestyle diseases, is becoming an increasingly important part of the health mix.

Globally, nearly 28 million wearable devices were sold in the second quarter of 2018. SEE CAPTION INFO

In supporting and propelling that general shift, there has been an explosion in devices, apps and technology designed to record or modify everything from what we eat to how we breathe.

Tech giants such as Google are rumoured to be working on AI-assisted wellness coaches that push you towards healthier menu options where you're dining, or customise workouts and meal plans for you. Apple is making huge investments in both consumer and clinician-level health and wellness technology. These are not sci-fi dreams. These are available or in development now. We have never before had access to this level of information about our health. And we have never before shared this information so widely. We're still figuring out what it means for the way we live, how the medical profession treats us, how public health is managed and how we are insured. How much information is too much?


Globally, nearly 28 million wearable devices were sold in the second quarter of 2018 – a 5.5 per cent increase on the previous year – according to the International Data Corporation. That's $US4.8 billion ($6.7 billion) worth – an 8.3 per cent rise. The IQVIA Institute of Health Data Sciences says there are more than 310,000 health apps now available. The business of keeping well is booming. In October, the Global Wellness Institute reported that the wellness industry, covering everything from spas to apps, was worth $US4.2 trillion in 2017 – a growth of 12.8 per cent over two years which, it says, now represents more than 5 per cent of global output.

Instant genetic information

Diabetes is an area of intense activity in health tech. Between 1980 and 2014 the global population of diabetics nearly tripled to 422 million. For those with type 2 diabetes – the form of the disease that affects 90 per cent of diabetics – which a change of diet can fix the problem. If people can change their food buying behaviour it makes sticking to a healthful diet easier. That's where entrepreneurs like Professor Chris Toumazou come in.

Not long before I met him, Professor Toumazou wanted a chocolate. "I'm not going to not have a chocolate," he says. So at the shop counter, he waved his wristband over his two preferred options: a Snickers and a Mars bar.It flashed green on the Snickers. Based on his DNA, it had determined the bar to be the healthier option. (He has the hypertension gene, not the obesity one).

The wristband and analysis are developments from the Imperial College biomedical engineering professor's company, DnaNudge. The London-based company has developed palm-sized micro-labs which do on-the-spot DNA analysis for key risk factors – including diabetes and hypertension. It also looks for genetic markers that reveal how well substances including carbohydrates, proteins, saturated fat, caffeine and sodium are metabolised. The data is encrypted and uploaded to the user's app and wristband. They then scan or photograph foods to find out if an item is healthy for them.


The object is to help people gradually change how they shop by being able to quickly tell which food options are best for them. For example, someone with a poor ability to break down fat will be guided away from foods high in fats.

In October, the company announced a year-long trial of the technology with a group of 1000 pre-diabetic customers of British supermarket chain Waitrose who will try to reduce their risk of developing the disease. Toumazou hopes to be rolling the technology out commercially in key global markets, including Australia, by the end of 2019.

There are a number of startups using DNA to direct eating behaviour but large companies are also getting in on the act. Nestle in Japan has a Wellness Ambassador programme. Subscribers to the programme upload pictures of their meals onto photo-sharing app Line, the food image is then analysed for its nutritional content. Users can also submit their DNA to a third party for analysis. On the basis of all this data, Nestle makes tailored diet and recipe recommendations. It also proposes particular supplements or kale and fruit smoothies for use in the Nestle Dolce Gusto machine.

DnaNudge says that when the technology is fully commercialised, the company will have booths in every supermarket where a shopper could swab their cheek and pick up a wristband complete with their genetic information 15 minutes later. The micro-lab cartridge with the DNA sample would be destroyed immediately afterwards. Toumazou is intent on making the technology affordable; he says the hardware will retail for tens of dollars and there will be a small subscription fee for the app – which could branch into monitoring inactivity levels, offering meal plans and building social networks of people with similar conditions.


