A Systems Approach for Assessing Low Back Pain Care Quality in Veterans Health Administration Chiropractic Visits: A Cross-Sectional Analysis.

OBJECTIVE: The purpose of this study was to explore a systemwide process for assessing components of low back pain (LBP) care quality in Veterans Health Administration (VHA) chiropractic visits using electronic health record (EHR) data. METHODS: We performed a cross-sectional quality improvement project. We randomly sampled 1000 on-station VHA chiropractic initial visits occurring from October 1, 2017, to September 30, 2018, for patients with no such visits within the prior 12 months. Characteristics of LBP visits were extracted from VHA national EHR data via structured data queries and manual chart review. We developed quality indicators for history and/or examination and treatment procedures using previously published literature and calculated frequencies of visits meeting these indicators. Visits meeting our history and/or examination and treatment indicators were classified as "high-quality" visits. We performed a regression analysis to assess associations between demographic/clinical characteristics and visits meeting our quality criteria. RESULTS: There were 592 LBP visits identified. Medical history, physical examination, and neurologic examination were documented in 76%, 77%, and 63% of all LBP visits, respectively. Recommended treatments, such as any manipulation, disease-specific education/advice, and therapeutic exercise, occurred in 75%, 69%, and 40% of chronic visits (n = 383), respectively. In acute/subacute visits (n = 37), any manipulation (92%), manual soft tissue therapy (57%), and disease-specific advice/education (54%) occurred most frequently. Female patients and those with a neck pain comorbid diagnosis were significantly less likely to have a "high-quality" visit, while other regression associations were non-significant. CONCLUSION: This study explored a systemwide process for assessing components of care quality in VHA chiropractic visits for LBP. These results produced a potential framework for uniform assessment of care quality in VHA chiropractic visits for LBP and highlight potential areas for improvements in LBP care quality assessments.

Evaluating rates of chiropractic use and utilization by patient sex within the United States Veterans Health Administration: a serial cross-sectional analysis.

BACKGROUND: Within the United States Veterans Health Administration (VHA), the number of patients using healthcare services has increased over the past several decades. Females make up a small proportion of overall patients within the VHA; however, this proportion is growing rapidly. Previous studies have described rates of VHA chiropractic use; however, no prior study assessed differences in use or utilization rates between male and female veterans. The purpose of this study was to assess rates of use and utilization of chiropractic care by sex among VHA patients receiving care at VHA facilities with on-station chiropractic clinics. METHODS: A serial cross-sectional analysis of VHA national electronic health record data was conducted in Fall 2021 for fiscal year (FY) 2005-2021. The cohort population was defined as VHA facilities with on-station chiropractic clinics, and facilities were admitted to the cohort after the first FY with a minimum of 500 on-station chiropractic visits. Variables extracted included counts of unique users of any VHA on-station facility outpatient services, unique users of VHA on-station facility chiropractic services, number of chiropractic visits, and sex. To calculate use, we determined the proportion of patients of each sex who received chiropractic services to the total patients of the same sex receiving any outpatient care within each facility. To calculate utilization, we determined the number of chiropractic care visits per patient per fiscal year. A linear mixed effects model was applied to examine the difference in chiropractic care utilization by sex. RESULTS: The percentage of female VHA on-station chiropractic patients increased from 11.7 to 17.7% from FY2005-FY2021. Among VHA facilities with on-station chiropractic care, the percentage of female VHA healthcare users who used chiropractic care (mean = 2.3%) was greater than the percentage of male VHA healthcare users who used chiropractic care (mean = 1.1%). Rates of chiropractic utilization by sex among VHA facilities with on-station chiropractic clinics were slightly higher for females (median = 4.3 visits per year, mean = 4.9) compared to males (median = 4.1 visits per year, mean = 4.6). CONCLUSION: We report higher use and utilization of VHA chiropractic care by females compared with males, yet for both sexes rates were lower than in the private US healthcare system. This highlights the need for further assessment of the determinants and outcomes of VHA chiropractic care.

Association between early nonpharmacological management and follow-up for low back pain in the veterans health administration.

