| Abstract/Notes |
Introduction:Integration can have different meanings. Recently a conceptual framework for comparing different models has been constructe. Integration ranges from parallel practice to full integration and must be classified for comparing outcomes across different types. Baselines on care utilization are needed beyond the traditional silos of parallel practice to evaluate clinical efficiency. Methods:Patient distribution was monitored across five sites providing primary and secondary spine-care defined as median level multidisciplinary integration: common administrative structure, communication and shared patient records, a spine care team. Patients scheduled by telephone where staff accounted for reported functional deficit, insurance and preference. Patients were assigned a treating provider (D.C., M.D. or surgeon) for triage and /or care management. Access and distribution were monitored from 2001 to 2004, establishing generalizability. June 2005 served as practice pattern surrogate. Parameters included scheduled and actual new patients, follow-ups, therapy referrals, advanced diagnostics and interventional procedures monitored by treating provider type. Data were evaluated by Chi-Square analysis. Results:Annual new patient volume was 14,322 (14,198 to 15,386) varying 5.5%. June was the most stable month (1374, 50 SD) varying 3.6%. Provider types were 17% chiropractors, 25% M.D.s and 58% surgeons, showing little change over the epoch. One D.C. left in 2000. Two were added. In 2001, one surgeon semi-retired and three added. D.C. volume increased from 1,478 to 2,613. Clinic numbers decreased before resuming gradual upward trend, yet D.C. volume increased by 58%. Scheduled new patients were 22% D.C., 12% M.D. and 66% surgeons. Overall contrast of provider types against parameters was highly significant (X2 = 48.3; p<0.001). Actual new patients differed from scheduled (20% D.C., 36% M.D., 44% Surgeon; X2 = 16.5, p<0.001) reflecting the net of interdisciplinary cross-referral for management and schedule compliance. Follow-ups similarly differed by provider with D.C. producing 35%, M.D. 27% and surgeon 38% (X2 = 10.5, p = 0.005). Combined referral for physical, occupational and massage therapy by provider type was 19% D.C., 17% M.D. and 64% surgeons paralleling provider types (X2 = 1.93; p = 0.381). A consistent trend was observed for consultations, advanced diagnostics and interventional treatments (X2 = 4.7; p = 0.09) with D.C. 6.9% (2.4% SD), M.D. 27.8% (9.0% SD) and surgeons 65.2% (10.9% SD). Discussion:Some observations here support common wisdom about differences between disciplines. Chiropractors have more frequent follow-up visits, may recommend fewer high cost diagnostic and therapeutic interventions and generally see fewer secondary spine-care patients. Surgeons use the most therapy referrals and sophisticated diagnostics. Several observations pose interesting hypotheses for further study. The proportion of D.C. managed cases seems higher than expected from the general literature for facilities attracting primary and secondary spine care patients. While the total patients slowly increased, a disproportionate increase was observed for chiropractors that was not substantively altered with 30% expansion of the surgical team. Percent change of new patients for each provider (scheduled vs. actual) suggests that chiropractors participate effectively in primary triage. Proponents of integrative care offer that joint professional interaction will a) decrease reliance on traditional biomedical models, b) diminish the reliance on provider hierarchy, and c) improve outcomes of care. While the data here do not directly test these hypotheses, they provide indirect support for a) and b). Moreover, it provides the context for understanding dynamics of patient access and distribution while evaluating outcomes. Conclusion:Future research should consider the distribution of patients by diagnosis and complexity for provider type in assessing care outcomes. This abstract is reproduced with the permission of the publisher. |