Toumazou says decades of healthy eating advice has failed to stem a global obesity epidemic. Something needs to disrupt that tide. "It's got to be very simple so people make small changes, without really affecting their behaviour too much in the short term," he says.

Chronic condition management

By taking a long-term approach, Australian tech start-up Perx is hoping to crack chronic condition management. According to the Australian Institute of Health and Welfare, half of the Australian adult population has one of eight chronic conditions – arthritis, asthma, back pain, cancer, cardiovascular disease, chronic obstructive pulmonary disease, diabetes and mental health conditions – and 39 per cent of potentially preventable hospitalisations were due to these eight conditions.

Through a cluttered bookshop on Bourke Street, Surry Hills, in Sydney, and up a winding staircase, old high school friends Scott Taylor and Hugo Rourke have set up an office for Perx, an app that encourages people to stick to clinical treatments through gamification. The young co-founders are bright-eyed, wearing matching branded T-shirts, Apple Watches and physiques that suggest participation in amateur rowing or rugby union teams. They sit in their sparse, small meeting room, a blank white board against one wall.

Users of Perx have to upload evidence that they have taken their medication, a photo perhaps. They are then sent a simple game to play which offers the possibility of winning a prize such as movie tickets or a donation to their favourite charity.

Imagine a contact lens that continuously monitors diabetics' blood glucose levels from their tear drops and transmits the data to an app.  Google

The start-up is partnering with the NSW Health Sydney service, Diabetes NSW and ACT and Novartis, among others, which pay a licence fee for the technology; for the end user, the app is free. Data from the users is encrypted and aggreggated and general reports are sent to the participating organisations about the level of the groups' adherence. They have several thousand users.

Perx began as a side project when Taylor was working in private banking and Rourke was a consultant across a number of consumer industries. Both men had family members struggling to manage different chronic conditions and they realised how few behavioural economics tactics were being used in the health sector. Two years after they started, the team now numbers seven (who are hard at work in a small room adjoining the meeting room) and a further three people are about to join the company.

"It's pretty rapid growth given that this time last year it was three guys in a room in Bondi," says Taylor. "We're super excited about it."

There is plenty of room to grow since 230,000 hospitalisations a year in Australia are because people fail to take their medications as prescribed. In Europe the problem is the cause of 190,000 avoidable deaths.

Dr Harry Nespolon, president of the Royal College of Australian General Practitioners, says the role of the GP will evolve, and become more central.  RACGP

"Healthcare has traditionally suffered from top-down direction, not treating the patient as a person who can manage their own care," says Rourke. "If we can empower people, health will be in a better place."

The invisible doctor

At the Consumer Electronics Show conference in Las Vegas, run by the Consumer Technology Association, wellness and health technology formed a large part of this year's new products. There were lots of cutting-edge devices making huge claims: E-vone smart shoes can detect a fall and call an emergency contact; a magnetic attachment for Motorola phones, which can measure respiratory rate, blood pressure, body temperature and blood oxygen levels; a Somnox robot pillow which glows and contracts as the user cuddles it in bed, all the while detecting carbon dioxide, sound and movement.

But in terms of the leading edge, few companies scrape it so closely as Emerald Innovations. It isn't in the business of wearables, but "invisibles".

Emerald Innovations, a Boston start-up led by MIT professor and Macarthur "genius" prize winner Professor Dina Katabi, has already put hundreds of its Wi-Fi-like boxes in homes in the United States. The Emerald is able to detect a user's posture, gait, heart beat and breathing without ever touching them. Without even being in the same room. Katabi says the technology could herald a new era of independence for people with serious conditions or older people, and could transform the way we conduct clinical trials, with pharmaceutical companies able to take continuous readings from trial participants to assess a drug's efficacy. In a TED talk, Katabi said the device has even been deployed in homes of people with depression and anxiety.

