McAndrews Lecture. Challenges of the Past, Challenges of the Present. American Chiropractic Association National Chiropractic Leadership Conference

Transcription

1 American Chiropractic Association National Chiropractic Leadership Conference McAndrews Lecture Challenges of the Past, Challenges of the Present Washington DC February 28,

2 Setting 1 January, 1962 Davenport, Iowa 1

3 Jerry McAndrew Davenport, Iowa Director of Clinics, Palmer College of Chiropractic, 1961 to 1963 Chairman, Division of Chiropractic Sciences, Palmer College of Chiropractic, 1964 to 1966 Coordinator, Principles and Practices Division, Palmer College of Chiropractic, 1963 to

4 Status Enthusiasm for the profession Lyceum and other meetings drew 4000 chiropractors In South Africa the members of SACA met every month for an education symposium and personal interaction Philosophy dominates discussion although varies between institutions Research: BJ osteology lab, radiology, Carl Cleveland animal models, JC Watkins clinical research - all philosophy driven research Most chiropractors had a cash practice 3

5 Events 1960s BJ Palmer had just died AMA Committee on Quackery established in 1963 Formation of ACA from NCA, ICA separates 4

6 Challenges 1960s Isolation Principles based on clinical experience and belief Philosophy is either a strongly held belief or basis for ridicule No significant research culture No consistent education curriculum Divided profession No Clear or consistent Identity (Straight or mixer) 5

7 Setting 2 January,1973 Vancouver, Canada 6

8 Status AMA actively changes ethics contain and destroy chiropractic Chiropractic being attacked all over the world, licensure rare outside North America with Commissions of enquiry in New Zealand, Australia, South Africa. Chiropractic not licensed in Louisiana and Quebec in North America Virtually no research and no qualified researchers No chiropractic textbooks by major commercial publication companies 7

9 The Iowa Plan s section (1962) What Medicine Should Do About The Chiropractic Menace Encourage ethical complaints against doctors of chiropractic; Oppose chiropractic inroads in health insurance; Oppose chiropractic inroads in workmen s compensation; Oppose chiropractic inroads into labor unions; Oppose chiropractic inroads into hospitals; and Contain chiropractic schools. 8

10 Jerry McAndrew Executive Vice President, International Chiropractors Association, 1971 to 1979 Executive Vice President, Foundation for the Advancement of Chiropractic Tenets and Science (FACTS); Washington, DC, 1977 to

11 Events 1970s The University of Colorado, Chung-Ha Su research NINCDS Conference on Spinal Manipulative Therapy 1977 FCER and FACTS begin to fund research 1977 proposal for an interdisciplinary conference on Modern Developments in the Principles and Practice of Chiropractic 1979 conference draws 500 paricipants 1978 New Zealand Commission of enquiry into Chiropractic 10

12 Challenges 1970s Open hostility (containment) and ethical enforcement by AMA NINCDS - There are little scientific data of significance to evaluate this clinical approach to health and to the treatment of disease Early recognition of the importance of research but minimal research culture or support Divided profession No Clear or consistent Identity (Straight or mixer, chiropractic medicine, named technique practitioners) Professional led primarily by technique or practice building gurus 11

13 Setting Chicago, Illionois 12

14 Events 1980s George McAndrews attorney with pashion for chiropractic Wilke et al verses AMA et al 1981 Antitrust trial Wilke et al verses AMA 1987 Appeal Antitrust trial 13

15 Events 1980s Publication of first chiropractic text book by medical publishing house World Federation of Chiropractic established David Cassidy awarded Ph.D. under Bill Kirkaldy-Willis North American Spine Society and American Back Society formed Manipulation clinical trials. UCI, Hadler, Palmer 14

16 Challenges 1980s The plaintiffs clearly want more from the court, Judge Getzendanner pronounced. They want a judicial pronouncement that chiropractic is a valid, efficacious, even scientific health care service. I believe that the answer to that question can only be provided by a well designed, controlled, scientific study. 15

17 Challenges 1980s Engagement with the research and medical community Change medical and hospital attitudes Training of chiropractic researchers Develop of standards of care Divided profession, lack of consensus of how chiropractors should practice No Clear or consistent Identity for chiropractic Lack of participation in spine and public health deliberations and societies 16

18 Setting Washington, DC AHCPR 17

19 George and Jerry McAndrews Chairman, National Task Force on Managed Care, American Chiropractic Association, 1991 to 1994 Vice President for Professional Affairs, American Chiropractic Association, 1992 to

