J Altern Complement Med. 2018 (Aug); 24 (8): 792800 ~ 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 2day 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. 
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.  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. 
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.  Previous work has demonstrated positive
patient and provider perceptions, beneficial outcomes, and
expanded use of services in these systems.  Chiropractic
services are also included in U.S. private medical settings
ranging from large healthcare systems to smaller care delivery
sites.  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.  Previous studies
on chiropractic care report high patient satisfaction ;
improved health outcomes in patients with musculoskeletal
pain ; 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.  Although reasonable evidence supports the safety and effectiveness of multimodal chiropractic care, medical
physician opinion of chiropractic practice is variable. 
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. 
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. 
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
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
Bronfort G, Haas M, Evans R, Leiniger B, Triano J.
Effectiveness of Manual Therapies: The UK Evidence Report
Chiropractic & Osteopathy 2010 (Feb 25); 18 (1): 3
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
Bishop PB, Quon JA, Fisher CG, Dvorak MF.
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
Qaseem A, Wilt TJ, McLean RM, Forciea MA;
Clinical Guidelines Committee of the American College of Physicians.
Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain:
A Clinical Practice Guideline From the American College of Physicians
Annals of Internal Medicine 2017 (Apr 4); 166 (7): 514530
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): 263266
Vogt MT, Kwoh CK, Cope DK, et al.
Analgesic usage for low back pain: Impact on health care costs and service use.
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):26032612.
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, 20022005.
Clin J Pain 2009;25:743751.
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): 552556
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): 837843
Lisi AJ, Goertz C, Lawrence DJ, Satyanarayana P.
Characteristics of Veterans Health Administration Chiropractors and Chiropractic Clinics
J Rehabil Res Dev. 2009; 46 (8): 9971002
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): 749757
Goertz CM, Long CR, Hondras MA, Petri R, Delgado R, Lawrence DJ, 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): 627634
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): 381386
Williams V, Clark L, McNellis M.
Use of Complementary Health Approaches at Military Treatment Facilities, Active Component,
U.S. Armed Forces, 2010-2015
Medical Surveillance Monthly Report (MSMR) 2016 (Jul); 23 (7): 922
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
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;23:2634.
Hospital-Based Chiropractic Integration Within a Large Private Hospital System
in Minnesota: A 10-Year Example
J Manipulative Physiol Ther. 2009 (Nov); 32 (9): 740748
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.
Davis MA, McDevitt L, Alin K.
Establishing a chiropractic service in a rural primary health care facility.
J Altern Complement Med 2007;13:697702.
Berwick DM, Nolan TW, Whittington J.
The triple aim: Care, health, and cost.
Health Affairs 2008;27:759769.
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): 913917
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
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): 16281633
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): 390396
Martin, BI, Gerkovich, MM, Deyo, RA et al.
The Association of Complementary and Alternative Medicine Use and Health Care Expenditures
for Back and Neck Problems
Medical Care 2012 (Dec); 50 (12): 10291036
Case Study Research and Applications: Design and Methods. 6th ed.
Thousand Oaks, CA: SAGE Publications, 2018.
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): 149155
Christianson JB, Finch MD, Choate CG, Findlay B.
Consumer-focused strategies of innovative hospitals: The role of complementary therapies.
Explore (NY) 2007;3: 158160.
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
Hsieh HF, Shannon SE.
Three approaches to qualitative content analysis.
Qual Health Res 2005;15:12771288.
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): 20002022
Meeker, W., & Haldeman, S. (2002).
Chiropractic: A Profession at the Crossroads of Mainstream and Alternative Medicine
Annals of Internal Medicine 2002 (Feb 5); 136 (3): 216227
Busse JW, Jacobs C, Ngo T, et al.
Attitudes toward chiropractic: A survey of North American orthopedic surgeons.
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): 533544
Haas M, Vavrek D, Peterson D, Polissar N, Neradilek MB.
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): 11061116
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: 10081013.
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;24:557563.
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