"Every single move that we make – even when we take a breath, or the pulsing of our blood – changes the electromagnetic waves around you," Katabi tells AFR Weekend. "Our idea is to have a sensitive device that can detect changes in electromagnetic waves, and use the advances in machine learning to interpret those changes so we can refer the physiological signal to the end user."

The end user may be a clinician monitoring a patient's condition remotely, an adult child concerned about an elderly parent or a drug company conducting a clinical trial.

Trials in the US for people with Parkinson's have been able to detect when a patient's medication has started to wear off by assessing their movement, and has helped doctors adjust doses accordingly. The traditional alternative has been sporadic visits to doctors who assess movement visually within a consultation.

Katabi says that the device use is based on the consent of the person monitored, that they can determine who gets what data. However, she says, just like you don't have to inform your house guests if you have a baby monitor or security camera, she expects that the user would not have to notify any guests that an Emerald box was in use, despite the fact that it could monitor their vital signs too (though their information won't be stored).

Perx co-founders Scott Taylor (left) and Hugo Rourke (right). Perx is hoping to crack chronic condition management. Kate Geraghty

"Getting information on anyone is getting information that they may consider private," she says. "But at the same time, you compare it to the alternative. For an older person who lives alone, what are their options? Putting a camera in the home would be way more invasive of privacy – as would asking a carer to live with them. It's really about trying to find the right trade-off to deliver something that can provide a lot of gain, while managing the privacy issue in the proper way."

Public health implications

A study published in the Digital Medicine journal, which analysed studies and trials of the efficacy of mobile health apps for things such as managing weight or mental health, found evidence that while some worked, overall the quality of the studies were too poor to reach any conclusions.

Professor Tim Shaw of the Digital Health Co-operative Research Council, which launched this year with $55 million worth of federal government funding, agrees.

"It's a bit like where pharmacy was in the 1800s. It was totally unregulated. You could buy a drug for just about any condition and it was largely financially driven. At the moment, people are building apps for $3, just as I'm sure you could buy a pill for leprosy for $3 back in the 1800s, and there's not a lot of evidence as to how that actually impacts on health," he says. "That's changing."

The US Food and Drug Administration has just cleared two Apple Watch medical apps – one that can take an electrocardiogram by the user touching a button on the series 4, and another that can detect signs of atrial fibrillation and warn the wearer. In Britain, the National Health Service has its own apps library, which recommends apps for everything from managing panic attacks to blood clots, and indicates which of these are undergoing NHS testing. Here in Australia, the CSIRO and Therapeutic Goods Administration are looking into how to regulate the emerging medical devices industry.

"As apps become part of how we deliver care – because we are heading towards prescribing apps – we will have a smaller number of evidence-based apps and devices that have impact," Shaw says.

The Digital Health CRC is investigating how all these data sets being created by personal apps and devices, and in clinical environments, can be utilised to improve individual and public health. The infrastructure supporting this is lacking, says Shaw. "It's like we have well and truly made it to Mars, but we dragged the rocket to the launch pad with a horse and cart," he says. "We have these fundamental failures in the underpinnings about how data is connected together."

This data, when combined with augmented intelligence, could shift the way the healthcare system works. Shaw says that at present, for instance, Sydney's Royal North Shore Hospital can predict that on the weekend it might have five people show up with a broken leg, four with influenza and 53 heart attacks. "What we can't predict is who those 53 people are that will have those heart attacks and reach out to them two months before and stop it happening. This is the really interesting piece that AI can contribute to; our predictive ability to make decisions on people's trajectories."

The US Food and Drug Administration has just cleared two Apple Watch medical apps – one that can take an electrocardiogram by the user touching a button on the series 4, and another that can detect signs of atrial fibrillation and warn the wearer.  Bloomberg

It might be, Shaw says, that a patient on a trajectory to a heart attack on the basis of data such as their heart rate, activity levels and other information might pop up on a doctor's computer. The doctor might then call in their patient to prescribe lifestyle changes and potentially medication that could prevent a catastrophic event.