Background: Low back pain (LBP) is a common reason individuals seek healthcare. Nonpharmacologic management (NPM) is often recommended as a primary intervention, and earlier use of NPM for LBP shows positive clinical outcomes. Our purpose was to evaluate how timing of engagement in NPM for LBP affects downstream LBP visits during the first year. Methods: This study was a secondary analysis of an observational cohort study of national electronic health record data. Patients entering the Musculoskeletal Diagnosis/Complementary and Integrative Health Cohort with LBP from October 1, 2016 to September 30, 2017 were included. Exclusive patient groups were defined by engagement in NPM within 30 days of entry ("very early NPM"), between 31 and 90 days ("early NPM"), or not within the first 90 days ("no NPM"). The outcome was time, in days, to the final LBP follow-up after 90 days and within the first year. Cox proportional hazards regression was used to model time to final follow up, controlling for additional demographic and clinical covariables. Results: The study population included 44,175 patients, with 16.7% engaging in very early NPM and 13.1% in early NPM. Patients with very early NPM (5.2 visits, SD=4.5) or early NPM (5.7 visits, SD=4.6) had a higher mean number of LBP visits within the first year than those not receiving NPM in the first 90 days (3.2 visits, SD = 2.5). The very early NPM (HR=1.50, 95% CI: 1.46-1.54; median=48 days, IQR=97) and early NPM (HR=1.27, 95% CI: 1.23-1.30; median=88 days, IQR=92) had a significantly shorter time to final follow-up than the no NPM group (median=109 days, IQR=150). Conclusions: Veterans Health Administration patients receiving NPM for LBP within the first 90 days after initially seeking care demonstrate a significantly faster time to final follow-up visit within the first year compared to those who do not.

Characteristics and productivity of the chiropractic workforce of the Veterans Health Administration.

BACKGROUND: Increasingly, integrated healthcare systems such as the United States Veterans Health Administration (VHA) are employing chiropractors. However, little is known about chiropractor employee clinical productivity which may be important for resource planning and monitoring care delivery. With its history of delivering chiropractic care and its enterprise-level assessment metrics, the VHA is an ideal setting to study a chiropractic workforce. We aim to assess characteristics of chiropractors employed by the VHA and explore associations between these characteristics and clinical productivity. METHODS: This was a cross-sectional and serial analyses of VHA administrative data. Characteristics of the chiropractor workforce were evaluated from fiscal year (FY) 2016 to FY2019. Productivity was calculated using the VHA productivity measure, the quotient of an individual's total work relative value units (wRVUs) per FY divided by the direct clinical full-time equivalent (FTE) worked. A multivariable regression model was used to analyze the association between productivity and characteristics of the chiropractor and VHA facility. RESULTS: From FY2016 to FY2019, the number of chiropractor employees increased from 102 to 167. In FY2019, the typical chiropractor employee was male, white, and 45.9 years old with 5.2 years of VHA experience. In FY2019, the VHA chiropractor workforce was 25.1% female, 79% white, and 20.4% Veteran. The productivity measure of a chiropractor was 3040 in FY2019. A higher facility complexity measure, presence of 3 chiropractor employees at a facility, and older age of the providers were the only characteristics studied that had a significant impact on productivity after adjusting for other covariates. CONCLUSION: Provider characteristics and productivity metrics of the VHA chiropractor employee workforce are presented. The productivity measure provides an initial benchmarking that may be relevant to future modeling of chiropractor personnel in VHA and other healthcare systems.

Care Outcomes for Chiropractic Outpatient Veterans (COCOV): a single-arm, pragmatic, pilot trial of multimodal chiropractic care for U.S. veterans with chronic low back pain.

