Improving the Assessment of Safety in Pediatric Chiropractic Manual Therapy

• Author / Creator

  Pohlman, Katherine A

• IntroductionAs the cornerstone of high-quality health care, patient safety was first brought to light with the Institute of Medicine’s (IOM) To Err is Human seminal report in 1999 that outlined the gulf between what is desired to what really exists. This report launched intense research efforts mostly focused on hospital-settings despite the majority of health care occurring in ambulatory settings, including chiropractic offices. Although 14% of US adults and 3.3% of children seek chiropractic care each year, there is a lack of prospective patient safety research focused on this profession. This thesis addresses the gap in patient safety research in ambulatory settings by assessing ways to measure patient safety culture and patient safety performance in such environment, as well as collecting primary data about children seeking care from chiropractors. MethodsTwo distinct methods were used in this thesis. The first was a cross-sectional survey used to assess patient safety culture and barriers/facilitators for participation in an active surveillance reporting system of chiropractors who belong to pediatric organizations. To assess patient safety culture, the AHRQ’s Medical Office Survey on Patient Safety Culture was adapted for use by spinal manipulation therapy providers, including chiropractors. This portion of the survey measured the attitudes and opinions of respondents to 10 patient safety dimensions, specific patient safety/quality issues, information exchange, and overall perception of patient safety/quality. The second portion of the cross-sectional survey asked participants about 9-factors identified in the literature as inhibitors to participation in active surveillance reporting systems. The second method was a pragmatic, superiority, cluster, stratified randomized controlled trial (RCT) to compare the quantity and quality of adverse event (AE) reports after chiropractic manual therapy in children less than 14 years of age using active versus passive surveillance reporting systems. Data were collected from 60 consecutive pediatric patient visits with participating chiropractors who were randomly allocated in a 1:1 ratio. For the active surveillance arm, AE information was collected with three questionnaires (one completed by chiropractors and two completed by patients/caregivers). For the passive surveillance arm, AE information was submitted by the chiropractors using a web-based system called “CPiRLS”. The quantity (by cumulative incidence) of AE reports was the primary analysis. Independent assessment by two content experts was used to evaluate quality of moderate, severe, and serious AEs reports submitted by the chiropractor. ResultsWhile patient safety attitudes and opinions of responding chiropractors in the first section of the cross-sectional survey were positive, the response rate was only 29.5%. Chiropractors with a pediatric certification were three times more likely to respond but did not differ in their responses from those without this certification on the patient safety dimensions evaluated. One fifth of respondents completed the questions regarding barriers and facilitators to an active surveillance reporting system; ‘time pressure’ and ‘patient concerns’ were identified as the most important barriers and the belief that reporting was necessary as the most important facilitator. Sixty-nine chiropractors participated in the RCT. Active surveillance had a 8.8% AE reporting rate, while passive surveillance had 0.1%. (p<0.001). No regression analyses were conducted because of the small number of reports in the passive surveillance group. In the active surveillance group, 135 AEs were reported by patients/caregivers: 76 (56.3%) were mild; 35 (25.9%) were moderate; and 24 (17.8%) were severe. Quality of AE reports were not evaluated because the five provider-generated AE reports were determined to be of mild severity by the adjudicators and therefore not assessed further.ConclusionResearch conducted in this thesis has increased the limited body of literature regarding patient safety for pediatric chiropractic care. The cross-sectional survey found responding chiropractors reported a positive patient safety culture, although the low response rate likely introduced selection bias. Key factors affecting providers’ willingness to participate in AE reporting systems were identified (i.e., time pressures and concerns about patient responses to such systems), which guided the methods used in the RCT comparing AE reports collected through active versus passive surveillance in pediatric chiropractic care. From the RCT, the frequency of AE reporting was 40-fold increased when using an active surveillance system as opposed to passive surveillance (8.8% vs. 0.1%, p<0.001). Recommendations for future research include developing evidence to address identified weaknesses in patient safety dimensions assessed (e.g., if a patient safety dimension, such as ‘communication’, is found to be a weakness, then interventions that successfully support that dimension can be suggested to the provider or organization as a way to try and improve this area) and more prospective evaluations to explore pediatric AE incidence for specific ages/conditions/treatments. As the inaugural prospective safety study of pediatric chiropractic, AEs were found to be more common than prior retrospective literature suggested, which is important for chiropractors to consider when making pediatric treatment recommendations, as well as to discuss with their patients when seeking informed consent. Further research is needed to identify how to mitigate or prevent moderate and severe pediatric AEs.

• Subjects / Keywords

  • chiropractic; pediatrics; patient safety; adverse events; manual therapy

• Graduation date

  Spring 2019

• Type of Item

  Thesis

• Degree

  Doctor of Philosophy

• DOI

  https://doi.org/10.7939/r3-zxnm-de52

• License

  Permission is hereby granted to the University of Alberta Libraries to reproduce single copies of this thesis and to lend or sell such copies for private, scholarly or scientific research purposes only. Where the thesis is converted to, or otherwise made available in digital form, the University of Alberta will advise potential users of the thesis of these terms. The author reserves all other publication and other rights in association with the copyright in the thesis and, except as herein before provided, neither the thesis nor any substantial portion thereof may be printed or otherwise reproduced in any material form whatsoever without the author's prior written permission.