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Fenton JJ, Fang SY, Ray M, Kennedy J, Padilla K, Amundson R, Elton D, Haldeman S, Lisi AJ, Sico J, Wayne PM, Romano PS. Longitudinal Care Patterns and Utilization Among Patients With New-Onset Neck Pain by Initial Provider Specialty. Spine (Phila Pa 1976) 2023; 48:1409-1418. [PMID: 37526092 DOI: 10.1097/brs.0000000000004781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/05/2023] [Indexed: 08/02/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To compare utilization patterns for patients with new-onset neck pain by initial provider specialty. SUMMARY OF BACKGROUND DATA Initial provider specialty has been associated with distinct care patterns among patients with acute back pain; little is known about care patterns among patients with acute neck pain. METHODS De-identified administrative claims and electronic health record data were derived from the Optum Labs Data Warehouse, which contains longitudinal health information on over 200M enrollees and patients representing a mixture of ages and geographical regions across the United States. Patients had outpatient visits for new-onset neck pain from October 1, 2016 to September 30, 2019, classified by initial provider specialty. Utilization was assessed during a 180-day follow-up period, including subsequent neck pain visits, diagnostic imaging, and therapeutic interventions. RESULTS The cohort included 770,326 patients with new-onset neck pain visits. The most common initial provider specialty was chiropractor (45.2%), followed by primary care (33.4%). Initial provider specialty was strongly associated with the receipt of subsequent neck pain visits with the same provider specialty. Rates and types of diagnostic imaging and therapeutic interventions during follow-up also varied widely by initial provider specialty. While uncommon after initial visits with chiropractors (≤2%), CT, or MRI scans occurred in over 30% of patients with initial visits with emergency physicians, orthopedists, or neurologists. Similarly, 6.8% and 3.4% of patients initially seen by orthopedists received therapeutic injections and major surgery, respectively, compared with 0.4% and 0.1% of patients initially seen by a chiropractor. CONCLUSION Within a large national cohort, chiropractors were the initial provider for a plurality of patients with new-onset neck pain. Compared with patients initially seen by physician providers, patients treated initially by chiropractors or therapists received fewer and less costly imaging services and were less likely to receive invasive therapeutic interventions during follow-up. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Joshua J Fenton
- Department of Family and Community Medicine, University of California, Davis, Sacramento, CA
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA
| | - Shao-You Fang
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA
| | - Monika Ray
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA
- Division of General Internal Medicine, University of California, Davis, Sacramento, CA
| | - John Kennedy
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA
| | - Katrine Padilla
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA
| | | | | | | | | | - Jason Sico
- Yale University, School of Medicine
- Headache Centers of Excellence Program, Veterans Health Administration, New Haven, CT
| | | | - Patrick S Romano
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA
- Division of General Internal Medicine, University of California, Davis, Sacramento, CA
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Graham SE, Coleman BC, Zhao X, Lisi AJ. Evaluating rates of chiropractic use and utilization by patient sex within the United States Veterans Health Administration: a serial cross-sectional analysis. Chiropr Man Therap 2023; 31:29. [PMID: 37563677 PMCID: PMC10416500 DOI: 10.1186/s12998-023-00497-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/03/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Within the United States Veterans Health Administration (VHA), the number of patients using healthcare services has increased over the past several decades. Females make up a small proportion of overall patients within the VHA; however, this proportion is growing rapidly. Previous studies have described rates of VHA chiropractic use; however, no prior study assessed differences in use or utilization rates between male and female veterans. The purpose of this study was to assess rates of use and utilization of chiropractic care by sex among VHA patients receiving care at VHA facilities with on-station chiropractic clinics. METHODS A serial cross-sectional analysis of VHA national electronic health record data was conducted in Fall 2021 for fiscal year (FY) 2005-2021. The cohort population was defined as VHA facilities with on-station chiropractic clinics, and facilities were admitted to the cohort after the first FY with a minimum of 500 on-station chiropractic visits. Variables extracted included counts of unique users of any VHA on-station facility outpatient services, unique users of VHA on-station facility chiropractic services, number of chiropractic visits, and sex. To calculate use, we determined the proportion of patients of each sex who received chiropractic services to the total patients of the same sex receiving any outpatient care within each facility. To calculate utilization, we determined the number of chiropractic care visits per patient per fiscal year. A linear mixed effects model was applied to examine the difference in chiropractic care utilization by sex. RESULTS The percentage of female VHA on-station chiropractic patients increased from 11.7 to 17.7% from FY2005-FY2021. Among VHA facilities with on-station chiropractic care, the percentage of female VHA healthcare users who used chiropractic care (mean = 2.3%) was greater than the percentage of male VHA healthcare users who used chiropractic care (mean = 1.1%). Rates of chiropractic utilization by sex among VHA facilities with on-station chiropractic clinics were slightly higher for females (median = 4.3 visits per year, mean = 4.9) compared to males (median = 4.1 visits per year, mean = 4.6). CONCLUSION We report higher use and utilization of VHA chiropractic care by females compared with males, yet for both sexes rates were lower than in the private US healthcare system. This highlights the need for further assessment of the determinants and outcomes of VHA chiropractic care.