BACKGROUND: Over 25% of veterans seeking care at U.S. Veterans Health Administration facilities have chronic low back pain (LBP), with high rates of mental health comorbidities. The primary objective of this study was to assess the feasibility of participant recruitment, retention, and electronic data collection to prepare for the subsequent randomized trial of multimodal chiropractic care for pain management of veterans with chronic low back pain. The secondary objectives were to estimate effect sizes and variability of the primary outcome and choose secondary outcomes for the full-scale trial. METHODS: This single-arm pilot trial enrolled 40 veterans with chronic LBP at one Veterans Health Administration facility for a 10-week course of pragmatic multimodal chiropractic care. Recruitment was by (1) provider referral, (2) invitational letter from the electronic health record pre-screening, and (3) standard direct recruitment. We administered patient-reported outcome assessments through an email link to REDCap, an electronic data capture platform, at baseline and 5 additional timepoints. Retention was tracked through adherence to the treatment plan and completion rates of outcome assessments. Descriptive statistics were calculated for baseline characteristics and outcome variables. RESULTS: We screened 91 veterans over 6 months to enroll our goal of 40 participants. Seventy percent were recruited through provider referrals. Mean age (range) was 53 (22-79) years and 23% were female; 95% had mental health comorbidities. The mean number of chiropractic visits was 4.5 (1-7). Participants adhered to their treatment plan, with exception of 3 who attended only their first visit. All participants completed assessments at the in-person baseline visit and 80% at the week 10 final endpoint. We had no issues administering assessments via REDCap. We observed clinically important improvements on the Roland-Morris Disability Questionnaire [mean change (SD): 3.6 (6.1)] and on PROMIS® pain interference [mean change (SD): 3.6 (5.6)], which will be our primary and key secondary outcome, respectively, for the full-scale trial. CONCLUSIONS: We demonstrated the feasibility of participant recruitment, retention, and electronic data collection for conducting a pragmatic clinical trial of chiropractic care in a Veterans Health Administration facility. Using the pilot data and lessons learned, we modified and refined a protocol for a full-scale, multisite, pragmatic, National Institutes of Health-funded randomized trial of multimodal chiropractic care for veterans with chronic LBP that began recruitment in February 2021. TRIAL REGISTRATION: ClinicalTrials.gov NCT03254719.

Characteristics of Chiropractic Patients in the Veterans Health Administration During the COVID-19 Pandemic: A Cross-Sectional Analysis.

OBJECTIVE: The purpose of this study was to determine whether patient characteristics were associated with face-to-face (F2F) and telehealth visits for those receiving chiropractic care for musculoskeletal conditions in the US Veterans Health Administration (VHA) during the COVID-19 pandemic. METHODS: A retrospective cross-sectional analysis of all patients (veterans, dependents, and spouses) who received chiropractic care nationwide at the VHA from March 1, 2020, to February 28, 2021, was performed. Patients were allocated into 1 of the following 3 groups: only telehealth visits, only F2F visits, and combined F2F and telehealth visits. Patient characteristics included age, sex, race, ethnicity, marital status, and Charlson Comorbidity Index. Multinomial logistic regression estimated associations of these variables with visit type. RESULTS: The total number of unique patients seen by chiropractors between March 2020 and February 2021 was 62 658. Key findings were that patients of non-White race and Hispanic or Latino ethnicity were more likely to attend telehealth-only visits (Black [odds ratio 1.20, 95% confidence interval {1.10-1.31}], other races [1.36 {1.16-1.59}], and Hispanic or Latino [1.35 {1.20-1.52}]) and combination telehealth and F2F care (Black [1.32 {1.25-1.40}], other races [1.37 {1.23-1.52}], and Hispanic or Latino [1.63 {1.51-1.76}]). Patients younger than 40 years of age were more likely to choose telehealth visits ([1.13 {1.02-1.26}], 66-75 years [1.17 {1.01-1.35}], and >75 years [1.26 {1.06-1.51}] vs those 40-55 years of age). Sex, visit frequency, and Charlson Comorbidity Index showed significant relationships as well, while marital status did not. CONCLUSION: During the COVID-19 pandemic, VHA patients with musculoskeletal complaints using chiropractic telehealth were more ethnically and racially diverse than those using F2F care alone.

Exploring the application of the Charlson Comorbidity Index to assess the patient population seen in a Veterans Affairs chiropractic residency program.

OBJECTIVE: Chiropractic trainees require exposure to a diverse patient base, including patients with multiple medical conditions. The Veterans Affairs (VA) Chiropractic Residency Program aims for its doctor of chiropractic (DC) residents to gain experience managing a range of multimorbid cases, yet to our knowledge there are no published data on the comorbidity characteristics of patients seen by VA DC residents. We tested 2 approaches to obtaining Charlson Comorbidity Index (CCI) scores and compared CCI scores of resident patients with those of staff DCs at 1 VA medical center. METHODS: Two processes of data collection to calculate CCI scores were developed. Time differences and agreement between methods were assessed. Comparison of CCI distribution between resident DC and staff DCs was done using 100 Monte Carlo simulation iterations of Fisher's exact test. RESULTS: Both methods were able to calculate CCI scores (n = 22). The automated method was faster than the manual (13 vs 78 seconds per patient). CCI scores agreement between methods was good (κ = 0.67). We failed to find a significant difference in the distribution of resident DC and staff DC patients (mean p = .377; 95% CI, .375-.379). CONCLUSION: CCI scores of a VA chiropractic resident's patients are measurable with both manual and automated methods, although automated may be preferred for its time efficiency. At the facility studied, the resident and staff DCs did not see patients with significantly different distributions of CCI scores. Applying CCI may give better insight into the characteristics of DC trainee patient populations.