Meanwhile, for healthy people and those with chronic conditions alike, having access to personal and continuous data about their health and wellbeing will see them more empowered in their relationships with clinicians.

"You're almost getting the emergence of expert consumers that understand their own data best, and can start to work much more collaboratively with the clinician in terms of what matters to them," he says.

New roles may be created within medicine, says Shaw. People can manage their lifestyle and chronic conditions largely on their own, when supported by technology. The remote monitoring of these things could mean the creation of a something like a virtual coach, who may co-ordinate different aspects of an individual's health and wellbeing and call in consultants or doctors when needed.

Dr Harry Nespolon, president of the Royal College of Australian General Practitioners, says the role of the GP will evolve, and become more central. The GP could monitor a thousand patients at once as they upload their data about sugar levels, heart rate and the like, but only need to call in a few for consultations. The lower-value consultations will start to disappear; managed by patients themselves, nurses or even pharmacists.

"It's exciting," he says. "It will help patients understand what they're doing better – whether they do anything about that is going to be their choice."

Privacy and data

The implications of this personal health data go beyond healthcare. It could change the way some industries do business.

For a few years now, MLC has been offering discounts on life insurance premiums for policy holders who agree to share their steps data with the insurer. In return for demonstrating that they are walking at least 37,500 steps a week for 30 weeks out of 40, the policy holders get a 5 per cent annual discount on their premium; if they don't meet the target, the premium rises the following year. Just under 5000 people are enrolled in the programme. The data from their Fitbits, Apple Watches or other activity trackers is sent to a third party, encrypted and then the step count alone is passed on to MLC for verification. For the insurer, it's a way to not only make their customers healthier – and therefore lower risk – but also to build a closer relationship with them.

For a few years now, MLC has been offering discounts on life insurance premiums for policy holders who agree to share their steps data with the insurer. 

Last year, MLC's head of retail, Sean McCormack, broke his sternum in a car accident on the way to Tullamarine Airport in Melbourne. He went from averaging about 15,000 steps a day, to nothing. In the future, McCormack would like the insurance company to notice such a change and make contact. They could say: 'Hey Sean, we've noticed you're really inactive. Something seems to have happened. Is everything all right? Is there anything we can do to help you?'" And then signpost things such as recovery tools or programmes. "This positive customer engagement I think is the real opportunity for us in the future," he says.

Technologies such as the in-development contact lens that monitors blood glucose levels or heart-rate monitors are also of interest. It could change the way companies underwrite customers, able to show that while an individual has a chronic condition, it is well managed and therefore a lower risk. "It's really, really exciting," he says.

For Dr Lisa Carver, a sociologist at the Queens University in Canada, the scenario put forward by MLC sounds terrifying.

Dr Carver has raised concerns that the multiple sets of health and wellness data that stream into the ether from our devices, phones, apps, watches could be used to create a wellness score report – much like the financial credit reports held on every individual. And just like credit reports, they would be compiled without the participation or notification of individuals, she says, and potentially used to restrict access to various services, such as health insurance (in countries where insurers can charge or refuse policies to individuals who present high risk), or even medical procedures in public health systems.

"These programmes can become gatekeepers," she says. "Just like credit reports, they may be full of errors." Carver paints a hypothetical picture of a wine enthusiast, who spends time researching fine wine, enjoying a moderate amount but not drinking beyond limits. Perhaps this person's data is skewed because they're wearing their heart rate monitor wrong, or they break their leg and are rendered sedentary. And say that person also ended up requiring a liver transplant in a public health system. "What concerns me is if your app, browser and credit card history linked to wine is added to health data, all of these factors combined could end up with you being told you don't get a liver transplant because you're labelled by your 'health report' data profile as an alcoholic.

"We're sitting here like it's our birthday. We have all these apps we're opening up and we're just jumping right in there," says Carver. "It's too easy for this technology to just become part of life. They'll be ingrained so completely that it'll be impossible for any government to step in and clean it up, because they'll be so integrated into everything. And that really worries me."