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Affiliation(s)
- Sarah E Graham
- VA Connecticut Healthcare System, West Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Brian C Coleman
- VA Connecticut Healthcare System, West Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Xiwen Zhao
- Yale Center for Analytical Sciences, New Haven, CT, USA
| | - Anthony J Lisi
- VA Connecticut Healthcare System, West Haven, CT, USA.
- Yale School of Medicine, New Haven, CT, USA.
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Coleman BC, Lisi AJ, Abel EA, Runels T, Goulet JL. Association between early nonpharmacological management and follow-up for low back pain in the veterans health administration. N Am Spine Soc J 2023; 14:100233. [PMID: 37440983 PMCID: PMC10333712 DOI: 10.1016/j.xnsj.2023.100233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/23/2023] [Accepted: 05/26/2023] [Indexed: 07/15/2023]
Abstract
Background Low back pain (LBP) is a common reason individuals seek healthcare. Nonpharmacologic management (NPM) is often recommended as a primary intervention, and earlier use of NPM for LBP shows positive clinical outcomes. Our purpose was to evaluate how timing of engagement in NPM for LBP affects downstream LBP visits during the first year. Methods This study was a secondary analysis of an observational cohort study of national electronic health record data. Patients entering the Musculoskeletal Diagnosis/Complementary and Integrative Health Cohort with LBP from October 1, 2016 to September 30, 2017 were included. Exclusive patient groups were defined by engagement in NPM within 30 days of entry ("very early NPM"), between 31 and 90 days ("early NPM"), or not within the first 90 days ("no NPM"). The outcome was time, in days, to the final LBP follow-up after 90 days and within the first year. Cox proportional hazards regression was used to model time to final follow up, controlling for additional demographic and clinical covariables. Results The study population included 44,175 patients, with 16.7% engaging in very early NPM and 13.1% in early NPM. Patients with very early NPM (5.2 visits, SD=4.5) or early NPM (5.7 visits, SD=4.6) had a higher mean number of LBP visits within the first year than those not receiving NPM in the first 90 days (3.2 visits, SD = 2.5). The very early NPM (HR=1.50, 95% CI: 1.46-1.54; median=48 days, IQR=97) and early NPM (HR=1.27, 95% CI: 1.23-1.30; median=88 days, IQR=92) had a significantly shorter time to final follow-up than the no NPM group (median=109 days, IQR=150). Conclusions Veterans Health Administration patients receiving NPM for LBP within the first 90 days after initially seeking care demonstrate a significantly faster time to final follow-up visit within the first year compared to those who do not.
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Affiliation(s)
- Brian C. Coleman
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, United States
- Yale School of Medicine, Yale University, 333 Cedar Street, New Haven, CT 06510, United States
| | - Anthony J. Lisi
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, United States
- Yale School of Medicine, Yale University, 333 Cedar Street, New Haven, CT 06510, United States
| | - Erica A. Abel
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, United States
- Yale School of Medicine, Yale University, 333 Cedar Street, New Haven, CT 06510, United States
| | - Tessa Runels
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, United States
| | - Joseph L. Goulet
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Ave, West Haven, CT 06516, United States
- Yale School of Medicine, Yale University, 333 Cedar Street, New Haven, CT 06510, United States
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C. Coleman B, Finch D, Wang R, L. Luther S, Heapy A, Brandt C, J. Lisi A. Extracting Pain Care Quality Indicators from U.S. Veterans Health Administration Chiropractic Care Using Natural Language Processing. Appl Clin Inform 2023; 14:600-608. [PMID: 37164327 PMCID: PMC10411229 DOI: 10.1055/a-2091-1162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/27/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Musculoskeletal pain is common in the Veterans Health Administration (VHA), and there is growing national use of chiropractic services within the VHA. Rapid expansion requires scalable and autonomous solutions, such as natural language processing (NLP), to monitor care quality. Previous work has defined indicators of pain care quality that represent essential elements of guideline-concordant, comprehensive pain assessment, treatment planning, and reassessment. OBJECTIVE Our purpose was to identify pain care quality indicators and assess patterns across different clinic visit types using NLP on VHA chiropractic clinic documentation. METHODS Notes from ambulatory or in-hospital chiropractic care visits from October 1, 2018 to September 30, 2019 for patients in the Women Veterans Cohort Study were included in the corpus, with visits identified as consultation visits and/or evaluation and management (E&M) visits. Descriptive statistics of pain care quality indicator classes were calculated and compared across visit types. RESULTS There were 11,752 patients who received any chiropractic care during FY2019, with 63,812 notes included in the corpus. Consultation notes had more than twice the total number of annotations per note (87.9) as follow-up visit notes (34.7). The mean number of total classes documented per note across the entire corpus was 9.4 (standard deviation [SD] = 1.5). More total indicator classes were documented during consultation visits with (mean = 14.8, SD = 0.9) or without E&M (mean = 13.9, SD = 1.2) compared to follow-up visits with (mean = 9.1, SD = 1.4) or without E&M (mean = 8.6, SD = 1.5). Co-occurrence of pain care quality indicators describing pain assessment was high. CONCLUSION VHA chiropractors frequently document pain care quality indicators, identifiable using NLP, with variability across different visit types.