Characteristics and Practice Patterns of U.S. Veterans Health Administration Doctors of Chiropractic: A Cross-sectional Survey.

OBJECTIVE: The purpose of this study was to survey U.S. Veterans Health Administration (VA) chiropractors to assess current demographic and professional characteristics, including practice parameters, interprofessional collaboration, academic experience, and scholarly activity. METHODS: A cross-sectional survey was performed from August 21, 2019, to September 6, 2019, including all chiropractors identified with any VA appointment. REDCap software was used to conduct the survey. Data from surveys were exported to Microsoft Excel for data analysis. RESULTS: Of the 177 providers solicited, 118 returned completed surveys (67% response rate). Respondents predominantly self-reported as white (84%) and male (77.1%), with a mean age of 47 years, and reported spending at least 75% of time on clinical care. Most respondents reported being VA employees (96%) with full-time appointments (94%). Approximately half reported having prior hospital training (48%), supervising chiropractic students (53%) and students in other health professions (47%), and authoring or coauthoring ≥1 peer-reviewed publications (42%). Respondents reported performing an average of 6 to 15 new-patient consultations and 31 to 60 follow-up visits per week. Most patient referrals to chiropractic care originated from primary care providers, with low back conditions without radiculopathy as the most frequently seen condition. Diversified manipulation and flexion-distraction techniques, along with myofascial therapies, therapeutic exercises, and self-management advice, were the most commonly reported interventions. CONCLUSION: We report provider and practice characteristics from chiropractors working in a large, integrated health care system. Most are full-time employees, work in physical medicine departments, and have held their position for up to 5 years. The majority of respondents report diagnostic and treatment approaches concordant with current clinical practice guidelines.

Changes in the Use of Telehealth and Face-To-Face Chiropractic Care in the Department of Veterans Affairs Before and After the COVID-19 Pandemic.

OBJECTIVE: The purpose of this study was to describe the use of face-to-face and telehealth chiropractic care in the U.S. Veterans Health Administration (VHA) before and after the declaration of the COVID-19 pandemic. METHODS: A cross-sectional study was performed of VHA administrative data, including monthly numbers of unique patients and visits for face-to-face and telehealth (synchronous video or telephone) chiropractic care from October 1, 2019, to March 31, 2021. RESULTS: During the pre-pandemic phase (October 2019 to February 2020), a mean of 28 930 (SD 289) total monthly visits were conducted face-to-face (99.9%). In March 2020, total monthly visits decreased to 17.0% of the pre-pandemic average, 25.0% being face-to-face, with over a 200-fold increase in telehealth visits (rising to 1331 visits) compared to the pre-pandemic average. April showed the lowest number of face-to-face visits at (4094). May-October 2020 showed that face-to-face visits increase on average by 70.7% per month, while telehealth visits averaged 17.3% per month. October-February 2020 had total monthly visits plateau at a mean of 22 250 (76.9% of the pre-pandemic average). Telehealth visits reduced to a mean of 1245 monthly visits over this 5-month period, a drop of -5.6% of the average of monthly visits. In March 2021, total monthly visits (31 221) exceeded the pre-pandemic average for the first time since January 2020; 4.0% remained in telehealth. CONCLUSION: Face-to-face visits decreased early in the pandemic but increased after May 2020. Chiropractic telehealth use rapidly increased during the early stage of the COVID-19 pandemic, and decreased later, but remained slightly higher than pre-pandemic levels.

An overview of the medical specialties most relevant to chiropractic practice and education.

