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.

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.

The rate of use of Veterans Affairs chiropractic care: a 5-year analysis.

BACKGROUND: The US Department of Veterans Affairs (VA) has initiated various approaches to provide chiropractic care to Veterans. Prior work has shown substantial increase in use of VA chiropractic care between fiscal years (FY) 2005-2016. However, the extent of the availability of these services to the Veteran population remains unclear. The purpose of this study was to analyze the rate of Veteran use of VA chiropractic services, both from on-site care at VA facilities and VA purchased care from community care providers. This study analyzed facility characteristics associated with chiropractic use by both care delivery mechanisms (on-site and in the community). METHODS: Cross-sectional analyses of administrative data were conducted for FY 2014-2019. Data were obtained from VA's Corporate Data Warehouse. The variables extracted included number of unique Veterans receiving VA chiropractic care on-site and in the community, total Veteran population of the VA facilities, size of the VA chiropractic workforce (measured as Full-Time Equivalent, FTE), and facility characteristics (geographic region and the facility complexity). Descriptive statistics, mixed model, and multivariant models were used to analyze data. RESULTS: Use of VA chiropractic care increased over the six-year period for both on-site and community care. National average for on-site use of the population was 1.27% in FY14 and 1.48% in FY19. Community care use was 0.29% and 1.76% for the same years. Use at individual facilities varied widely in each FY. Factors such as chiropractor FTE, geographic locations, and the complexity of the VA facility are associated with use of chiropractic services. CONCLUSION: The VA has expanded the non-pharmacologic treatments available to Veterans by providing chiropractic services, yet chiropractic use remains low compared to other US populations. As Veterans have a high prevalence of pain and musculoskeletal conditions, continued work to assess and achieve the optimal levels of chiropractic use in this population is warranted.

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.

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.

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.

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.

Changes in female veterans' neck pain following chiropractic care at a hospital for veterans.

OBJECTIVE: To determine if U.S. female veterans had demonstrable improvements in neck pain after chiropractic management at a Veterans Affairs (VA) hospital. METHODS: This was a retrospective cross-sectional study of medical records from female veterans attending a VA chiropractic clinic for neck pain from 2009 to 2015. Paired t-tests were used to compare baseline and discharge numeric rating scale (NRS) and Neck Bournemouth Questionnaire (NBQ) scores with a minimum clinically important difference (MCID) set at a 30% change from baseline. RESULTS: Thirty-four veterans met the inclusion criteria and received a mean of 8.8 chiropractic treatments. For NRS, the mean score improvement was 2.7 (95%CI, 1.9-3.5, p < .001). For the NBQ, the mean score improvement was 13.7 (95%CI, 9.9-17.5, p < .001). For the MCID, the average percent improvement was 45% for the NRS and 38% for the NBQ. CONCLUSION: Female veterans with neck pain experienced a statistically and clinically significant reduction in NRS and NBQ scores.

Chiropractic Management for US Female Veterans With Low Back Pain: A Retrospective Study of Clinical Outcomes.

OBJECTIVE: The purpose of this study was to determine if female US veterans had clinically significant improvement in low back pain after chiropractic management. METHODS: This is a retrospective chart review of 70 courses of care for female veterans with a chief complaint of low back pain who received chiropractic management through the VA Western New York Healthcare System in Buffalo, New York. A paired t test was used to compare baseline and discharge outcomes for the Back Bournemouth Questionnaire. The minimum clinically important difference was set as a 30% improvement in the outcome measure from baseline to discharge. RESULTS: The average patient was 44.8 years old, overweight (body mass index 29.1 kg/m2), and white (86%). The mean number of chiropractic treatments was 7.9. Statistical significance was found for the Back Bournemouth Questionnaire outcomes. The mean raw score improvement was 12.4 points (P < .001), representing a 27.3% change from baseline with 47% of courses of care meeting or exceeding the minimum clinically important difference. CONCLUSION: For our sample of female veterans with low back pain, clinical outcomes from baseline to discharge improved under chiropractic care. Although further research is warranted, chiropractic care may be of value in contributing to the pain management needs of this unique patient population.