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Affiliation(s)
- Brian C. Coleman
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States
- Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, Connecticut, United States
| | - Dezon Finch
- Research Service, James A. Haley Veterans Hospital, Tampa, Florida, United States
| | - Rixin Wang
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States
- Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, Connecticut, United States
| | - Stephen L. Luther
- Research Service, James A. Haley Veterans Hospital, Tampa, Florida, United States
- College of Public Health, University of South Florida, Tampa, Florida, United States
| | - Alicia Heapy
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, Connecticut, United States
| | - Cynthia Brandt
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States
- Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, Connecticut, United States
| | - Anthony J. Lisi
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States
- Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, Connecticut, United States
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Muller RD, Graham SE, Zhao X, Bastian LA, Sites AR, Corcoran KL, Lisi AJ. A Systems Approach for Assessing Low Back Pain Care Quality in Veterans Health Administration Chiropractic Visits: A Cross-Sectional Analysis. J Manipulative Physiol Ther 2023; 46:171-181. [PMID: 38142380 DOI: 10.1016/j.jmpt.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 10/16/2023] [Accepted: 11/07/2023] [Indexed: 12/25/2023]
Abstract
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.
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Affiliation(s)
- Ryan D Muller
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, Yale University, New Haven, Connecticut.
| | - Sarah E Graham
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Xiwen Zhao
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut
| | - Lori A Bastian
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Anna R Sites
- Quality Insights, Inc, Charleston, West Virginia
| | - Kelsey L Corcoran
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Anthony J Lisi
- VA Connecticut Healthcare System, West Haven, Connecticut; Yale School of Medicine, Yale University, New Haven, Connecticut
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Roytman GR, Cheung KH, Bathulapalli H, Goertz CM, Long CR, Lisi AJ. Characteristics of Chiropractic Patients in the Veterans Health Administration During the COVID-19 Pandemic: A Cross-Sectional Analysis. J Manipulative Physiol Ther 2022; 45:615-622. [PMID: 37294219 PMCID: PMC10254439 DOI: 10.1016/j.jmpt.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 03/25/2023] [Accepted: 04/08/2023] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- Gregory R Roytman
- Yale Center for Medical Informatics, Yale University, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut.