OBJECTIVE: The purpose of this article is to present an overview of the key medical and surgical specialties most likely relevant to chiropractic practice in the United States. Understanding the similarities and differences in the training and typical practices of these medical providers may enhance a chiropractor's likelihood to collaborate and increase participation in team-based care. METHODS: This was a descriptive analysis to develop preliminary content on US medical physician specialties. Selection was informed by the authors' clinical experience with medical collaboration, along with results of previously published work on medical specialties most commonly reported to be involved in referral patterns with US chiropractors. Data from the Accreditation Council for Graduate Medical Education and individual specialty boards were synthesized through an iterative process, and supplemented by qualitative input from subject matter experts. Data were entered into tabular format for review and analysis. RESULTS: We propose that the medical and surgical specialties most relevant to typical US chiropractic practice are internal medicine, family medicine, emergency medicine, physical medicine and rehabilitation, neurology, pain medicine, rheumatology, radiology, orthopedic surgery, and neurological surgery. There is overlap in scope of conditions and diagnostic and therapeutic tools utilized by various medical specialties. CONCLUSION: This work describes 8 medical and 2 surgical specialties proposed to be most relevant to general chiropractic practice in the United States. The results may have relevance to interprofessional education and collaboration.

Veteran Response to Dosage in Chiropractic Therapy (VERDICT): Study Protocol of a Pragmatic Randomized Trial for Chronic Low Back Pain.

BACKGROUND: Low back pain is a leading cause of disability in veterans. Chiropractic care is a well-integrated, nonpharmacological therapy in Veterans Affairs health care facilities, where doctors of chiropractic provide therapeutic interventions focused on the management of low back pain and other musculoskeletal conditions. However, important knowledge gaps remain regarding the effectiveness of chiropractic care in terms of the number and frequency of treatment visits needed for optimal outcomes in veterans with low back pain. DESIGN: This pragmatic, parallel-group randomized trial at four Veterans Affairs sites will include 766 veterans with chronic low back pain who are randomly allocated to a course of low-dose (one to five visits) or higher-dose (eight to 12 visits) chiropractic care for 10 weeks (Phase 1). After Phase 1, participants within each treatment arm will again be randomly allocated to receive either monthly chiropractic chronic pain management for 10 months or no scheduled chiropractic visits (Phase 2). Assessments will be collected electronically. The Roland Morris Disability Questionnaire will be the primary outcome for Phase 1 at week 10 and Phase 2 at week 52. SUMMARY: This trial will provide evidence to guide the chiropractic dose in an initial course of care and an extended-care approach for veterans with chronic low back pain. Accurate information on the effectiveness of different dosing regimens of chiropractic care can greatly assist health care facilities, including Veterans Affairs, in modeling the number of doctors of chiropractic that will best meet the needs of patients with chronic low back pain.

Exploring supervised machine learning approaches to predicting Veterans Health Administration chiropractic service utilization.

BACKGROUND: Chronic spinal pain conditions affect millions of US adults and carry a high healthcare cost burden, both direct and indirect. Conservative interventions for spinal pain conditions, including chiropractic care, have been associated with lower healthcare costs and improvements in pain status in different clinical populations, including veterans. Little is currently known about predicting healthcare service utilization in the domain of conservative interventions for spinal pain conditions, including the frequency of use of chiropractic services. The purpose of this retrospective cohort study was to explore the use of supervised machine learning approaches to predicting one-year chiropractic service utilization by veterans receiving VA chiropractic care. METHODS: We included 19,946 veterans who entered the Musculoskeletal Diagnosis Cohort between October 1, 2003 and September 30, 2013 and utilized VA chiropractic services within one year of cohort entry. The primary outcome was one-year chiropractic service utilization following index chiropractic visit, split into quartiles represented by the following classes: 1 visit, 2 to 3 visits, 4 to 6 visits, and 7 or greater visits. We compared the performance of four multiclass classification algorithms (gradient boosted classifier, stochastic gradient descent classifier, support vector classifier, and artificial neural network) in predicting visit quartile using 158 sociodemographic and clinical features. RESULTS: The selected algorithms demonstrated poor prediction capabilities. Subset accuracy was 42.1% for the gradient boosted classifier, 38.6% for the stochastic gradient descent classifier, 41.4% for the support vector classifier, and 40.3% for the artificial neural network. The micro-averaged area under the precision-recall curve for each one-versus-rest classifier was 0.43 for the gradient boosted classifier, 0.38 for the stochastic gradient descent classifier, 0.43 for the support vector classifier, and 0.42 for the artificial neural network. Performance of each model yielded only a small positive shift in prediction probability (approximately 15%) compared to naïve classification. CONCLUSIONS: Using supervised machine learning to predict chiropractic service utilization remains challenging, with only a small shift in predictive probability over naïve classification and limited clinical utility. Future work should examine mechanisms to improve model performance.

Management of patients with prior lumbar fusion: a cross-sectional survey of Veterans Affairs chiropractors' attitudes, beliefs, and practices.

