206 back pain patients were included in the pilot test. Only two indicators met the pre-specified standards and two were close to meetingthe standards.

After evaluating the test-results, the indicator group decided to maintain all nine indicators, however lowering the standards for case-history,discogenic back pain, and classification

AIM

The overall aim of this study was to develop disease-specific quality indicators for Danish chiropractic patients with low back pain as an initial effort to include chiropractors in the Danish Health Care Quality Programme.

In addition, we present results from a pilot implementation of these indicators in eight Danish chiropractic clinics.

Development of Disease-Specific Quality Indicators for Danish Chiropractic Patients with Low Back Pain

Jan Hartvigsen1,2 Line Press Sørensen3 Birgitte Randrup Krogh3

Alice Kongsted1,2 Gert Brønfort 1,4

jhartvigsen@health.sdu.dk

BACKGROUND

Quality development through indicator monitoring is used as surveillance of quality in clinical practice and as a tool in the implementation of professional guidelines into everyday clinical practice. In quality indicator monitoring, selected items (indicators), which are each expected to constitute an important aspect of quality in clinical practice, are defined by a group of academics and clinicians together.

Denmark is among the leading countries with respect to implementation of systematic quality development in health care, and in 2008 the Danish National Indicator Project in Collaboration with the Danish Chiropractors Association decided to initiate a focused quality development process with the long term aim of including chiropractors in the Danish Health Care Quality Program.

This is relevant within the field of back pain because Danish chiropractors see around 400,000 patients every year constituting over one third of Danes seeking care for back pain in in the primary care sector.

METHODSDevelopment of quality indicators: 11 health care professionals developed the quality indicators during two full-day meetings based on evidence, suspected poor quality in practice, and measurability.

Feasibility testing: Eight chiropractic clinics were instructed to include all back pain patients until a total of 25 adult patients per clinic was reached. These patients and the chiropractors filled in the data registration forms.

Hearing: A hearing meeting was held where researchers and clinicians shared experiences and discussed the project.

Data validation and analysis: 10 patient files from each test clinic were randomly pulled and checked by an independent clinician against the patient and chiropractor registrations. Proportions of indicators meeting the pre-determined standards were calculated with the number of registrations meeting the indicator in the denominator and the possible number of patients in the numerator. nip

RESULTS

Affiliations:

1. Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark

2. University of Southern Denmark, Odense, Denmark

3. Danish National Indicator Project, Aarhus, Denmark

4. Northwestern Health Sciences University, Bloomington, MN, USA

REFERENCESorensen LP, Krog BR, Kongsted A, Bronfort G, Hartvigsen J. Development of disease-specific quality indicators for Danish chiropractic patients with low back pain. J Maulative Physiol Ther 2011;34:204-10

CONCLUSIONS• It was possible to develop indicators in the chiropractic field that are consistent with the disease accreditation standards in the Danish Healthcare Quality Program

• Measureble clinical indicators can be implemented in chiropractic practice

• Specific and measurable indicators can facilitate implementation of clinical guidelines in chiropractic practice

Domain Indicator Standard Goal, %

Standard Reached, %

Case History Proportion of patients with sufficient case-history ≧ 98% 24.8%

Discogenic back pain Proportion of patients with leg pain examined for centralization symptoms

≧ 90% 34.2%

Neurology Proportion of patients with leg pain who had adequate neurologic examination

≧ 90% 83.8%

Radiology Proportion of patients x-rayed with indication ≧ 80% 59.1%

Radiology Proportion of patients not x-rayed with indication absent ≧ 80% 61.9%

Classification Proportion of patients ≧ 98% 92.2%

Exercise therapy Proportion of patients with symptoms > 6 weeks instructed in exercise therapy

≧ 90% 37.5%

Outcome assessment(process)

Proportion of patients with global rating outcome assessment at 4th visit

≧ 95% 95.8%

Outcome assessment(outcome)

Proportion of patients describing their symptoms as “better” or “much better” at 4th visit

≧ 50% 67.7%

Re-evaluation Proportion of un-improved patients who had their treatment plan re-evaluated at 5th visit

≧ 90% 28.3%