CHIROPRACTIC INTEGRATION INTO PRIVATE SECTOR MEDICAL FACILITIES: A MULTISITE QUALITATIVE CASE STUDY
 
   

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

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org
 
   

FROM:   J Altern Complement Med. 2018 (Jul 17) [Epub] ~ FULL TEXT

Anthony J. Lisi, DC, Stacie A. Salsbury, PhD, RN, Elissa J. Twist, DC, MS, and Christine M. Goertz, DC, PhD,

Pain Research, Informatics, Multi-Comorbidities and Education Center, VA Connecticut Healthcare System , West Haven, CT.


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.

KEYWORDS:   chiropractic; delivery of healthcare; health services research; integrative medicine; interprofessional relations; organizational case studies



From the FULL TEXT Article:

Introduction

Although not delivered on-site at most U.S. medical facilities, chiropractic care is a treatment approach with demonstrated safety and efficacy for managing pain and disability associated with musculoskeletal disorders. [1–3] Components of multimodal chiropractic care (such as spinal manipulation, manual therapies, exercise, and patient education) are recommended as first-line treatments by current low back pain clinical practice guidelines. [4] Of particular relevance to a current important national healthcare initiative, use of chiropractic services has been associated with decreased use of opioid medications in patients with spinal pain conditions. [5–9]

Over the past two decades, the large U.S. public healthcare delivery systems of the Department of Defense and Department of Veterans Affairs have increased delivery of chiropractic services. [10–12] Previous work has demonstrated positive patient and provider perceptions, beneficial outcomes, and expanded use of services in these systems. [13–17] Chiropractic services are also included in U.S. private medical settings ranging from large healthcare systems to smaller care delivery sites. [18–20] However, there is no central coordination or assessment of these programs. Consequently, data are lacking on the optimal means of chiropractic service implementation in private medical facilities.

Improving the quality of chiropractic service delivery in private medical facilities supports the Triple Aim of optimizing the U.S. healthcare system in terms of patient experience, population health, and cost reduction. [21] Previous studies on chiropractic care report high patient satisfaction [22–24]; improved health outcomes in patients with musculoskeletal pain [1–3]; and cost reduction in conservative management of spinal pain conditions. [25, 26] A better understanding of the existing models of chiropractic integration into private sector medical settings is a key precursor to overall quality improvement. Since healthcare systems are highly complex entities, and the inclusion of chiropractic services is subject to much variation, the objective of this study was to describe the delivery of chiropractic services in private sector healthcare facilities using a qualitative case study approach.



Discussion

This work presents a qualitative evaluation of chiropractic clinics at nine U.S. private sector medical facilities. Although inclusion of chiropractic services in medical facilities is a recent phenomenon, current clinical practice guidelines support increased use of interventions central to chiropractic care for common spinal conditions. [4, 32] Thus, chiropractic care likely will be implemented and/or expanded in such facilities.

The chiropractic profession has been described as at the ‘‘crossroads’’ between mainstream and integrative medicine. [33] Although reasonable evidence supports the safety and effectiveness of multimodal chiropractic care, medical physician opinion of chiropractic practice is variable. [34] Despite this, we found chiropractic services were used and valued by the physicians in our study sites. Certain facilities did experience some physician tensions regarding DC implementation — most notably in the early adoption phase — but these were overcome with communication, shared experiences, and relatively little effort in most cases. Study patients also were highly satisfied with chiropractic care, consistent with other published work. [23, 35] Some differences of opinion crossed patients, providers, and administrators regarding the optimal timing, frequency, and duration of chiropractic treatment plans, which is likely a reflection of the generally limited knowledge in the area of chiropractic dosage. [36]

Although our study facilities have not coordinated planning among themselves, it was striking to notice how similar the structures of chiropractic care were at each. All chiropractic clinics saw primarily musculoskeletal and neuromuscular conditions, with a wide range of associated comorbidities. Chiropractors were privileged for a full scope of diagnosis and management consistent with training and licensure, and treatment procedures invariably included manipulation and other manual therapies, patient education/ active care, exercise, and lifestyle counseling. Depending on the specifics of a given patient case, collaboration between DCs and medical providers ranged from virtually no communication to ongoing in-person discussions. The DCs themselves also appeared strikingly similar in that they demonstrated and/or were perceived to have demonstrated exceptional clinical competence, an evidence-based practice approach, altruistic behavior, and collegial interpersonal traits. This cluster of characteristics has been associated with successful chiropractic integration in other settings. [16]

These healthcare facilities implemented chiropractic care under several different business models. While we did not collect quantitative data, it was reported that some chiropractic clinics were profitable, and others broke even or operated at a loss but were perceived to have secondary value, as has been noted in prior studies of conventional medical facilities seeking to establish and finance integrative medicine services. [20, 37, 38] Cost savings by offsetting other healthcare services was reported to be a noteworthy accomplishment at one and a goal of another. Facilities will likely encounter differing incentives when implementing chiropractic services in fee-for-service versus value-based reimbursement models. Future work including formal healthcare economic analyses is needed to better understand the fiscal impacts of implementing chiropractic care in private medical facilities.

