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

This section is compiled by Frank M. Painter, D.C.
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FROM:   J Altern Complement Med. 2018 (Aug); 24 (8): 792–800 ~ 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:


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.


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.


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.


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