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

Patient-reported pain and physical health for acupuncture and chiropractic care delivered by Veterans Affairs versus community providers

BACKGROUND

Acupuncture and chiropractic care are evidence-based pain management alternatives to opioids. The Veterans Health Administration (VA) provides this care in some VA facilities, but also refers patients to community providers. We aimed to determine if patient-reported outcomes differ for acupuncture and chiropractic care from VA versus community providers.

MATERIALS AND METHODS

We conducted an observational study using survey outcome data and electronic medical record utilization data for acupuncture and chiropractic care provided in 18 VA facilities or in community facilities reimbursed by VA. Study participants were users of VA primary care, mental health, pain clinic, complementary and integrative therapies, coaching or education services in 2018-2019. Patients received 1) 4+ acupuncture visits (N = 201) or 4+ chiropractic care visits (N = 178) from a VA or community provider from 60 days prior to baseline to six-months survey and 2) no acupuncture or chiropractic visits from 1 year to 60 days prior to baseline. Outcomes measured included patient-reported pain (PEG) and physical health (PROMIS) at baseline and six-month surveys. Multivariate analyses examined outcomes at six months, adjusting for baseline outcomes and demographics.

RESULTS

In unadjusted analyses, pain and physical health improved for patients receiving community-based acupuncture, while VA-based acupuncture patients experienced no change. Unadjusted analyses also showed improvements in physical health, but not pain, for patients receiving VA-based chiropractic care, with no changes for community-based chiropractic care patients. Using multivariate models, VA-based acupuncture was no different from community-based acupuncture for pain (-0.258, p = 0.172) or physical health (0.539, p = 0.399). Similarly, there were no differences between VA- and community-based chiropractic care in pain (-0.273, p = 0.154) or physical health (0.793, p = 0.191).

CONCLUSIONS

Acupuncture and chiropractic care were associated with modest improvements at six months, with no meaningful differences between VA and community providers. The choice to receive care from VA or community providers could be based on factors other than quality, like cost or convenience.

Assessment of back pain behaviors, attitudes, and beliefs of chiropractic research conference attendees after a biopsychosocial educational workshop

OBJECTIVE

The purpose of this study was to assess the behaviors, attitudes, and beliefs of attendees of a chiropractic research conference (which included chiropractic students, clinicians, researchers, and educators) toward chronic low back pain (CLBP) before and after a biopsychosocial (BPS)-based CLBP educational workshop.

METHODS

This single-arm intervention study used the Health Care Providers' Pain and Relationship Scale (HC-PAIRS) and CLBP-related clinic vignettes to assess behaviors, attitudes, and beliefs toward CLBP before and after a single 90-minute educational workshop. The HC-PAIRS is a self-reporting questionnaire that consists of 15 items rated on a 7-point rating scale, with a higher score suggesting a belief that pain is linked to movement and that recommendations should be given to avoid physical activities.

RESULTS

The pre-education intervention HC-PAIRS and vignettes were completed by 40 of 56 attendees. A total of 18 participants completed the posteducation intervention HC-PAIRS and CLBP-related clinical vignettes. Most of participants identified as full-time clinicians, employees of the United States Department of Veterans Affairs, and musculoskeletal/neuromusculoskeletal providers. The pre-education intervention HC-PAIRS mean score was 44.8 (SD 9.22), and the postscore was 39.5 (SD 6.49).

CONCLUSION

Findings suggest an immediate change in HC-PAIRS scores following a BPS-focused CLBP education intervention for a chiropractic audience. However, due to limitations related to sample size and target population, findings should be interpreted cautiously.

Integrated clinical opportunities for training offered through US doctor of chiropractic programs

OBJECTIVE

The primary objective of this study was to assess, summarize, and compare the current integrated clinical learning opportunities offered for students who matriculated in US doctor of chiropractic programs (DCPs).

METHODS

Two authors independently searched all accredited DCP handbooks and websites for clinical training opportunities within integrated settings. The 2 data sets were compared with any discrepancies resolved through discussion. We extracted data for preceptorships, clerkships, and/or rotations within the Department of Defense, Federally Qualified Health Centers, multi-/inter-/transdisciplinary clinics, private/public hospitals, and the Veterans Health Administration. Following data extraction, officials from each DCP were contacted with a request to verify the collected data.

RESULTS

Of the 17 DCPs reviewed, all but 3 offered at least 1 integrated clinical experience, while 41 integrated clinical opportunities were the most offered by a single DCP. There was an average of 9.8 (median 4.0) opportunities per school and an average of 2.5 (median 2.0) clinical setting types. Over half (56%) of all integrated clinical opportunities were within the Veterans Health Administration, followed by multidisciplinary clinic sites (25%).

CONCLUSION

This work presents preliminary descriptive information of the integrated clinical training opportunities available through DCPs.

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.

Sequential and Comparative Evaluation of Pain Treatment Effectiveness Response (SCEPTER), a pragmatic trial for conservative chronic low back pain treatment

BACKGROUND

Chronic low back pain (cLBP) is a common and highly disabling problem world-wide. Although many treatment options exist, it is unclear how to best sequence the multitude of care options to provide the greatest benefit to patients.

METHODS

The Sequential and Comparative Evaluation of Pain Treatment Effectiveness Response (SCEPTER) trial uses a pragmatic, randomized, stepped design. Enrollment targets 2529 participants from 20 Veterans Affairs (VA) medical centers. Participants with chronic low back pain will first be randomized to one of three options: 1) an internet-based self-management program (Pain EASE); 2) a tailored physical therapy program (Enhanced PT); or 3) continued care with active monitoring (CCAM), a form of usual care. Participants not achieving a 30% or 2-point reduction on the study's primary outcome (Brief Pain Inventory Pain Interference (BPI-PI) subscale), 3 months after beginning treatment may undergo re-randomization in a second step to cognitive behavioral therapy for chronic pain, spinal manipulation therapy, or yoga. Secondary outcomes include pain intensity, back pain-related disability, depression, and others. Participants will be assessed every three months until 12 months after initiating their final trial therapy. Companion economic and implementation analyses are also planned.

RESULTS

The SCEPTER trial is currently recruiting and enrolling participants.

CONCLUSIONS

Trial results will inform treatment decisions for the stepped management of chronic low back pain - a common and disabling condition. Additional analyses will help tailor treatment selection to individual patient characteristics, promote efficient resource use, and identify implementation barriers of interventions.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT04142177.

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.