Biomedical subjects

P G Shekelle

Publications and source records attributed to P G Shekelle.

10 recordsLinked to original sources

PubMed1995

An epidemiologic study of episodes of back pain care.

STUDY DESIGN: This was a prospective community-based, observational design. OBJECTIVE: To describe the epidemiology and risk/prognostic factors for back pain episodes of care in a population representing the nonelderly in the United States. SUMMARY OF BACKGROUND DATA: Previous United States studies of the epidemiology of back pain care have used defined industrial populations or have relied on the patient's recall of symptoms and care. METHODS: Claims forms from the RAND Health Insurance Experiment, a randomized controlled trial of the use of health services, were analyzed. Claims forms were selected if one of the patient-designated reasons for the visit was back pain. Visits were grouped into episodes of care. Descriptive statistics were calculated for episodes. Multivariate logistic regression was used to calculate adjusted odds ratios for independent explanatory sociodemographic and health status variables associated with back pain episodes of care. RESULTS: The 3105 adults in the Health Insurance Experiment had a combined 11,171 person-years of exposure. Six-hundred-eighty-six persons (22%) had a total 1020 episodes of back pain care, representing 8825 visits. Seventy-one percent of persons had a single episode during the Health Insurance Experiment, and 40% of these episodes consisted of a single visit. There were 9.1 episodes per 100 person-years. Insurance status, geographic site, white race, lesser education, poorer physical functioning, and greater pain at base-line all were independently associated with having a back pain episode of care. CONCLUSIONS: Back pain episodes of care occur commonly in the adult U.S. population, but usually are brief and recur infrequently.

Adult↗

PubMed1995

Comparing the costs between provider types of episodes of back pain care.

STUDY DESIGN: This study was a prospective, community-based, observational design. OBJECTIVES: The authors compared the costs of episodes of back pain care between different provider types in a population representative of the U.S. SUMMARY OF BACKGROUND DATA: Previous comparisons between provider types of the costs for back pain care have been restricted to the worker's compensation population or have used something other than the episode as the unit of analysis. METHODS: Data from the RAND Health Insurance Experiment (HIE) were analyzed. Insurance claims forms were examined for all visits specified by the patient as occurring for back pain. Visits were grouped into episodes using decision rules and clinical judgment. The primary provider was defined as the provider who delivered most of the care. Comparisons of costs between provider types were made. RESULTS: There were 1020 episodes of back pain care made by 686 different persons and encompassing 8825 visits. Chiropractors and general practitioners were the primary providers for 40% and 26% of episodes, respectively. Chiropractors had a significantly greater mean number of visits per episode (10.4) than did other practitioners. Orthopedic physicians and "other" physicians were significantly more costly on a per visit basis. Orthopedists had the highest mean total cost per episode, and general practitioners the lowest. Chiropractors had the highest, and general practitioners the lowest mean outpatient cost per episode. CONCLUSIONS: These are economically significant differences in the costs of back pain care of persons seeing chiropractors, general practitioners, internists, and orthopedists.

Back Pain↗

PubMed1995

Factors associated with choosing a chiropractor for episodes of back pain care.

Back pain is a common illness and chiropractors provide a large proportion of back pain care in the United States. This is the first study to systematically compare chiropractic patients with those who saw other providers for back pain. The authors analyzed data from the RAND Health Insurance Experiment, a community-based study of the use of health services. Insurance claims forms were examined for all visits specified by the patient as occurring for back pain. Visits were grouped into episodes using decision rules and clinical judgment. The primary provider of back pain care was defined as the provider who delivered most of the services. Sociodemographic and health status and attitudes variables of patients were examined for association with the choice of chiropractor. Multivariate logistic regression models were constructed to calculate adjusted odds ratios for independent predictors. There were 1020 episodes of back pain care made by 686 different persons and encompassing 8825 visits. Results indicated that chiropractors were the primary provider for 40% of episodes, and retained as primary provider a greater percentage of their patients (92%) who had a second episode of back pain care than did medical doctors. Health insurance experiment site, white race, male sex, and high school education were independent predictors of choosing a chiropractor. Conclusions suggested that chiropractors were the choice of one third of all patients who sought back pain care, and provided care for 40% of all episodes of care. Geographic site, education, gender, and income were independent patient factors predicting chiropractic use.

Adult↗

PubMed1995

The appropriateness of chiropractic spinal manipulation for low back pain: a pilot study.

OBJECTIVE: Spinal manipulation is an efficacious therapy for some patients with low back pain (LBP). In this pilot study, we tested the feasibility of assessing the appropriateness of chiropractic spinal manipulation for patients with LBP. METHODS: Criteria for the appropriate and inappropriate use of spinal manipulation for low back pain were developed using the RAND/UCLA appropriateness method. Two separate expert panels, one multidisciplinary and one all chiropractic, each rated a comprehensive array of clinical scenarios for appropriateness. A random sample of practicing chiropractors was selected, and data were collected from ten randomly selected office records from each participating clinician. Assessment of the appropriateness for the use of spinal manipulation was made by comparing the care delivered with the appropriateness criteria determined by each expert panel. RESULTS: Eight of thirteen (62%) eligible chiropractors agreed to participate. For the remainder, by the multidisciplinary panel's criteria, 38% of care was appropriate and 26% of care was inappropriate. By the all-chiropractic panel's criteria, the same cases were judged 74% appropriate and 7% inappropriate. The two panel's appropriateness ratings were in agreement on 48% of all cases. CONCLUSIONS: In this geographic area, the rate of appropriate care is between 38% and 74% and the rate of inappropriate care is between 7% and 19%, depending on the criteria used to assess appropriateness. Data from other geographic areas of the U.S. will be needed before inferences to a larger population may be drawn, and we have demonstrated that such a study is feasible.