20 Events 1990s House Subcommittee on the military Commissions Bill 1992 AHCPR Guidelines on Acute Low Back Pain Guidelines for Chiropractic Practice Parameters and Formation of the World Federation of Chiropractic North American Spine Society, ABS and ISSLS includes chiropractors Quebec Task Force on Whiplash Related Disorders includes manipulation as one of few EB treatments Second Edition of Principles and Practice of Chiropractic 19

21 Challenges 1990s Chiropractors do not participate in hospital and multidisciplinary health delivery systems Lack of engagement with medical profession or the spine or public health societies No distribution of chiropractic research breakthroughs or communication between scientists and clinicians Philosophical purists become more aggressive Divided profession No Clear or consistent Identity (Straight or mixer) 20

22 Setting Saskatoon, Canada 21

23 Events 2000s Duke Evidence Based Practice Center Behavioral and physical treatments for tension and cervicogenic headaches Bone and Joint Decade Task Force on Neck Pain and Associated Disorders Third Edition of P& P of Chiropractic Evidence Based Management of Low Back Pain 22

24 Perceptions of effectiveness of conventional care and CAM for specific ailments (Eisenberg et al, Ann Intern Med 2001;135: ) 23

25 Challenges 2000s Finding and training of chiropractors interested in reseach Finding and training of chiropractors to serve in multidisciplinary centers including hospitals, VA and Military Distribution of chiropractic research breakthroughs or communication between scientists and clinicians Defining the role of chiropractors in health care Lack of participation in professional societies by practicing chiropractors 24

26 Setting 6 March 23, 2010 Washington DC Affordable Care Act PICORI 25

27 Setting 7 December 2010 Lancet Global Burden of Disease 26

28 Global Burden of Disease 2010 Report Key results spinal disorders: Low back pain is the leading cause of disability worldwide (YLDs) contributing 10 7% of total. Neck Pain is the fourth leading cause of disability worldwide Low back pain is the sixth most important contributor to the global burden of disease (death YLLS and disability YDLS) It has a greater impact on global health than: - malaria or tuberculosis - preterm birth complications - COPD - diabetes or lung cancer. 27

29 Global Burden of Disease 2010 Report Key results spinal disorders When combined with neck pain (#21 on this list) back pain and neck pain are second only to ischemic heart disease in its impact on the global burden of disease Back and neck pain combined have a greater impact on global health than HIV/AIDs -- Diabetes Lower respiratory infections Stroke Breast and lung cancer combined -- Alzheimer s Disease -- Depression -- Traffic injuries 28

30 World Report on Disability 2011 WHO and World Bank Back problems, arthritis, and rheumatism were the most common health conditions related to disability People with disabilities have generally poorer health lower education achievements fewer economic opportunities and higher rates of poverty than people without disabilities. 29

31 Setting 8 April, 2012 Durban, South Africa Mahalapye, Botswana 30

32 Surgeon Attitudes Toward Nonphysician Screening of Low Back or Low Back Related Leg Pain Patients Referred for Surgical Assessment A Survey of Canadian Spine Surgeons Busse JW et al. Spine 38:E Survey to all 101 surgeon members of the Canadian Spine Society A majority of respondents (75.3%) agreed that they would be comfortable not assessing patients with low back related complaints referred to their practice if indications for surgery were ruled out by an NPC.

33 JAMA PATIENT PAGE Low Back Pain 1738 JA M A, April24, 20l3-Vol309, No 16 Many treatments are available for low back pain. Often exercises and physical therapy can help. Some people benefit from chiropractic therapy or acupuncture. Sometimes medications are needed, including analgesics (painkillers) or medications that reduce inflammation. Surgery is not usually needed but may be considered if other therapies have failed. 32

34 Setting 9 October, 2014 San Francisco, CA NASS Annual Meeting 33

35 February Washington DC JAMA Forum: Payment Reform Is About to Become a Reality Secretary Burwell s proposal calls for 30% of Medicare payments to be based on non fee-for-service models by the end of 2016, and 50% to be so by the end of Such payments did not exist in The Secretary intends to have 85% of Medicare fee-forservice payments tied to quality or value in some fashion by the end of

36 Setting 10 February 6, 2015 Washington DC, NCCAM to NCCIH 35

37 Setting 11 February 26, 2015 Palm Springs, California Palmer Board of Trustees 36

38 Palmer College Identity statement The primary care professional for spinal health and well-being CMCC Mission Statement An academic institution recognized for creating leaders in spinal health 37