BACKGROUND: Little is known about the preferred treatment strategies of chiropractors in managing low back pain patients with prior lumbar fusions. There are several case reports which describe chiropractic care following surgical intervention, but there are no cohort or experimental studies published. Therefore, we sought to examine self-reported management approaches and practice patterns related to the management of patients with prior surgical lumbar fusion, among United States Veterans Affairs (VA) chiropractors. METHODS: An electronic survey was administered nationwide to all chiropractors providing clinical care within VA. Questions were informed by a prior survey and piloted on a sample of chiropractors external to VA. Statistical analysis included respondent background information, and quantitative analysis of chiropractic referral patterns and practices. This survey collect information on 1) provider demographics, 2) VA referral patterns, and 3) attitudes, beliefs, practices and interventions utilized by VA chiropractors to manage patients with a history of surgical lumbar fusion. RESULTS: The survey response rate was 46.3% (62/134). The respondents were broadly representative of VA chiropractic providers in age, gender, and years in practice. The majority of respondents (90.3%) reported seeing at least 1 post-fusion patient in the past month. The most common therapeutic approaches utilized by VA chiropractors were healthy lifestyle advice (94.9%), pain education (89.8%), exercise prescription (88.1%), stretching (66.1%) and soft tissue manual therapies (62.7%). A relatively smaller proportion described always or frequently incorporating lumbar (16.9%), thoracic (57.6%) or pelvic (39.0%) spinal manipulation. CONCLUSION: This survey provides preliminary data on VA chiropractic services in the management of patients with prior lumbar fusion. These patients are often seen by VA chiropractors, and our findings support the need for further study to advance understanding of interventions utilized by chiropractors in this patient population.

Factors Associated With Posttraumatic Stress Disorder Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care.

OBJECTIVES: Post-traumatic stress disorder (PTSD) is thought to complicate pain management outcomes, which is consistent with the impact of other psychosocial factors in the biopsychosocial model of pain. This study aimed to identify patient sociodemographic and clinical characteristics associated with PTSD prevalence among veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who received Veterans Affairs (VA) chiropractic care. METHODS: A cross-sectional analysis of electronic health record data from a national cohort study of OEF/OIF/OND veterans with at least 1 visit to a VA chiropractic clinic from 2001 to 2014 was performed. The primary outcome measure was a prior PTSD diagnosis. Variables including sex, race, age, body mass index, pain intensity, alcohol and substance use disorders, and smoking status were examined in association with PTSD diagnosis using logistic regression. RESULTS: We identified 14,025 OEF/OIF/OND veterans with at least 1 VA chiropractic visit, with a mean age of 38 years and 54.2% having a diagnosis of PTSD. Male sex (adjusted odds ratio [OR] = 1.23, 95% CI = 1.11-1.37), younger age (OR = 0.99, CI = 0.98-0.99), moderate-to-severe pain intensity (numerical rating scale ≥ 4) (OR = 1.72, CI = 1.59-1.87), body mass index ≥ 30 (OR = 1.34, CI = 1.24-1.45), current smoking (OR = 1.32, CI = 1.20-1.44), and having an alcohol or substance use disorder (OR = 4.51, CI = 4.01-5.08) were significantly associated with a higher likelihood of PTSD diagnosis. CONCLUSION: Post-traumatic stress disorder is a common comorbidity among OEF/OIF/OND veterans receiving VA chiropractic care and is significantly associated with several patient characteristics. Recognition of these factors is important for the appropriate diagnosis and management of veterans with PTSD seeking chiropractic treatment for pain conditions.

Association Between Chiropractic Use and Opioid Receipt Among Patients with Spinal Pain: A Systematic Review and Meta-analysis.

