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PubMedDate not supplied

Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias.

BACKGROUND CONTEXT: The growing recognition of cervical manipulation as a treatment of neck pain and cervicogenic headaches has lead to increased interest in potential complications that may result from this treatment approach. Recent surveys have reported that many neurologists will encounter cases of vertebral artery dissection that occur at various times after cervical manipulation, whereas most practitioners of spinal manipulation are of the opinion that these events are extremely rare. We asked the question whether these differences in perception could be explained in part by referral or selection bias. PURPOSE: To assess the effect of referral bias on the differences in perceived incidence of vertebral artery dissection after cervical manipulation between neurologists and chiropractors in Canada. STUDY DESIGN: This study was a retrospective review of cases where neurological symptoms consistent with cerebrovascular ischemia were reported by chiropractors in Canada. METHODS: An analysis of data from a chiropractic malpractice insurance carrier (Canadian Chiropractic Protective Association [CCPA]) and results of a survey of chiropractors was performed to determine the likelihood that a vertebral artery dissection after cervical manipulation would be reported to practicing chiropractors. This was compared with the likelihood that a neurologist would be made aware of such a complication. RESULTS: For the 10-year period 1988 to 1997, there were 23 cases of vertebral artery dissection after cervical manipulation reported to the CCPA that represents 85% of practicing chiropractors in Canada. Based on the survey, an estimated 134,466,765 cervical manipulations were performed during this 10-year period. This gave a calculated rate of vertebral artery dissection after manipulation of 1:5,846,381 cervical manipulations. Based on the number of practicing chiropractors and neurologists during the period of this study, 1 of every 48 chiropractors and one of every two neurologists would have been made aware of a vascular complication from cervical manipulation that was reported to the CCPA during their practice lifetime. CONCLUSIONS: The perceived risk after cervical manipulation by chiropractors and neurologists is related to the probability that a practitioner will be made aware of such an incident. The difference in the number of chiropractors (approximately 3,840 in 1997) and neurologists (approximately 4,000 in 1997) in active practice and the fact that each patient who has a stroke after manipulation will likely be seen by only one chiropractor but by three or more neurologists partly explains the difference in experience and the perception of risk of these two professions. This selection or referral bias is important in shaping the clinical opinions of the various disciplines and distorts discussion on the true incidence of these complications of cervical manipulation. The nature of this study, however, describes the likelihood that a clinician will be made aware of such an event and cannot be interpreted as describing the actual risk of stroke after manipulation.

Bias↗
PubMed1992

Clinical PET scanning. A "short-lived" orphan.

Positron emission tomography (PET) is a method of nuclear medicine imaging that uses short-lived radiopharmaceuticals to detect and quantify the metabolic abnormalities of disease processes. PET initially was developed in a research environment as a research tool; data from these research studies resulted in the gradual recognition that PET studies would be useful for various routine clinical applications. The diffusion of PET into clinical practice has been slow in comparison with other new imaging methods (e.g., magnetic resonance imaging). This slow diffusion is attributable to several factors, including the complexity and high cost of PET, the uncertain role of the U.S. Food and Drug Administration in regulating the radiopharmaceuticals that are produced and used on-site for PET studies, and the apparent slow pace at which the Health Care Financing Administration and other third-party payers are developing policies for reimbursing for PET.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2000

Technology and the management of trust in insurance medicine.

This article deals with the question how technology contributed to the performing of objective assessments of health risks and to the public trust in the insurance institution. Many authors have pointed to the relevance of medical or statistical technology with regard to the constitution of objectivity, because these technologies should be capable of diminishing the influence of social interactions--the "human element"--on the process of producing knowledge about health risks. However, in this article it is shown that the constitution of objective risk assessments and public trust cannot be seen as the product of one particular type of technology, but that it is the product of a socio-technical network, in which several heterogeneous elements become interrelated and interdependant. The historical reconstruction of this network also sheds a new light on the role of 'the human element' in the constitution of objectivity and trust. It shows that elements in the network which regulate the social interaction between the subjects involved are of no less importance to generate trust than technologies which tend to abstract from this interaction. In other words, objective and subjective elements are intertwined much more than is often recognized, and public trust is to a fairly large degree depends on conventions in social interaction.

Biomedical Technology↗
PubMed1994

Insurance--a dental viewpoint. Part II: Sickness and accident.