| | - Kei-Hoi Cheung
- Yale Center for Medical Informatics, Yale University, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut; Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Harini Bathulapalli
- Yale Center for Medical Informatics, Yale University, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - Christine M Goertz
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Cynthia R Long
- Palmer Center for Chiropractic Research, Davenport, Iowa
| | - Anthony J Lisi
- Yale Center for Medical Informatics, Yale University, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
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Kerns RD, Burgess DJ, Coleman BC, Cook CE, Farrokhi S, Fritz JM, Goertz C, Heapy A, Lisi AJ, Rhon DI, Vining R. Self-Management of Chronic Pain: Psychologically Guided Core Competencies for Providers. Pain Med 2022; 23:1815-1819. [PMID: 35642906 PMCID: PMC9629397 DOI: 10.1093/pm/pnac083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Robert D Kerns
- Department of Psychiatry
- Department of Neurology
- Department of Psychology, Yale University, New Haven, Connecticut
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Diana J Burgess
- VA Health Services Research and Development Service (HSR&D) Center for Care Delivery and Outcomes Research, Minneapolis VA Medical Center, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Brian C Coleman
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale Center for Medical Informatics, Yale School of Medicine, New Haven, Connecticut
| | - Chad E Cook
- Departments of Orthopedics and Population Health Sciences, and the Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Shawn Farrokhi
- Department of Defense–Department of Veterans Affairs (DOD-VA) Extremity Trauma and Amputation Center of Excellence and Naval Medical Center, San Diego, California
| | - Julie M Fritz
- Department of Physical Therapy and Athletic Training, College of Health, The University of Utah, Salt Lake City, Utah
| | - Christine Goertz
- Department of Orthopaedics, Duke University School of Medicine, and Core Faculty Member, Duke-Margolis Center for Health Policy, Durham, North Carolina
| | - Alicia Heapy
- Department of Psychiatry
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Anthony J Lisi
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale Center for Medical Informatics, Yale School of Medicine, New Haven, Connecticut
| | - Daniel I Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
- Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Robert Vining
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa, USA
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Corcoran KL, Peterson DR, Zhao X, Moran EA, Lisi AJ. Characteristics and productivity of the chiropractic workforce of the Veterans Health Administration. Chiropr Man Therap 2022; 30:18. [PMID: 35410303 PMCID: PMC8996387 DOI: 10.1186/s12998-022-00429-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 04/01/2022] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Kelsey L. Corcoran
- grid.281208.10000 0004 0419 3073Pain Research, Informatics, Multimorbidity and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT USA ,grid.47100.320000000419368710Yale Center for Medical Informatics, Yale School of Medicine, 300 George Street, New Haven, CT USA
| | - Douglas R. Peterson
- grid.413721.20000 0004 0419 317XOffice of Productivity, Efficiency and Staffing, VA Central Office, 810 Vermont Ave NW, Washington, DC USA
| | - Xiwen Zhao
- grid.281208.10000 0004 0419 3073Pain Research, Informatics, Multimorbidity and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT USA ,grid.47100.320000000419368710Yale Center for Analytical Sciences, Yale School of Public Health, 300 George Street, New Haven, CT USA
| | - Eileen A. Moran
- grid.413721.20000 0004 0419 317XOffice of Productivity, Efficiency and Staffing, VA Central Office, 810 Vermont Ave NW, Washington, DC USA
| | - Anthony J. Lisi
- grid.281208.10000 0004 0419 3073Pain Research, Informatics, Multimorbidity and Education (PRIME) Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT USA ,grid.47100.320000000419368710Yale Center for Medical Informatics, Yale School of Medicine, 300 George Street, New Haven, CT USA
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Long CR, Salsbury SA, Vining RD, Lisi AJ, Corber L, Twist E, Abrams T, Wallace RB, Goertz CM. Care Outcomes for Chiropractic Outpatient Veterans (COCOV): a single-arm, pragmatic, pilot trial of multimodal chiropractic care for U.S. veterans with chronic low back pain. Pilot Feasibility Stud 2022; 8:54. [PMID: 35256010 PMCID: PMC8900358 DOI: 10.1186/s40814-022-01008-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/18/2022] [Indexed: 08/30/2023] Open
Abstract
Background Over 25% of veterans seeking care at U.S. Veterans Health Administration facilities have chronic low back pain (LBP), with high rates of mental health comorbidities. The primary objective of this study was to assess the feasibility of participant recruitment, retention, and electronic data collection to prepare for the subsequent randomized trial of multimodal chiropractic care for pain management of veterans with chronic low back pain. The secondary objectives were to estimate effect sizes and variability of the primary outcome and choose secondary outcomes for the full-scale trial. Methods This single-arm pilot trial enrolled 40 veterans with chronic LBP at one Veterans Health Administration facility for a 10-week course of pragmatic multimodal chiropractic care. Recruitment was by (1) provider referral, (2) invitational letter from the electronic health record pre-screening, and (3) standard direct recruitment. We administered patient-reported outcome assessments through an email link to REDCap, an electronic data capture platform, at baseline and 5 additional timepoints. Retention was tracked through adherence to the treatment plan and completion rates of outcome assessments. Descriptive statistics were calculated for baseline characteristics and outcome variables. Results We screened 91 veterans over 6 months to enroll our goal of 40 participants. Seventy percent were recruited through provider referrals. Mean age (range) was 53 (22–79) years and 23% were female; 95% had mental health comorbidities. The mean number of chiropractic visits was 4.5 (1–7). Participants adhered to their treatment plan, with exception of 3 who attended only their first visit. All participants completed assessments at the in-person baseline visit and 80% at the week 10 final endpoint. We had no issues administering assessments via REDCap. We observed clinically important improvements on the Roland-Morris Disability Questionnaire [mean change (SD): 3.6 (6.1)] and on PROMIS® pain interference [mean change (SD): 3.6 (5.6)], which will be our primary and key secondary outcome, respectively, for the full-scale trial. Conclusions We demonstrated the feasibility of participant recruitment, retention, and electronic data collection for conducting a pragmatic clinical trial of chiropractic care in a Veterans Health Administration facility. Using the pilot data and lessons learned, we modified and refined a protocol for a full-scale, multisite, pragmatic, National Institutes of Health-funded randomized trial of multimodal chiropractic care for veterans with chronic LBP that began recruitment in February 2021. Trial registration ClinicalTrials.gov NCT03254719 Supplementary Information The online version contains supplementary material available at 10.1186/s40814-022-01008-0.