Greg Williams, lead author of the CSIRO's Future of Health report, says he is optimistic about the role of technology in supporting individual health and wellbeing, but many things need to be got right. Ensuring equal access to the technology is critical. On privacy, he says: "The funny thing is that none of us have much privacy at all, really. It's just a matter of how aware of that you are."

And on that note, my Apple Watch has beeped. It's time for me to focus on breathing for one minute. I can relax now.

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Doctors pen 'social prescriptions' aimed at easing depression, loneliness in patients 

Doctors pen 'social prescriptions' aimed at easing depression, loneliness in patients  | heaith | Scoop.it

When Tammy McEvoy was asked to share her time and crafting talents to engage with other patients at her local health centre, she ended up getting back as much as she gave — maybe more.

McEvoy is one of 15 "health champions" at the Belleville and Quinte West Community Health Centre taking part in an innovative Ontario pilot project in which doctors or other practitioners write out a "social prescription" for patients experiencing depression, anxiety or loneliness that affects their sense of well-being. 

The concept — prescribing a social activity like taking a yoga class, visiting an art gallery or joining a knitting circle — has proven to be an effective tool in the U.K., where research has shown that not only do patients benefit from a mental-health boost, but many also end up with reduced medications and find less need to visit their doctors.

Since the pilot project began in October, McEvoy has taught classes on wreath-making, and cooked an evening meal for an addiction group meeting at the centre's Quinte West site in Trenton. 

The wreath-making classes brought together 16 participants. "The first one I did, I watched magic happen because they all started helping each other," says the 52-year-old self-described empty-nester who's often alone while her husband works long hours.

"I've spent the last six years not working and not being out because of health reasons," says McEvoy, who has a heart condition. "But now I can go there, I'm comfortable there.

"It helps me just as much as it helps them."

Meghan Shanahan Thain, a social worker at the Trenton health centre, says the program is based on a U.K. collaborative practice model called Altogether Better.

"So people come up with their own ideas based on their own talents and skills, but they also have a lens that we don't see in terms of what the community needs and what our clients need," she says of the health champions, who included a singing circle in the social activities on offer.

On one occasion, "we had two people who are widowed who connected to each other and just sang," she says. "A girl from the community showed up with a guitar.

"Music really brings people together, but it also taps into the socially isolated folks as well ... Just having a social connection has a lot of health benefits. Being socially isolated can make us sick in a lot of different ways."

The 18-month pilot project, supported by a $600,000 Ontario Health Ministry grant, is being spearheaded by the Alliance for Healthier Communities, which represents more than 100 primary health-care organizations across the province.

The grant allowed the Alliance to trial social prescribing in 10 of the centres, with a goal of evaluating benefits to patients, says Kate Mulligan, director of policy and communications.

"One example from Thunder Bay that really resonates is there's a long-haul trucker who was experiencing social isolation and he started up a knitting group at the community health centre," she says, adding that it's especially satisfying to see a person in need become a volunteer to help others form social connections.

"They start to recognize their own value and self-worth when they're participating and contributing to the community," Mulligan says. "So you're not just seen as a patient with deficits and problems, but you're a person who has something to offer."

Another of the pilot sites is the Rexdale Community Health Centre in Toronto. A large proportion of patients are recent immigrants or refugees, who are at risk of social isolation that can lead to depression and anxiety, says Dr. Sonali Srivastava, a primary-care physician on staff.

"Really, the research is showing us that social integration is a major part of people's level of happiness and health," she says. "If there's a social component in there that is missing, we need to address it."

That could mean writing a prescription for a patient to join a tai chi class, for example, or to tour a museum or art gallery.

Indeed, the Montreal Museum of Fine Arts (MMFA) and the Royal Ontario Museum (ROM) are two cultural institutions in Canada that have embraced the idea of coupling social activities with health and well-being.