39 Setting 12 February 28, 2015 Washington DC, ACA/NCLC Conference 38

40 US Supreme Court Ruling North Carolina State Board of Dental Examiners v Federal Trade Commission February 25, 2015 State professional boards controlled by active market participants must be supervised by state government to avoid federal antitrust scrutiny 39

41 Current Status Chiropractic care is one of the few accepted Evidence Based Treatments for spinal pain Chiropractic theory has a solid but incomplete body of scientific experimental support Chiropractors are invited to participate in most spine and public health policy conferences, meetings and discussions Chiropractors are now serving on the interdisciplinary teams at the VA, Military Health Care, increasing numbers of hospitals and interdisciplinary spine centers There is growing support for a primary spine care identity for the practice of chiropractic amongst the non-chiropractic community 40

42 Christine Goertz at NCCIH I used to be asked: How could chiropractic possibly work? Then: Is there evidence that it helps people? Now: How can I find a good chiropractor? 41

43 Challenges 2015 How to counter the continued effort to redefine primary general practice physicians to include chiropractic Failure to participate in recognition programs such as URAC and NCQA, registries, PQRS Poor participation at national and international forums discussing spinal disorders Continued claims of chiropractic cures without evidence Poor support and participation in state and national societies Inadequate continuing educational to prepare profession for the new reality Threats from other health professions to protect their turf or to challenge chiropractors role in states with low professional participation or leadership understanding of the new world 42

44 Pitfalls of Clinical Experience In 2005, in a paper in the online journal PLoS Medicine, Ioannidis laid out detailed mathematical proof evaluated studies in different fields of medical research that 80 % of non-randomized studies turn out to be in error 43

45 Addressing the Challenges 2015 Promotion of a condition-based identity that follows the data Stop trying to redefine primary care physicians to include chiropractic or chiropractic as a non-spine care profession Participate in recognized programs such as URAC and NCQA, registries, PQRS etc. Increase professional participation in the major chiropractic and spine societies Ensure chiropractic institutions train for the new reality Ensure current practicing chiropractors understand and are able to practice within the new reality 44

46 Knights in Shining Armor Jerry and George McAndrews have had marked impact in changing the scientific, legal and professional opportunities for chiropractors and created an environment that allows for unimpeded inter-professional cooperation and professional advancement 45

47 Essential elements to ensure the future Identify and recognize the gender neutral knights who are currently representing the profession Train more gender neutral knights (researchers, policy authorities, instructors0 More support of these Knights armor and weapons (research support, travel and salary support, political support, publicity) 46

48 An Example of What Chiropractic can do and the role they can play Improving the lives of people in underserved communities through sustainable, evidencebased spine care

49 A non-profit charity registered in the United States and Canada with the goal of helping people with spinal disorders in under served communities throughout the world. Supported by The Bone and Joint Decade, An initiative of The World Health Organization 48

50 Archbishop Emeritus Desmond Tutu Nobel Peace Prize laureate Member, Advisory Council, World Spine Care Elon Musk Board of Directors, World Spine Care CEO and CTO of SpaceX CEO and Product Architect of Tesla motors Chairman of SolarCity Co-founder of Paypal 49

51 Professional and institutional endorsements 50

52 Collaborating institutions 51

53 Major financial sponsors 52

54 International volunteer advisors Paul Bishop DC, MD, Ph.D Don Powell MIPM William Watters Spine Surgeon Eric Hurwitz DC, PhD Bjorn Rydevik MD, Ph.D Orthopedics Deborah Jan Hartvigsen DC, PhD Christian Etter - Spine Surgeon Kopansky-Giles DC MSc Max Aebi MD Emre Aceroglu - Spine surgeon Charles Branch Eurospine Neurosurgeon John Mayer DC, Ph.D Eduardo Bracher DC, MD, Ph.D Carolyn Wilson, Vanessa Beyleveld Premiere consulting Norman Fisher-Jeffes Neurosurgeon Reginald Engelbrecht, DC Lindsay Rowe Radiologist Paul Hodges Physiotherapist 53

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56 A BILLION PEOPLE WORLDWIDE SUFFER FROM SPINAL PAIN 55

57 Spinal disorders have a greater impact than: HIV/AIDs Depression Malaria Breast & lung cancer combined Stroke Diabetes Alzheimer s disease Traffic injuries Lower respiratory infections 56

58 The prevalence of spinal pain is 4 times higher in developing countries 57

59 World Spine Care is the only organization worldwide that is tackling this global health crisis in an inter-professional, evidence-based, sustainable way 58