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10
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Higgins DM, Han L, Kerns RD, Driscoll MA, Heapy AA, Skanderson M, Lisi AJ, Mattocks KM, Brandt C, Haskell SG. Risk factors associated with healthcare utilization for spine pain. Pain Med 2022; 23:1423-1433. [PMID: 34999899 DOI: 10.1093/pm/pnab351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/15/2021] [Accepted: 12/13/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE This study examined potential risk factors associated with healthcare utilization among patients with spine (i.e., neck and back) pain. METHODS A two-stage sampling approach examined spine pain episodes of care among veterans with a yearly outpatient visit for six consecutive years. Descriptive and bivariate statistics, followed by logistic regression analyses, examined baseline characteristics of veterans with new episodes of care who either continued or discontinued spine pain care. A multivariable logistic regression model examined correlates associated with seeking continued spine pain care. RESULTS Among 331,908 veterans without spine pain episodes of care during the two-year baseline observation period, 16.5% (n = 54,852) had a new episode of care during the following two-year observation period. Of those 54,852 veterans, 37,025 had an outpatient visit data during the final two-year follow-up period, with 53.7% (n = 19,865) evidencing continued spine pain care. Those with continued care were more likely to be overweight or obese, non-smokers, Army veterans, have higher education, and had higher rates of diagnoses of all medical and mental health conditions examined at baseline. Among several important findings, women had 13% lower odds of continued care during the final two-year observation period, OR 0.87 (0.81, 0.95). CONCLUSIONS A number of important demographics and clinical correlates were associated with increased likelihood of seeking new and continued episodes of care for spine pain; however, further examination of risk factors associated with healthcare utilization for spine pain is indicated.
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Affiliation(s)
- Diana M Higgins
- VA Boston Healthcare System, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Ling Han
- Yale School of Public Health, New Haven, Connecticut
| | - Robert D Kerns
- Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Mary A Driscoll
- Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Alicia A Heapy
- Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | | | - Anthony J Lisi
- Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Kristin M Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, MA.,University of Massachusetts Medical School, Worcester, MA
| | - Cynthia Brandt
- Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Sally G Haskell
- Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
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11
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Ly VT, Coleman BC, Coulis CM, Lisi AJ. Exploring the application of the Charlson Comorbidity Index to assess the patient population seen in a Veterans Affairs chiropractic residency program. J Chiropr Educ 2021; 35:199-204. [PMID: 33428733 PMCID: PMC8528440 DOI: 10.7899/jce-20-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 01/17/2020] [Accepted: 07/27/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Chiropractic trainees require exposure to a diverse patient base, including patients with multiple medical conditions. The Veterans Affairs (VA) Chiropractic Residency Program aims for its doctor of chiropractic (DC) residents to gain experience managing a range of multimorbid cases, yet to our knowledge there are no published data on the comorbidity characteristics of patients seen by VA DC residents. We tested 2 approaches to obtaining Charlson Comorbidity Index (CCI) scores and compared CCI scores of resident patients with those of staff DCs at 1 VA medical center. METHODS Two processes of data collection to calculate CCI scores were developed. Time differences and agreement between methods were assessed. Comparison of CCI distribution between resident DC and staff DCs was done using 100 Monte Carlo simulation iterations of Fisher's exact test. RESULTS Both methods were able to calculate CCI scores (n = 22). The automated method was faster than the manual (13 vs 78 seconds per patient). CCI scores agreement between methods was good (κ = 0.67). We failed to find a significant difference in the distribution of resident DC and staff DC patients (mean p = .377; 95% CI, .375-.379). CONCLUSION CCI scores of a VA chiropractic resident's patients are measurable with both manual and automated methods, although automated may be preferred for its time efficiency. At the facility studied, the resident and staff DCs did not see patients with significantly different distributions of CCI scores. Applying CCI may give better insight into the characteristics of DC trainee patient populations.