A recent study conducted by the MMFA, McGill University and the Jewish General Hospital found that seniors who participated in drawing and painting workshops reported an improved sense of well-being, health and quality of life.

Starting in January, the ROM will begin providing 5,000 sets of free passes to patients with social prescriptions for a tour of its exhibits for themselves and three companions, working with 20 of its ROMCAN (Community Access Network) partners in the Greater Toronto Area, including the Alliance for Healthier Communities. The program will then be rolled out to the other 80 partners in the network.  

Jennifer Czajkowski, deputy director for engagement at the Toronto museum, says research has shown that museums can be restorative environments for visitors.

"They're with other people, also people are able to see objects that might be from their own heritage, things that help them connect to their own culture or to the cultures of others, other times and places," she says.

"These things can all help to alleviate a sense of loneliness."

Srivastava says social prescribing reflects a change in how the medical community views health and wellness and the role that doctors and allied practitioners can play.

"If I just tell somebody verbally 'I want you to go for a walk for 30 minutes, three times a week,' they're less likely to do it than if I were to write it down on a prescription pad," she says.

"Usually we write down medications, right? But when it's put on a pad of paper and a doctor writes it down and signs it, all of a sudden it means it's serious.

"And I believe the reason why it's important is because we forget that health is not only about physical well-being and mental well-being, it's also about social well-being."

—Follow @SherylUbelacker on Twitter.

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Tweeting about quality: How social media can help improve care

Tweeting about quality: How social media can help improve care | heaith | Scoop.it

Informing and connecting: If social media is supporting the development of quality care in Ontario and elsewhere, it is through effectively performing these two key tasks.

While social media may still only be used by a portion of health care providers, policy-makers and patients in the province, the platforms we have come to associate with social media – Twitter, Facebook, LinkedIn etc. – can be influential in supporting quality care initiatives.

In developing a system that we wish to be patient-centred, social media has emerged as an important platform for allowing patients and members of the public to engage with health care providers and policy-makers to make their views clear. The degree of interaction between those with lived experience with a disease or illness with those providing their care is unprecedented thanks to online communities and social media like Twitter.

The Twitter hashtag #metoomedicine, galvanized women physicians and their supporters through Twitter to demand more equity and gender equality within the medical profession and has helped bring a much higher profile to this issue. It is an example of how social media has emerged as a powerful tool for helping health care providers share their experiences and insights. It can also help providers deal with their challenges to support the fourth pillar of the Quadruple Aim in quality care – that of enhancing provider wellbeing (although to be fair, social media can also impede this by adding more time pressures to already stressed providers or exposing practitioners to frankly hostile or upsetting views or individuals).

Social media has enhanced the development of a quality care network too, connecting people provincially, nationally and globally. Leaders in the development and promotion of quality care initiatives exist in every jurisdiction, and platforms such as Twitter allow them to share their experiences and knowledge with each other and those who follow them. Examples in Ontario include Health Quality Ontario’s own Dr. Irfan Dhalla (@IrfanDhalla), Lee Fairclough (@LFairclo) and Dr. David Kaplan (@DavidKaplanMD) and family physicians such as Dr. Sarah Newbery (@snewbery1) and Dr. Cathy Faulds (@fauldsca). Elsewhere in Canada there are others too numerous to list although some such as Dr. Dennis Kendel (@DennisKendel) in Saskatchewan merit mention because of the outstanding job they do in sharing information about quality care initiatives. Globally, health quality leaders such as Helen Bevan (@helenbevan) in the UK are highly active on social media and have shared ideas that appear in health quality presentations in Canada and elsewhere.

Conferences such as Health Quality Transformation hosted by Health Quality Ontario and the upcoming BC Quality Forum (#QF19) hosted by the BC Patient Safety & Quality Council significantly expand their reach and generate much broader conversations about quality through use of Twitter and other social media channels.

For health quality organizations such as Health Quality Ontario, social media are invaluable for sharing information and engaging about initiatives and programs. Any organization or individual choosing to use social media needs to first consider how and why they are going to use certain platforms or tools.

