Researching the Appropriateness of Care in the Complementary and Integrative Health Professions Part 5: Using Patient Records: Selection, Protection, and Abstraction.

OBJECTIVES: The purpose of this paper is to describe the 4-step process (consent, selection, protection, and abstraction) of acquiring a large sample of chiropractic patient records from multiple practices and subsequent data abstraction. METHODS: From April 2017 to December 2017, RAND acquired patient records from 99 chiropractic practices across the United States. The records included patients enrolled in a survey e-study (prospective sample) and a random sample of all clinic patients (retrospective sample) with chronic back or neck pain. Clinic staff were trained to collect the sample, scan, and transfer the records. We designed an online data collection tool for abstraction. Protocols were instituted to protect patient confidentiality. Doctors of chiropractic were selected and trained as abstractors, and a system was established to monitor data collection. RESULTS: In compliance with data protection protocols, 3603 patient records were scanned, including 1475 in the prospective sample and 2128 in the random sample. A total of 1716 patients (prospective sample) consented to having their records scanned, but only 1475 could be retrieved. Of records scanned, 19% were unusable owing to illegibility, no care during the period of interest, or poor scanning. The abstractor interrater reliability for appropriateness of care decisions was fair to moderate (κ .38-.48). CONCLUSION: The acquisition, handling, and abstraction of a large sample of chiropractic records was a complex task with challenges that necessitated adapting planned approaches. Of the records abstracted, many revealed incomplete provider documentation regarding the details of and rationale for care. Better documentation and more standardized record keeping would facilitate future research using patient records.

Researching the Appropriateness of Care in the Complementary and Integrative Health Professions Part 4: Putting Practice Back Into Evidence-based Practice by Recruiting Clinics and Patients.

OBJECTIVES: This paper focuses on the methods of a single study, incorporating data from chiropractic clinics into an evidenced-based investigation of the appropriateness of manipulation for chronic back pain. METHODS: A cluster sample of clinics (125) from 6 sites across the United States was chosen for this observation study. Patients with chronic low-back and neck pain were recruited using iPads, completed a series of online questionnaires, and gave permission for their patient records to be scanned. Patient records for a random sample were also obtained. The RAND staff and clinic personnel collected record data. RESULTS: We obtained survey data from 2024 patients with chronic low back pain, chronic neck pain, or both. We obtained patient record data from 114 of 125 clinics. These included the records of 1475 of the individuals who had completed surveys (prospective sample), and a random sample of 2128 patients. Across 114 clinics, 22% of clinics had patient records that were fully electronic, 32% had paper files, and 46% used a combination. Of the 114 clinics, about 47% scanned the records themselves with training from RAND. We obtained a total of 3603 scanned records. The patient survey data were collected from June 2016 to February 2017, the provider surveys from June 2016 to March 2017, and the chart pull from April 2017 to December 2017. CONCLUSIONS: Clinics can be successfully recruited for practice-based studies, and patients can be recruited using iPads. Obtaining patient records presents considerable challenges, and clinics varied in whether they had electronic files, nonelectronic records, or a mixture. Clinic staff can be trained to select and scan samples of charts to comply with randomization and data protection protocols in transferring records for research purposes.