Shekelle P G, Coulter I, Hurwitz E L, Genovese B, Adams A H, Mior S A, Brook R H
West Los Angeles Veterans Affairs Medical Center, California, USA.
Ann Intern Med. 1998 Jul 1;129(1):9-17. doi: 10.7326/0003-4819-129-1-199807010-00003.
Recent U.S. practice guidelines recommend spinal manipulation for some patients with low back pain. If followed, these guidelines are likely to increase the number of persons referred for chiropractic care. Concerns have been raised about the appropriate use of chiropractic care, but systematic data are lacking.
To determine the appropriateness of chiropractors' decisions to use spinal manipulation for patients with low back pain.
Retrospective review of chiropractic office records against preset criteria for appropriateness that were developed from a systematic review of the literature and a nine-member panel of chiropractic and medical specialists. Appropriateness criteria reflect the expected balance between risk and benefit.
131 of 185 (71%) chiropractic offices randomly sampled from sites in the United States and Canada.
10 randomly selected records of patients presenting with low back pain from each office (1310 patients total).
Sociodemographic data on patients and chiropractors; use of health care services by patients; assessment of the decision to initiate spinal manipulation as appropriate, uncertain, or inappropriate.
Of the 1310 patients who sought chiropractic care for low back pain, 1088 (83%) had spinal manipulation. For 859 of these patients (79%), records contained data sufficient to determine whether care was congruent with appropriateness criteria. Care was classified as appropriate in 46% of cases, uncertain in 25% of cases, and inappropriate in 29% of cases. Patients who did not undergo spinal manipulation were less likely to have a presentation judged appropriate and were more likely to have a presentation judged inappropriate than were patients who did undergo spinal manipulation (P = 0.01).
The proportion of chiropractic spinal manipulation judged to be congruent with appropriateness criteria is similar to proportions previously described for medical procedures; thus, the findings provide some reassurance about the appropriate application of chiropractic care. However, more than one quarter of patients were treated for indications that were judged inappropriate. The number of inappropriate decisions to use chiropractic spinal manipulation should be decreased.
美国近期的实践指南建议对一些腰痛患者进行脊柱推拿。如果遵循这些指南，可能会增加接受整脊治疗的人数。人们对整脊治疗的合理使用提出了担忧，但缺乏系统性数据。
确定整脊师为腰痛患者进行脊柱推拿决策的合理性。
根据从文献系统综述以及由九名整脊和医学专家组成的小组制定的预设合理性标准，对整脊诊所记录进行回顾性审查。合理性标准反映了风险与益处之间的预期平衡。
从美国和加拿大的地点随机抽取的185家整脊诊所中的131家（71%）。
从每家诊所随机选取10例腰痛患者的记录（共1310例患者）。
患者和整脊师的社会人口统计学数据；患者使用医疗服务的情况；对开始脊柱推拿决策的评估，分为适当、不确定或不适当。
在1310名因腰痛寻求整脊治疗的患者中，1088名（83%）接受了脊柱推拿。其中859名患者（79%）的记录包含足以确定治疗是否符合合理性标准的数据。46%的病例中治疗被归类为适当，25%的病例中不确定，29%的病例中不适当。未接受脊柱推拿的患者比接受脊柱推拿的患者更不容易有被判定为适当的表现，且更有可能有被判定为不适当的表现（P = 0.01）。
被判定符合合理性标准的整脊脊柱推拿比例与先前描述的医疗程序比例相似；因此，这些结果为整脊治疗的合理应用提供了一些保证。然而，超过四分之一的患者接受治疗的指征被判定为不适当。应减少整脊脊柱推拿不适当决策的数量。