Adolescent↗

PubMed1994

A brief introduction to the critical reading of the clinical literature.

Clinicians are bombarded by reports of new diagnostic tests or treatments for patients with spine problems. To provide the best possible patient care, clinicians need to be able to critically appraise the results of such studies for validity and relevance to patient care. Important questions to be asked of any description of diagnostic or treatment studies are the following questions: 1) Are the patients described in detail so that you can decide whether they are comparable to those that you see in your practice? 2) Are the treatments or assessments described well enough so that you could provide the same for your patients? 3) Was a clinically relevant endpoint measured? 4) Is there an appropriate comparison group? 5) Are potential sources of bias appropriately attended to? 6) Are the results clinically significant?

Humans↗

PubMed1994

Spinal manipulation.

Explore the source record for details and available documents.

Biomechanical Phenomena↗

PubMed1992

Spinal manipulation for low-back pain.

PURPOSE: To review the use, complications, and efficacy of spinal manipulation as a treatment for low-back pain. DATA IDENTIFICATION: Articles were identified through a MEDLINE search, review of articles' bibliographies, and advice from expert orthopedists and chiropractors. STUDY SELECTION: All studies reporting use and complications of spinal manipulation and all controlled trials of the efficacy of spinal manipulation were analyzed. Fifty-eight articles, including 25 controlled trials, were retrieved. DATA ANALYSIS: Data on the use and complications of spinal manipulation were summarized. Controlled trials of efficacy were critically appraised for study quality. Data from nine studies were combined using the confidence profile method of meta-analysis to estimate the effect of spinal manipulation on patients' pain and functional outcomes. RESULTS OF DATA SYNTHESIS: Chiropractors provide most of the manipulative therapy used in the United States for patients with low-back pain. Serious complications of lumbar manipulation, including paraplegia and death, have been reported. Although the occurrence rate of these complications is unknown, it is probably low. For patients with uncomplicated, acute low-back pain, the difference in probability of recovery at 3 weeks favoring treatment with spinal manipulation is 0.17 (for example, increase in recovery from 50% to 67%; 95% probability limits of estimate, 0.07 to 0.28). For patients with low-back pain and sciatic nerve irritation, the difference in probabilities of recovery at 4 weeks is 0.098 (probability limits, -0.016 to 0.209). CONCLUSIONS: Spinal manipulation is of short-term benefit in some patients, particularly those with uncomplicated, acute low-back pain. Data are insufficient concerning the efficacy of spinal manipulation for chronic low-back pain.

Back Pain↗

PubMed1992

Evaluating the treatment of sexually transmitted diseases at an urban public hospital outpatient clinic.

Sexually transmitted diseases occur disproportionately among the poor, are often treated in public hospitals and clinics, and have not been subjected to quality-of-care evaluation. We designed a medical record abstraction system using well-established, specific process-of-care criteria drawn from the medical literature and experts and grouped into three levels of quality: excellent, adequate, and minimal. One hundred seventy-six consecutive patients were identified from the clinic logbook and their medical records abstracted. Deficiencies in history taking, physical examination, laboratory testing, treatment, and public health reporting were identified.

Abstracting and Indexing↗

PubMed1991

A community-based study of the use of chiropractic services.

BACKGROUND: Little population-based information is available on the use of chiropractic services. METHODS: We analyzed data from the RAND Health Insurance Experiment (HIE), a community-based study of the use of health services. Insurance claim forms for all fee-for-service patients who completed the study were examined for all visits coded as being seen by a chiropractor. Services provided and patient-specified symptoms were taken from these forms. Population-based use rates were calculated for each HIE site. Use rates and services were calculated separately for first visits and repeat visits. RESULTS: There were 5,279 persons who contributed 19,021 person-years of exposure during the study; 395 different persons used 7,873 chiropractic services for a visit rate of 41 per 100 person-years and rate of use of 7.5 percent. Forty-two percent of all visits were for pain in the back. Spinal manipulation accounted for 61 percent of all services provided. Compared to non-users, users tended to be White, middle-aged, married, and high school educated. Seven-fold geographic variations in the use of chiropractic services were seen. CONCLUSIONS: Chiropractors deliver a substantial amount of health care to the US population, and there are significant geographic variations in the rate and intensity of use of chiropractic services.

Adolescent↗

PubMed1982

Coordinate synthesis of the enzymes of pyrimidine biosynthesis in Bacillus subtilis.

Strains of Bacillus subtilis that were resistant to repression of pyrimidine nucleotide biosynthetic enzymes were selected by isolating spontaneous uracil-tolerant derivatives of a uracil-sensitive strain, which lacks arginine-repressible carbamyl phosphate synthetase. The relative content of all six enzymes of uridylic acid biosynthesis de novo in these strains was in a constant ratio over a 10-fold range of derepression, which indicates that synthesis of these enzymes is coordinately regulated.

Aspartate Carbamoyltransferase↗