OBJECTIVE: To investigate the current evidence to determine if there is an association between chiropractic use and opioid receipt. DESIGN: Systematic review and meta-analysis. METHODS: The protocol for this review was registered on PROSPERO (CRD42018095128). The MEDLINE, PubMed, EMBASE, AMED, CINAHL, and Web of Science databases were searched for relevant articles from database inception through April 18, 2018. Controlled studies, cohort studies, and case-control studies including adults with noncancer pain were eligible for inclusion. Studies reporting opioid receipt for both subjects who used chiropractic care and nonusers were included. Data extraction and risk of bias assessment were completed independently by pairs of reviewers. Meta-analysis was performed and presented as an odds ratio with 95% confidence interval. RESULTS: In all, 874 articles were identified. After detailed selection, 26 articles were reviewed in full, and six met the inclusion criteria. Five studies focused on back pain and one on neck pain. The prevalence of chiropractic care among patients with spinal pain varied between 11.3% and 51.3%. The proportion of patients receiving an opioid prescription was lower for chiropractic users (range = 12.3-57.6%) than nonusers (range = 31.2-65.9%). In a random-effects analysis, chiropractic users had a 64% lower odds of receiving an opioid prescription than nonusers (odds ratio = 0.36, 95% confidence interval = 0.30-0.43, P < 0.001, I2 = 92.8%). CONCLUSIONS: This review demonstrated an inverse association between chiropractic use and opioid receipt among patients with spinal pain. Further research is warranted to assess this association and the implications it may have for case management strategies to decrease opioid use.

A Pulsed Electromagnetic Field Therapy Device for Non-Specific Low Back Pain: A Pilot Randomized Controlled Trial.

INTRODUCTION: Low back pain (LBP) poses a significant burden of disease worldwide, and identifying safe and effective non-pharmacologic treatment options for LBP is a research priority. The aim of this study was to pilot a clinical trial of a portable pulsed electromagnetic field (PEMF) therapy device for subjects with mixed duration non-specific LBP. METHODS: This work was a randomized, double-blind, sham-controlled, parallel-group study conducted at a chiropractic school outpatient clinic. The primary end point was functional capacity measured by the Oswestry Disability Index (ODI) at baseline, 6 weeks, and 12 weeks. Analysis was conducted on the intent-to-treat population and as a trend of change in pain scores over time using the Freidman test of repeated measures. RESULTS: Forty-two participants were randomized to receive usual care plus PEMF therapy or usual care plus sham, and 25 completed the study. Significant improvements in ODI scores from baseline to week 6 were reported in the experimental group (χ2 = 14.68, p < 0.001, compared with patients in the sham group, χ2 = 4.00, p = 0.135, n.s.). This difference persisted at week-12 follow-up. Adverse events were rare and mild. CONCLUSION: It is feasible to conduct a clinical trial of a PEMF therapy device for non-specific LBP. This work shows that the device was safe and provides preliminary evidence of effectiveness in improving function in patients with non-specific LBP. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT03053375. FUNDING: Aerotel Ltd.

Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care.

Objective: To examine patient sociodemographic and clinical characteristics associated with opioid use among Veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who receive chiropractic care, and to explore the relationship between timing of a chiropractic visit and receipt of an opioid prescription. Methods: Cross-sectional analysis of administrative data on OEF/OIF/OND veterans who had at least one visit to a Veterans Affairs (VA) chiropractic clinic between 2004 and 2014. Opioid receipt was defined as at least one prescription within a window of 90 days before to 90 days after the index chiropractic clinic visit. Results: We identified 14,025 OEF/OIF/OND veterans with at least one chiropractic visit, and 4,396 (31.3%) of them also received one or more opioid prescriptions. Moderate/severe pain (odds ratio [OR] = 1.87, 95% confidence interval [CI] = 1.72-2.03), PTSD (OR = 1.55, 95% CI = 1.41-1.69), depression (OR = 1.40, 95% CI = 1.29-1.53), and current smoking (OR = 1.39, 95% CI = 1.26-1.52) were associated with a higher likelihood of receiving an opioid prescription. The percentage of veterans receiving opioid prescriptions was lower in each of the three 30-day time frames assessed after the index chiropractic visit than before. Conclusions: Nearly one-third of OEF/OIF/OND veterans receiving VA chiropractic services also received an opioid prescription, yet the frequency of opioid prescriptions was lower after the index chiropractic visit than before. Further study is warranted to assess the relationship between opioid use and chiropractic care.

Chiropractic Integration into Private Sector Medical Facilities: A Multisite Qualitative Case Study.