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12
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Halloran SM, Coleman BC, Kawecki T, Long CR, Goertz C, Lisi AJ. Characteristics and Practice Patterns of U.S. Veterans Health Administration Doctors of Chiropractic: A Cross-sectional Survey. J Manipulative Physiol Ther 2021; 44:535-545. [DOI: 10.1016/j.jmpt.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 12/14/2021] [Accepted: 12/17/2021] [Indexed: 12/29/2022]
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13
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Fritz JM, Davis AF, Burgess DJ, Coleman B, Cook C, Farrokhi S, Goertz C, Heapy A, Lisi AJ, McGeary DD, Rhon DI, Taylor SL, Zeliadt S, Kerns RD. Pivoting to virtual delivery for managing chronic pain with nonpharmacological treatments: implications for pragmatic research. Pain 2021; 162:1591-1596. [PMID: 33156148 PMCID: PMC8089114 DOI: 10.1097/j.pain.0000000000002139] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/28/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Julie M Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT, United States
| | - Alison F Davis
- Pain Management Collaboratory, Department of Psychiatry (dept. affiliation for Dr. Davis) Yale University School of Medicine, New Haven, CT, United States
| | - Diana J Burgess
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Medical Center, Minneapolis, MN, United States. Dr. Burgess is now with Department of Medicine (dept. affiliation for Dr. Burgess) University of Minnesota Medical School, Minneapolis, MN, United States
| | - Brian Coleman
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, Pain Management Collaboratory Coordinating Center, Yale School of Medicine, New Haven, CT, United States
| | - Chad Cook
- Doctor of Physical Therapy Division, Duke University School of Medicine, Durham, NC, United States
| | - Shawn Farrokhi
- DoD-VA Extremity and Amputation Center of Excellence, Department of Physical and Occupational Therapy, Naval Medical Center, San Diego, CA, United States
| | - Christine Goertz
- Department of Orthopaedics, Duke University School of Medicine, and Core Faculty Member, Duke-Margolis Center for Health Policy, Durham, NC, United States
| | - Alicia Heapy
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States. Dr. Heapy is now with VA Connecticut Healthcare System Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, Health Services Research and Development Center of Innovation, West Haven/Yale School of Medicine, New Haven, CT, United States
| | - Anthony J Lisi
- Department of Veterans Affairs, and Associate Research Scientist, Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, CT, United States
| | - Donald D McGeary
- Departments of Rehabilitation Medicine and Psychiatry (Dept. affiliation for Dr. McGeary) University of Texas Health, San Antonio, TX, United States
| | - Daniel I Rhon
- Brooke Army Medical Center and Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Stephanie L Taylor
- VA HSR&D, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States. Dr. McGeary is now with Departments of Medicine and Health Policy and Management, UCLA, Los Angeles, CA, United States
| | - Steven Zeliadt
- Veterans Administration Puget Sound Health Care System, Department of Health Services, University of Washington, Seattle, WA, United States
| | - Robert D Kerns
- Departments of Psychiatry, Neurology, and Psychology, Yale University, New Haven, CT, United States. Dr. Kerns is now with VA Connecticut Healthcare System Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, West Haven, CT, United States
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14
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Long CR, Lisi AJ, Vining RD, Wallace RB, Salsbury SA, Shannon ZK, Halloran S, Minkalis AL, Corber L, Shekelle PG, Krebs EE, Abrams TE, Lurie JD, Goertz CM. Veteran Response to Dosage in Chiropractic Therapy (VERDICT): Study Protocol of a Pragmatic Randomized Trial for Chronic Low Back Pain. Pain Med 2021; 21:S37-S44. [PMID: 33313732 DOI: 10.1093/pm/pnaa289] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Low back pain is a leading cause of disability in veterans. Chiropractic care is a well-integrated, nonpharmacological therapy in Veterans Affairs health care facilities, where doctors of chiropractic provide therapeutic interventions focused on the management of low back pain and other musculoskeletal conditions. However, important knowledge gaps remain regarding the effectiveness of chiropractic care in terms of the number and frequency of treatment visits needed for optimal outcomes in veterans with low back pain. DESIGN This pragmatic, parallel-group randomized trial at four Veterans Affairs sites will include 766 veterans with chronic low back pain who are randomly allocated to a course of low-dose (one to five visits) or higher-dose (eight to 12 visits) chiropractic care for 10 weeks (Phase 1). After Phase 1, participants within each treatment arm will again be randomly allocated to receive either monthly chiropractic chronic pain management for 10 months or no scheduled chiropractic visits (Phase 2). Assessments will be collected electronically. The Roland Morris Disability Questionnaire will be the primary outcome for Phase 1 at week 10 and Phase 2 at week 52. SUMMARY This trial will provide evidence to guide the chiropractic dose in an initial course of care and an extended-care approach for veterans with chronic low back pain. Accurate information on the effectiveness of different dosing regimens of chiropractic care can greatly assist health care facilities, including Veterans Affairs, in modeling the number of doctors of chiropractic that will best meet the needs of patients with chronic low back pain.