It is a very fortunate dentist indeed who survives an average 40-year working life without suffering illness or an accident. This will normally keep the dentist away from work and the ability to earn for a period of time. In the worst cases the disability may prevent a return to normal work with disastrous effects upon career earnings. Insurance against loss of earnings has therefore a very high priority.

Dentists↗
PubMed1994

Insurance--a dental viewpoint. Part IV: Professional risks indemnity.

Over the last decade professional practice has changed in many ways, not least in the willingness of patients to seek damages. The treasurer of the Medical Defence Union, in his report on the year 1989, stated that claims paid out on behalf of doctors in Britain doubled in frequency and the average amount awarded also doubled between 1985 and 1988, subscription rates increased fourfold. By contrast, 40 years ago life membership of a 'defence organisation' was available for less that an annual subscription today.

Humans↗
PubMed1997

Review article: insurance risks for patients with ulcerative colitis or Crohn's disease.

Prospective population-based studies have allowed a re-evaluation of the risks of insuring patients with ulcerative colitis or Crohn's disease. Life expectancy, the risk of cancer and working capacity are very much better than previously recognised and are normal for many patients. Three population-based studies in ulcerative colitis have shown a mortality similar to or slightly less than the general population except in the first year after diagnosis, whilst two have shown a slightly higher mortality (standardized mortality ratio, SMR = 1.4), except for those with proctitis. In Crohn's disease, two population-based studies have also shown an increased mortality (SMR = 1.4), which is similar to that of unskilled manual labourers (SMR = 1.43) from all causes of death. Three other studies have shown no increase in overall mortality, except in the first 5 years after diagnosis, in those with proximal small intestinal disease and in some patients needing multiple operations. Insurance risks should be evaluated on an individual basis, after details of the extent and pattern of disease have been obtained. Although the 'standard life' in insurance terms differs from that of the general population, because people who seek life assurance are self-selected from a more affluent section of society, many patients can be identified who have a particularly good prognosis. These include patients with ulcerative proctitis, those with left-sided colitis in extended remission (> 12 months), and patients more than 30 years old with localized ileal or ileocaecal Crohn's disease that has responded to treatment. From the published data, it is difficult to justify increasing the insurance premium in such patients.

Activities of Daily Living↗
PubMed1999

Mohs micrographic surgery referral patterns: the University of Missouri experience.

BACKGROUND: Mohs micrographic surgery (MMS) provides a higher cure rate for nonmelanoma skin cancer (NMSC) than other forms of therapy. The American Academy of Dermatology has published recommended guidelines for MMS referral. However, factors other than the location, size, and type of NMSC may often affect the referral process. OBJECTIVE: To tabulate and analyze the rates of referral of NMSC for MMS by the dermatology clinics within the University of Missouri system. Data obtained for every biopsy-proven basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) diagnosed at each of our four dermatology clinics during the 3-year period of October 1993-September 1996 were cross-referenced with our Mohs surgery clinic logbook to identify which patients had been referred for MMS. RESULTS: During the study period, 19.2% of NMSC patients diagnosed were referred for MMS. However, there was significant disparity in referral rates among our four clinics. When the skewed data from our Veterans Administration Hospital clinic were discounted, the overall referral rate from the other clinics was found to be 30.8%. CONCLUSION: Our finding of a 30.8% referral rate of NMSC for MMS (27. 4% for SCC and 32.9% for BCC) within our university dermatology system is similar to the rates found in previous studies by the Mayo Clinic and Brooke Army Medical Center. MMS referral patterns are affected by many factors besides whether the NMSC meets MMS criteria, including the preference of each individual referring physician, patient, and involved insurance carrier.

Basal Cell Carcinoma↗
PubMed2002

[Criteria for selection of patients for bariatric surgery].

Because of the high prevalence of co-morbid conditions and poor life expectancy a Body Mass Index (BMI) of 40 kg/m(2) or more is an indication for surgery in a fully informed, consenting adult in optimal medical condition to tolerate general anaesthesia. Patients with BMI of 35-40 kg/m(2) and the existence of one or more serious obesity-related conditions ameliorated by weight loss, such as hypertension, pulmonary insufficiency, non-insulin-dependent diabetes mellitus etc., are also candidates for surgical treatment. The bariatric surgeon should use these international criteria as guidelines only, not strict rules. Attempts on the part of internists and more frequently insurance carriers to require documented failure of previous non-operative treatment is not meaningful.

Body Mass Index↗