60 Clinical program Low cost, low tech Evidence-based Fully integrated into local health care infrastructure Long term presence Inter-professional and collaborative Measured clinical outcomes 59

61 Clinical team 1. Primary spine practitioner Screen for serious pathology Timely referral when appropriate Offer Evidence-based interventions: o o o o manual therapy exercise education (including psychosocial) occasional mild analgesics 2. Surgical Specialists 3. Rheumatologists 60

62 Prevention Scoliosis screening Exercise programs o Straighten Up program o WSC Yoga project 61

63 Capacity building Patient/community education Front line health care worker training/education WSC spine conferences and professional development Student Scholarships Advanced surgical training 62

64 Sustainability Elements Volunteer clinic supervisor Short term volunteer clinicians Integration into the existing health care system Spine care Clinician training Education of local clinicians Scholarships Fellowship training Transition to local control 63

65 Mahalapye District Hospital, Botswana Secondary Care Facility 64

66 Moca Project Dominican Republic 65

67 Magu Project Tanzania Providing care for 500,000 people 66

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69 The Global Spinal Care Initiative The Development and Evaluation of an Innovative, Integrated Model of Care to Improve the Management of Spinal Disorders with the Goal of Reducing the Associated Global Disability and Burden of Disease. 68

70 Global Spine Care Initiative Develop and disseminate an effective, low-cost spine care model that can be sustainably implemented in communities with limited resources. This 6-year Initiative is being launched in 2014, and it involves four phases: Develop a universally acceptable model of care for spinal disorders; Implement and test the model in 5 carefully chosen countries, with it modified to address prevalent language, culture, resources, and other local factors. Measure the impact of the model on the burden of disease in these communities Disseminate the results through WHO, and government and academic channels 69

71 SCIENTIFIC SECRETARIAT Scott Haldeman, DC, MD, Ph.D., FRCP(C), FAAN USA (Neurology, chiropractic) Margareta Nordin, Dr. Med. Sci., PT, CIE. France (Rehabilitation, EB Medicine, Implementation, Physical Therapy) Roger Chou, MD, FACP USA (Internal Medicine) Eric Hurwitz, DC, PhD USA (Epidemiology, DC) Pierre Cote, DC, PhD Canada (Epidemiology, DC) Emre Acaroglu, MD Turkey (Orthopedic surgery) Christine Cedraschi, Ph.D Switzer land (Psychology) Federico Balagué, MD Switzerland (Rheumatology) Damian Hoy, BAppSc (Physio/PT),MPH, PhD Australia (Epidemiology, PT) John Mayer, DC, PhD USA (Exercise physiology, DC) Rachelle Buchbinder, MBBS (Hons), MSc, PhD, FRACP Australia (Rheumatologist) Norman Fischer-Jeffes, MC, CHB, FCS South Africa (Neurosurgeon) Arthur Ameis MD Canada (Physcial Medicine and Rehab Deborah Kopansky-Giles, DC, FCCS, MSc Canada (Chiropractic) Claire Johnson, DC, MSEd, USA (Ethics and policy, DC) Geoff Outerbridge, DC, MSc Canada (chiropractor) Maria Hondras, DC, MPH, PhD Fellow USA Denmark (Epidemiology, DC) Christine Goertz, DC, PhD USA (Research methodology, DC) 70

72 ADVISORY COMMITTEE Robert Dunn, MBChB (UCT) MMed (Orth) Julie LaPlante Ph.D. Jean Moss, DC, MBA Jan Harsvigsen DC, Ph.D. Christoph Siepe, MD, PhD Gerold Stucki MD, MS William C. Watters III MD, MMS, MS Antony Woolf, BSC, MBBS, FRCP South Africa (Orthopedic surgery) Canada (Anthropology) Canada (Administration, policy) Canada (Epidemiology) Germany (Orthopedic surgery) Switzerland (Physical medicine) USA (Orthopedic surgery) United Kingdom (Rheumatology) 71

73 Conclusion The next 5 years will be the most dramatic and exciting in health care policy evolution and, in particular, spine care and the role of the chiropractic profession The challenges of the past are not the challenges of today The chiropractic profession is being asked to participate in all spine related health care issues The chiropractic organizations, educational institutions, researchers, policy experts and clinicians will have to understand what is happening and assume a leadership role Chiropractors must commit to helping people with spinal disorders throughout the world irrespective of their ability to pay 72

74 Do a little bit of good wherever you are; it s those little bits of good put together that overwhelm the world. Archbishop Emeritus Desmond Tutu Member of WSC Advisory board 73

75 Thank you! Re a Leboga! 74