For instance, Health Quality Ontario (@HQOntario) uses Twitter extensively to engage with its followers and others because it has found Twitter to be the most strategically useful platform to connect with work in or use the province’s health care system. We also use Facebook because many patients and members of the public rely on Facebook to keep informed and we have much that we would like to share with them and seek their opinion. Health Quality Ontario also hosts a vibrant online community about health care quality called Quorum.

It is important to remember that social media can promote and amplify bad ideas and opinions just as easily as good. “Fake news” flourishes on social media, but that is no reason to dismiss the platforms themselves.

For those choosing to embrace social media to support quality care, it is also important not to forget that your social media contacts and online communities do not mirror the real world. As we can choose who to follow on Twitter or which Facebook or LinkedIn groups to join, we often create social media worlds that are amicable to our own worldview and, unless we are careful, can forget other voices and opinions that can be just as influential. To combat this tendency, it is good to follow people or organizations on social media who have views with which you may not agree, so as to gain a broader perspective.

Writing in this space recently, the former CEO of Health Quality Ontario Dr. Joshua Tepper (@DrJoshuaTepper) said one of the seven core competencies of leadership should be familiarity with social media and an understanding of how the growth of social media platforms “is transforming traditional communications hierarchies, means of information sharing and participation.”

I would extend this argument beyond leaders to everyone who has an interest in supporting the principles of quality care and promoting agendas that see these principles more fully enshrined on our own health care system.

Pat Rich is Senior Digital Writer at Health Quality Ontario

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The Do's & Don'ts of Social Media Marketing for Healthcare

The Do's & Don'ts of Social Media Marketing for Healthcare | heaith | Scoop.it

Social media has fundamentally altered the way that patients perceive healthcare. According to a study conducted by Evariant, 57% of patients decide where to pursue medical treatment based on the provider’s social media. However, since only about 1 in 4 hospitals are using social media as part of their marketing mix, maintaining an active social media presence gives your organization an opportunity to stand out.

Healthcare social media marketing can further establish trust with patients, educate followers about health and wellness, and inspire individuals to pursue careers as medical professionals. Here are a few do’s and don’ts to make the most of your healthcare social media marketing strategy.

Don’t give personalized medical advice.

Healthcare providers may be in the business of helping others maintain good health, but social media is not the place for diagnosis and treatment. Some patients may post a medical question on one of your social media pages or send a direct message listing their symptoms. In these cases, ask them to follow up with an in-person appointment.

Your organization’s website and contact information should always be visible on your social media profiles. You may also wish to add a disclaimer on your social media sites that no medical diagnosis or treatment will be administered online.

Do share health-related news and articles.

Rather than giving individualized medical treatment, use social media to share industry news, medical breakthroughs, and relevant research. For example, Main Line Health, a healthcare network in the greater Philadelphia region, often uses Facebook to share health and wellness news that is relevant to patients and the community.

In a recent post for National Drug Take Back Day, Main Line Health’s Facebook page encouraged followers to go through their medicine cabinets to check for expired medications. Main Line Health’s post also offered a clear call to action by sharing different locations within their network where these medications can be safety disposed.

Don’t violate patient privacy laws.

Due to the sensitive nature of medical practice, it is important for healthcare companies to conform to all applicable privacy laws. HIPAA laws are in place to protect patient confidentiality, so any information that could possibly identify a patient without their consent (photos, names, etc.) cannot be shared on social media. If a patient wishes to be featured in a social media campaign, they will need to give explicit permission, in writing, to the healthcare provider.

Do communicate real-time updates that could affect patients.

Sometimes you may need a way to communicate with patients en masse. Real-time updates can be anything that would affect a patient’s ability to receive medical care at your facility. For example, is the parking garage closed for repairs? Has one of the offices temporarily moved to another wing of the building?