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Affiliation(s)
| | - Anthony J Lisi
- Yale School of Medicine-Center for Medical Informatics, Yale University, New Haven, Connecticut
| | | | - Robert B Wallace
- The University of Iowa, College of Public Health, Iowa City, Iowa
| | | | | | | | | | | | - Paul G Shekelle
- VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Erin E Krebs
- Minneapolis VA Health Care System, Minneapolis, Minnesota
| | | | - Jon D Lurie
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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15
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Kreiner DS, Matz P, Bono CM, Cho CH, Easa JE, Ghiselli G, Ghogawala Z, Reitman CA, Resnick DK, Watters WC, Annaswamy TM, Baisden J, Bartynski WS, Bess S, Brewer RP, Cassidy RC, Cheng DS, Christie SD, Chutkan NB, Cohen BA, Dagenais S, Enix DE, Dougherty P, Golish SR, Gulur P, Hwang SW, Kilincer C, King JA, Lipson AC, Lisi AJ, Meagher RJ, O'Toole JE, Park P, Pekmezci M, Perry DR, Prasad R, Provenzano DA, Radcliff KE, Rahmathulla G, Reinsel TE, Rich RL, Robbins DS, Rosolowski KA, Sembrano JN, Sharma AK, Stout AA, Taleghani CK, Tauzell RA, Trammell T, Vorobeychik Y, Yahiro AM. Corrigendum to "Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain" [The Spine Journal 20/7 (2020) p 998-1024]. Spine J 2021; 21:726-727. [PMID: 33640275 DOI: 10.1016/j.spinee.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- D Scott Kreiner
- Barrow Neurological Institute, 4530 E. Muirwood Dr. Ste. 110, Phoenix, AZ 85048-7693, USA.
| | - Paul Matz
- Advantage Orthopedics and Neurosurgery, Casper, WY, USA
| | | | - Charles H Cho
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Zoher Ghogawala
- Lahey Hospital and Medical Center, Burlington, MA, USA; Tufts University School of Medicine, Boston, MA, USA
| | | | | | - William C Watters
- Institute of Academic Medicine Houston Methodist Hospital, Houston, TX, USA
| | - Thiru M Annaswamy
- VA North Texas Health Care System, UT Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Shay Bess
- Denver International Spine Center, Denver, CO, USA
| | - Randall P Brewer
- River Cities Interventional Pain Specialists, Shreveport, LA, USA
| | | | - David S Cheng
- University of Southern California, Los Angeles, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Paul Park
- University Of Michigan, Ann Arbor, MI, USA
| | | | | | - Ravi Prasad
- University of California, Davis, Sacramento, CA, USA
| | | | - Kris E Radcliff
- Rothman Institute, Thomas Jefferson University, Egg Harbor Township, NJ, USA
| | | | | | | | | | | | | | | | | | | | - Ryan A Tauzell
- Choice Physical Therapy & Wellness, Christiansburg, VA, USA
| | | | - Yakov Vorobeychik
- Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Amy M Yahiro
- North American Spine Society, Burr Ridge, IL, USA
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16
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Austin-McClellan LE, Lisi AJ. An overview of the medical specialties most relevant to chiropractic practice and education. J Chiropr Educ 2021; 35:72-79. [PMID: 32471312 PMCID: PMC7958654 DOI: 10.7899/jce-18-26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 02/27/2019] [Accepted: 08/26/2019] [Indexed: 06/11/2023]
Abstract
OBJECTIVE The purpose of this article is to present an overview of the key medical and surgical specialties most likely relevant to chiropractic practice in the United States. Understanding the similarities and differences in the training and typical practices of these medical providers may enhance a chiropractor's likelihood to collaborate and increase participation in team-based care. METHODS This was a descriptive analysis to develop preliminary content on US medical physician specialties. Selection was informed by the authors' clinical experience with medical collaboration, along with results of previously published work on medical specialties most commonly reported to be involved in referral patterns with US chiropractors. Data from the Accreditation Council for Graduate Medical Education and individual specialty boards were synthesized through an iterative process, and supplemented by qualitative input from subject matter experts. Data were entered into tabular format for review and analysis. RESULTS We propose that the medical and surgical specialties most relevant to typical US chiropractic practice are internal medicine, family medicine, emergency medicine, physical medicine and rehabilitation, neurology, pain medicine, rheumatology, radiology, orthopedic surgery, and neurological surgery. There is overlap in scope of conditions and diagnostic and therapeutic tools utilized by various medical specialties. CONCLUSION This work describes 8 medical and 2 surgical specialties proposed to be most relevant to general chiropractic practice in the United States. The results may have relevance to interprofessional education and collaboration.