Since details of the actual population of chiropractic clinics within private sector medical facilities are unknown, our results are limited to the sample population. While we believe we captured a diverse representation of such clinics, further work is needed to assess this more fully. Using directed content analysis presents some inherent limitations since investigators approach the data with an informed theoretical construct, which can introduce bias. However, we feel this was minimized by our iterative approach to assessing emerging themes, and the participation of all four investigators to various degrees in the site visits, interviews, and data analysis.



Conclusions

We described the implementation of chiropractic services in a sample of nine U.S. private sector medical facilities. Chiropractic clinics were established within existing human resources, physical plant, information technology, and administrative support systems. Chiropractors were integrated in collaborative management of patients with musculoskeletal and co-morbid conditions. Chiropractic service delivery was perceived to have high value among patients, medical providers, and administration, with most facilities expanding their chiropractic workforce to meet increased demand. Patient clinical outcomes, patient satisfaction, provider productivity, and cost offset were identified as markers of clinic success.



References:

  1. Bronfort G, Haas M, Evans R, Leininger B, Triano J.
    Effectiveness of Manual Therapies: The UK Evidence Report
    Chiropractic & Osteopathy 2010 (Feb 25); 18 (1): 3

  2. Clar C, Tsertsvadze A, Court R, Hundt G, Clarke A, Sutcliffe P.
    Clinical Effectiveness Of Manual Therapy For The Management of Musculoskeletal And
    Non-Musculoskeletal Conditions: Systematic Review And Update Of UK Evidence Report

    Chiropractic & Manual Therapies 2014 (Mar 28);   22 (1):  12

  3. Bishop PB, Quon JA, Fisher CG, Dvorak MFS.
    The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) study:
    A Randomized Controlled Trial on the Effectiveness of Clinical Practice
    Guidelines in the Medical and Chiropractic Management of
    Patients with Acute Mechanical Low Back Pain

    Spine J. 2010 (Dec); 10 (12): 1055–1064

  4. Qaseem A, Wilt TJ, McLean RM, Forciea MA.
    Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain:
    A Clinical Practice Guideline From the American College of Physicians

    Ann Intern Med. 2017 (Apr 4); 166 (7): 514–530

  5. Weeks WB, Goertz CM.
    Cross-Sectional Analysis of Per Capita Supply of Doctors of Chiropractic
    and Opioid Use in Younger Medicare Beneficiaries

    J Manipulative Physiol Ther 2016 (May); 39 (4): 263–266

  6. Vogt MT, Kwoh CK, Cope DK, et al.
    Analgesic usage for low back pain: Impact on health care costs and service use.
    Spine 2005;30:1075–1081.

  7. Rhee Y, Taitel MS, Walker DR, Lau DT.
    Narcotic drug use among patients with lower back pain in employer health plans: A retrospective analysis of risk factors and health care services.
    Clin Ther 2007;29(Suppl):2603–2612.

  8. Franklin GM, Rahman EA, Turner JA, et al.
    Opioid use for chronic low back pain: A prospective, population-based study among injured workers in Washington state, 2002–2005.
    Clin J Pain 2009;25:743–751.

  9. Whedon JM, Toler AWJ, Goehl JM, Kazal LA.
    Association Between Utilization of Chiropractic Services for Treatment of Low-Back Pain
    and Use of Prescription Opioids

    J Altern Complement Med. 2018 (Jun);   24 (6):   552–556

  10. Herman PM, Sorbero ME, Sims-Columbia AC.
    Complementary and Alternative Medicine Services in the Military Health System
    J Altern Complement Med. 2017 (Nov); 23 (11): 837–843

  11. Lisi AJ, Goertz C, Lawrence DJ, Satyanarayana P.
    Characteristics of Veterans Health Administration Chiropractors and Chiropractic Clinics
    J Rehabil Res Dev. 2009; 46 (8): 997–1002

  12. Dunn AS, Green BN, Gilford S.
    An Analysis of the Integration of Chiropractic Services Within the United States
    Military and Veterans' Health Care Systems

    J Manipulative Physiol Ther. 2009 (Nov); 32 (9): 749–757

  13. Goertz CM, Long CR, Hondras MA, et al.
    Adding Chiropractic Manipulative Therapy to Standard Medical Care for Patients
    with Acute Low Back Pain: Results of a Pragmatic
    Randomized Comparative Effectiveness Study

    Spine (Phila Pa 1976). 2013 (Apr 15); 38 (8): 627–634

  14. Lisi AJ, Brandt CA.
    Trends in the Use and Characteristics of Chiropractic Services
    in the Department of Veterans Affairs

    J Manipulative Physiol Ther. 2016 (Jun); 39 (5): 381–386

  15. Williams VF, Clark LL, McNellis MG.
    Use of complementary health approaches at military treatment facilities, active component, U.S. Armed Forces, 2010–2015.
    MSMR 2016;23:9–22.

  16. Lisi, AJ, Khorsan, R, Smith, MM, and Mittman, BS.
    Variations in the Implementation and Characteristics of Chiropractic Services in VA
    Medical Care 2014 (Dec);   52 (12 Suppl 5):   S97-104

  17. Fletcher CE, Mitchinson AR, Trumble E, et al.
    Providers’ and administrators’ perceptions of complementary and integrative health practices across the Veterans Health Administration.
    J Altern Complement Med 2016;23:26–34.