You can pin a post to the top of your social media feed so that it is the first thing followers see when they visit your Page. You may wish to combine social media updates with an automated phone call or email message to ensure patients are aware of any changes that could affect their visit.

Don’t operate in a vacuum.

It can be tempting to post updates and news on social media without listening to follower feedback. But this leads to missed opportunities to understand your patients’ questions and concerns. For example, if followers are asking questions about whether or not to get a flu shot, it might be worth writing a blog post for your organization’s website and sharing it on social media so you can provide general, but timely health advice. If patients leave reviews on your social media pages, you can also use this information to identify your organization’s strengths and improve weaknesses.

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In addition, social media is part of a larger conversation, not a platform for just posting your own materials. Use industry-relevant hashtags, reshare other healthcare organizations’ content, and encourage patients and employees to interact with your Pages. Ask employees to reshare posts from your organization’s page to their personal page.

Do set clear expectations for your admins and your followers.

When used as a responsible communication tool, social media can deliver immense value to your organization. However, it only takes one person violating HIPAA to get you in a lot of trouble. Give employees a training session and a handbook with social networking policies and branding guidelines, whether they are managing your social media or just using their personal profiles. Restrict admin permissions for Company Pages and stay abreast of best practices.

Employees aren’t the only ones who should have a clear understanding of how to interact with your social media. It also helps for medical providers to establish expectations for social media followers at the outset. For example, the Canada-based Sunnybrook Hospital has published a social media commenting policy to ensure respectful discourse and protect individuals’ privacy. If you deem anything offensive or inappropriate, remove it from your Page immediately. Monitor your social media channels for comments, and respond quickly to violations.

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Don’t only use one form of content.

Are all of your social media posts linking to your blog or your website? Or do you only share press releases and industry news rather than also highlighting patient success stories (when, of course, they give explicit permission)? Share images, infographics, blog posts, videos, and other forms of media to keep audiences engaged. The Mayo Clinic Facebook page is an excellent example of diversifying content types to appeal to a range of audiences. Here is a sampling of posts that include video stories, blog articles, and infographics.

Do use the power of social media to advance public health.

Some organizations use social media to communicate public service announcements and combat misinformation. For example, the World Health Organization uses social media to share infographics with research or health and safety advice. In an effort to encourage more people to use vaccines, the World Health Organization’s Twitter feed has included many infographics related to the positive results of immunizations, including the near-eradication of diseases and the benefits of herd immunity. WHO also uses the hashtag #VaccinesWork, taking part in a broader national conversation about the need for vaccination.

Ready to bring your healthcare social media marketing to the next level? Contact Pacific54 today for aconsultation.

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The evolving role of social media in health-care delivery: measuring the perception of health-care professionals in Eastern Saudi Arabia

The evolving role of social media in health-care delivery: measuring the perception of health-care professionals in Eastern Saudi Arabia | heaith | Scoop.it

The objective of this study is to evaluate the perception of health-care professionals in Saudi Arabia toward the usages of social media in health-care delivery.

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In this cross-sectional study, an online-based questionnaire was distributed among the health-care professionals residing in the eastern region of Saudi Arabia. Their perception toward the uses of social media in health-care service delivery was evaluated by analyzing their attitude toward its benefits and risks involved.

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The sample size was 120 participants, and 80% of them agreed with the benefits of using social networks in health-care services and considered that the use of these technologies in the provision of health services improves their professional knowledge and is a suitable tool for patient education and public health awareness. However, some respondents (20%) believed that there are several risks associated with the use of social media, such as ethical or legal challenges, the risk to the patient’s health status, or the breaching of the privacy and confidentiality of the patient.

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The results of this research indicate that social media can be a useful tool by which physicians may promote their services and publish general health information. However, there are potential problems in the use of social networks that can have negative consequences for patients and HCPs. This implies that precautions must be taken to avoid ruptures of patient privacy and other risks that can result in legal action against health professionals damaging their image and professional status. The study also found that the participants are willing to use social media for professional purposes.

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