How well does acupuncture work? Of course, we all know it works, but exactly how well? Can you measure how much patients are improving under your care? What would you take such measurements for?
In case you haven't noticed, acupuncture is moving into the mainstream on two simultaneous fronts: by medical doctors performing acupuncture; and, of course, by licensed acupuncturists.
The average medical doctor (in a non-acupuncture practice) gets asked about acupuncture daily by patients who want to try it, most likely because the medical model isn't working so well for them. Studies also show that patients are spending billions of dollars a year out of pocket on acupuncture and herbs. Insurance companies now offer acupuncture reimbursement as a competitive edge with their policies. We are seeing it more in managed care groups (HMOs, PPOs, IPAs, etc.), and it is commonplace in workers' compensation.
Few of these groups understand about acupuncture and TCM. Most claims examiners probably think you are from a different planet. They have very little to go on with respect to guidelines. Little, if any, research has been done on TCM treatment outcomes, so the tendency is to resort to the "12 visit" rule: no matter what the diagnosis, you are authorized for 12 visits.
To get the right amount of visits to get your patients well, and for the profession at large to gain greater acceptance and greater reimbursement and achieve its rightful place in health care, outcomes need to be measured on a subjective and objective basis "per diagnosis." It is simply not enough anymore for you to record that your patient is feeling "better."
Subjective Outcome Measurements
Subjective loosely means what the patient says they have. On a subjective basis, there are many questionnaires patients can complete in your office that rate the amount of disability their pain is causing. Most of the health professions now use them now. Examples include visual analog scales (VAS); Neck Disability Index; Roland-Morris; Oswestry; SF-36; etc. VAS will take a patient about five seconds to complete and can be used every visit. Other forms, such as the disability scales, are more involved and should be used on a monthly or bi-weekly basis to show that your patient is recovering more of his or her quality of life.
I know, the last thing you need is more paperwork, but this is something the patient completes, not you. Scoring the tests usually takes very little time. By comparing the scores on these tests month-to-month, you can establish that what you are doing is working. This should be very valuable information for you, your patient, insurance adjusters, attorneys, etc. It will help you justify the need for more visits (if your patient is getting better). If your patient is responding only on a palliative basis and is not improving, this will make you reassess what you are doing. Should that be the case, you can then make important management decisions, such as changing the treatment plan; referring for a consult; ordering a special test; discharging the patient; et cetera.
After a year or so, you could do a retrospective research study on your practice and publish the results. For example, if you treated 40 patients for a lumbar sprain/strain this past year, and all of them completed Oswestry scales every two weeks, you could have someone do a statistical analysis of the scores and establish the average improvement. You could publish a research study in a journal and show just how effective acupuncture is. If several acupuncturists did this on several conditions, those outcome studies could collectively help the profession by establishing treatment guidelines per diagnosis. That would give the profession a lot of evidence to support the efficacy of acupuncture and TCM.
These tests are often free, or relatively inexpensive. Several can be downloaded and, if you are interested, I would be happy to e-mail samples to you. Simply send me an e-mail at the address below, and I'll forward several examples and/or give you website addresses where you can obtain them yourself.
Objective Outcome Measurements
On an objective basis, you should either perform or order objective functional tests. Measure a patient's range of motion and muscle strength. Doing this by the eyeball method is not acceptable. You should use a goniometer or inclinometer for musculoskeletal problems. In more advanced cases, such as workers' compensation or personal injury, you should use computerized measurement tools. With this apparatus, the patient performs the activity (motion/strength test) 3-4 times in a row. Results have to fall within 15% of each other, and there is statistical comparison from one exam to the next. With internal medicine problems, appropriate laboratory tests could provide similar information (e.g. glucose tolerance test, cholesterol panels, etc.). If you were treating hypertension, blood pressure would be important to measure on serial visits.
If you need computerized tests but don't have them, seek out an appropriate facility that does. You can find such equipment in certain chiropractic, physical therapy, orthopedic and physical medicine & rehabilitation (PM&R) offices. Several companies also make such equipment. If your practice grows heavily in this area, you can purchase such equipment for your own office. Although expensive, there are special CPT codes that can be billed for the use of such equipment.
The use of subjective and objective tests will also help you in determining long-term issues such as disability, vocational rehabilitation and other aspects. Such data will give you and other entities a much higher degree of confidence in making predictions about a patient.
In conclusion, I challenge the acupuncture profession to "raise the bar" and come up with this data measurement on its own. Sooner or later, someone will have to do this because there are just too many governmental, insurance and legal entities that need this kind of information, and because acupuncture is becoming too popular to merely "exist" as it is. Either the profession performs outcome studies on its own terms, or somebody else will do it on their terms. It doesn't take the Rand corporation. It doesn't take millions in grant money. It could simply take clinical outcome measurements on a per-office basis. Let's take responsibility now, rather than be victims later.
Click here for previous articles by Fred Lerner, DC, PhD, FACO.
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