OBJECTIVES: Chiropractic care may have value in improving patient outcomes and decreasing opioid use, but little is known about the impetus for or process of incorporating these services into conventional medical settings. The purpose of this qualitative study was to describe organizational structures, care processes, and perceived value of chiropractic integration within U.S. private sector medical facilities. DESIGN: Multisite, comparative organizational case study. SETTINGS: Nine U.S. private sector medical facilities with on-site chiropractic care, including five hospitals and four clinics. PARTICIPANTS: One hundred and thirty-five key facility stakeholders including doctors of chiropractic (DCs), non-DC clinicians, support staff, administrators, and patients. METHODS: Researchers conducted 2-day site visits to all settings. Qualitative data were collected from audio-recorded, semi-structured, role-specified, individual interviews; standardized organizational data tables; and archival document review. A three-member, interdisciplinary team conducted thematic content analysis of verbatim transcripts using an existing conceptual framework and emergent codes. RESULTS: These nine medical facilities had unique organizational structures and reasons for initiating chiropractic care in their settings. Across sites, DCs were sought to take an evidence-based approach to patient care, work collaboratively within a multidisciplinary team, engage in interprofessional case management, and adopt organizational mission and values. Chiropractic clinics were implemented within existing human resources, physical plant, information technology, and administrative support systems, and often expanded over time to address patient demand. DCs usually were co-located with medical providers and integrated into the collaborative management of patients with musculoskeletal and co-morbid conditions. Delivery of chiropractic services was perceived to have high value among patients, medical providers, and administration. Patient clinical outcomes, patient satisfaction, provider productivity, and cost offset were identified as markers of clinic success. CONCLUSION: A diverse group of U.S. private sector medical facilities have implemented chiropractic clinics, and a wide variety of facility stakeholders report high satisfaction with the care provided.

Chiropractic Integrated Care Pathway for Low Back Pain in Veterans: Results of a Delphi Consensus Process.

OBJECTIVE: The purpose of this study was to develop an integrated care pathway for doctors of chiropractic, primary care providers, and mental health professionals who manage veterans with low back pain, with or without mental health comorbidity, within Department of Veterans Affairs health care facilities. METHODS: The research method used was a consensus process. A multidisciplinary investigative team reviewed clinical guidelines and Veterans Affairs pain and mental health initiatives to develop seed statements and care algorithms to guide chiropractic management and collaborative care of veterans with low back pain. A 5-member advisory committee approved initial recommendations. Veterans Affairs-based panelists (n = 58) evaluated the pathway via e-mail using a modified RAND/UCLA methodology. Consensus was defined as agreement by 80% of panelists. RESULTS: The modified Delphi process was conducted in July to December 2016. Most (93%) seed statements achieved consensus during the first round, with all statements reaching consensus after 2 rounds. The final care pathway addressed the topics of informed consent, clinical evaluation including history and examination, screening for red flags, documentation, diagnostic imaging, patient-reported outcomes, adverse event reporting, chiropractic treatment frequency and duration standards, tailored approaches to chiropractic care in veteran populations, and clinical presentation of common mental health conditions. Care algorithms outlined chiropractic case management and interprofessional collaboration and referrals between doctors of chiropractic and primary care and mental health providers. CONCLUSION: This study offers an integrative care pathway that includes chiropractic care for veterans with low back pain.

Integration of Doctors of Chiropractic Into Private Sector Health Care Facilities in the United States: A Descriptive Survey.

OBJECTIVE: The purpose of this study was to describe the demographic, facility, and practice characteristics of doctors of chiropractic (DCs) working in private sector health care settings in the United States. METHODS: We conducted an online, cross-sectional survey using a purposive sample of DCs (n = 50) working in integrated health care facilities. The 36-item survey collected demographic, facility, chiropractic, and interdisciplinary practice characteristics, which were analyzed with descriptive statistics. RESULTS: The response rate was 76% (n = 38). Most respondents were men and mid-career professionals with a mean 21 years of experience in chiropractic. Doctors of chiropractic reported working in hospitals (40%), multispecialty offices (21%), ambulatory clinics (16%), or other (21%) health care settings. Most (68%) were employees and received salary compensation (59%). The median number of DCs per setting was 2 (range 1-8). Most DCs used the same health record as medical staff and worked in the same clinical setting. More than 60% reported co-management of patients with medical professionals. Integrated DCs most often received and made referrals to primary care, physical medicine, pain medicine, orthopedics, and physical or occupational therapy. Although in many facilities the DCs were exclusive providers of spinal manipulation (43%), in most, manipulative therapies also were delivered by physical therapists and osteopathic or medical physicians. Informal face-to-face consultations and shared health records were the most common communication methods. CONCLUSIONS: Doctors of chiropractic are working in diverse medical settings within the private sector, in close proximity and collaboration with many provider types, suggesting a diverse role for chiropractors within conventional health care facilities.