  18. Branson, RA.
    Hospital-Based Chiropractic Integration Within a Large Private Hospital System
    in Minnesota: A 10-Year Example

    J Manipulative Physiol Ther. 2009 (Nov); 32 (9): 740–748

  19. Carucci M, Lisi A.
    CAM services provided at select integrative medicine centers: What do their websites tell us?
    Topics Integr Health Care 2010;1:1.1004.

  20. Davis MA, McDevitt L, Alin K.
    Establishing a chiropractic service in a rural primary health care facility.
    J Altern Complement Med 2007;13:697–702.

  21. Berwick DM, Nolan TW, Whittington J.
    The triple aim: Care, health, and cost.
    Health Affairs 2008;27:759–769.

  22. Carey TS, Garrett J, Jackman A, et al.
    The Outcomes and Costs of Care for Acute Low Back Pain Among Patients
    Seen by Primary Care Practitioners, Chiropractors, and Orthopedic Surgeons

    New England J Medicine 1995 (Oct 5); 333 (14): 913–917

  23. Goertz CM, Salsbury SA, Long CR, et al.
    Patient-centered Professional Practice Models for Managing Low Back Pain
    in Older Adults: A Pilot Randomized Controlled Trial

    BMC Geriatr. 2017 (Oct 13); 17 (1): 235

  24. Hertzman-Miller RP, Morgenstern H, Hurwitz EL, et al.
    Comparing the Satisfaction of Low Back Pain Patients Randomized to Receive Medical
    or Chiropractic Care: Results From the UCLA Low-back Pain Study

    Am J Public Health 2002 (Oct); 92 (10): 1628–1633

  25. Kosloff TM, Elton D, Shulman SA, et al.
    Conservative Spine Care: Opportunities to Improve the Quality and Value of Care
    Popul Health Manag. 2013 (Dec); 16 (6): 390–396

  26. Martin BI, Gerkovich MM, Deyo RA, et al.
    The Association of Complementary and Alternative Medicine Use
    Health Care Expenditures for Back and Neck Problems

    Med Care. 2012 (Dec); 50 (12): 1029–1036

  27. Yin RK.
    Case Study Research and Applications: Design and Methods. 6th ed.
    Thousand Oaks, CA: SAGE Publications, 2018.

  28. Salsbury SA, Goertz CM, Twist EJ, Lisi AJ.
    Integration of Doctors of Chiropractic Into Private Sector Health Care Facilities
    in the United States: A Descriptive Survey

    J Manipulative Physiol Ther. 2018 (Feb); 41 (2): 149–155

  29. Christianson JB, Finch MD, Choate CG, Findlay B.
    Consumer-focused strategies of innovative hospitals: The role of complementary therapies.
    Explore (NY) 2007;3: 158–160.

  30. Khorsan R, Cohen AB, Lisi AJ, et al.
    Mixed-Methods Research in a Complex Multisite VA Health Services Study:
    Variations in the Implementation and Characteristics of Chiropractic Services in VA

    Evid Based Complement Alternat Med. 2013 (Dec 31); 701280

  31. Hsieh HF, Shannon SE.
    Three approaches to qualitative content analysis.
    Qual Health Res 2005;15:1277–1288.

  32. Cote P, Wong JJ, Sutton D, et al.
    Management of Neck Pain and Associated Disorders: A Clinical Practice Guideline
    from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

    European Spine Journal 2016 (Jul); 25 (7): 2000–2022

  33. Meeker WC, Haldeman S.
    Chiropractic: A Profession at the Crossroads of Mainstream and Alternative Medicine
    Ann Intern Med 2002 (Feb 5); 136 (3): 216–227

  34. Busse JW, Jacobs C, Ngo T, et al.
    Attitudes toward chiropractic: A survey of North American orthopedic surgeons.
    Spine 2009;34:2818–2825.

  35. Weeks WB, Goertz CM, Meeker WC, Marchiori DM.
    Public Perceptions of Doctors of Chiropractic: Results of a National Survey and Examination
    of Variation According o Respondents' Likelihood to Use Chiropractic, Experience With
    Chiropractic, and Chiropractic Supply in Local Health Care Markets

    J Manipulative Physiol Ther. 2015 (Oct); 38 (8): 533–544

  36. Haas M, Vavrek D, Peterson D, et al.
    Dose-response and Efficacy of Spinal Manipulation for Care of Chronic Low Back Pain:
    A Randomized Controlled Trial

    Spine J. 2014 (Jul 1); 14 (7): 1106–1116

  37. Hunter J, Corcoran K, Phelps K, Leeder S.
    The challenges of establishing an integrative medicine primary care clinic in Sydney, Australia.
    J Altern Complement Med 2012;18: 1008–1013.

  38. Dusek JA, Griffin KH, Finch MD, et al.
    Cost savings from reducing pain through the delivery of integrative medicine program to hospitalized patients.
    J Altern Complement Med 2018;24:557–563.



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