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17
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Corcoran KL, Bastian LA, Gunderson CG, Steffens C, Brackett A, Lisi AJ. Association Between Chiropractic Use and Opioid Receipt Among Patients with Spinal Pain: A Systematic Review and Meta-analysis. Pain Med 2021; 21:e139-e145. [PMID: 31560777 DOI: 10.1093/pm/pnz219] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Kelsey L Corcoran
- Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, Connecticut.,Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Lori A Bastian
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Craig G Gunderson
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Catherine Steffens
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Alexandria Brackett
- Cushing/Whitney Medical Library, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Anthony J Lisi
- Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, Connecticut.,Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
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18
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Coleman BC, Fodeh S, Lisi AJ, Goulet JL, Corcoran KL, Bathulapalli H, Brandt CA. Exploring supervised machine learning approaches to predicting Veterans Health Administration chiropractic service utilization. Chiropr Man Therap 2020; 28:47. [PMID: 32680545 PMCID: PMC7368704 DOI: 10.1186/s12998-020-00335-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 07/02/2020] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Brian C Coleman
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA.
- Yale School of Medicine, Yale University, New Haven, CT, USA.
| | - Samah Fodeh
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Anthony J Lisi
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Kelsey L Corcoran
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Harini Bathulapalli
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Cynthia A Brandt
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, 11-ACSL-G, 950 Campbell Avenue, West Haven, CT, 06516, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
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19
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Kreiner DS, Matz P, Bono CM, Cho CH, Easa JE, Ghiselli G, Ghogawala Z, Reitman CA, Resnick DK, Watters WC, Annaswamy TM, Baisden J, Bartynski WS, Bess S, Brewer RP, Cassidy RC, Cheng DS, Christie SD, Chutkan NB, Cohen BA, Dagenais S, Enix DE, Dougherty P, Golish SR, Gulur P, Hwang SW, Kilincer C, King JA, Lipson AC, Lisi AJ, Meagher RJ, O'Toole JE, Park P, Pekmezci M, Perry DR, Prasad R, Provenzano DA, Radcliff KE, Rahmathulla G, Reinsel TE, Rich RL, Robbins DS, Rosolowski KA, Sembrano JN, Sharma AK, Stout AA, Taleghani CK, Tauzell RA, Trammell T, Vorobeychik Y, Yahiro AM. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain. Spine J 2020; 20:998-1024. [PMID: 32333996 DOI: 10.1016/j.spinee.2020.04.006] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/13/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016. PURPOSE The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition. STUDY DESIGN This is a guideline summary review. METHODS This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors. RESULTS Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature. CONCLUSIONS The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx.
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Affiliation(s)
- D Scott Kreiner
- Barrow Neurological Institute, 4530 E. Muirwood Dr. Ste. 110, Phoenix, AZ 85048-7693, USA.
| | - Paul Matz
- Advantage Orthopedics and Neurosurgery, Casper, WY, USA
| | | | - Charles H Cho
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Zoher Ghogawala
- Lahey Hospital and Medical Center, Burlington, MA, USA; Tufts University School of Medicine, Boston, MA, USA
| | | | | | - William C Watters
- Institute of Academic Medicine Houston Methodist Hospital, Houston, TX, USA
| | - Thiru M Annaswamy
- VA North Texas Health Care System, UT Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Shay Bess
- Denver International Spine Center, Denver, CO, USA
| | - Randall P Brewer
- River Cities Interventional Pain Specialists, Shreveport, LA, USA
| | | | - David S Cheng
- University of Southern California, Los Angeles, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Paul Park
- University Of Michigan, Ann Arbor, MI, USA
| | | | | | - Ravi Prasad
- University of California, Davis, Sacramento, CA, USA
| | | | - Kris E Radcliff
- Rothman Institute, Thomas Jefferson University, Egg Harbor Township, NJ, USA
| | | | | | | | | | | | | | | | | | | | - Ryan A Tauzell
- Choice Physical Therapy & Wellness, Christiansburg, VA, USA
| | | | - Yakov Vorobeychik
- Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Amy M Yahiro
- North American Spine Society, Burr Ridge, IL, USA
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Daniels CJ, Gliedt JA, Suri P, Bednarz EM, Lisi AJ. Management of patients with prior lumbar fusion: a cross-sectional survey of Veterans Affairs chiropractors' attitudes, beliefs, and practices. Chiropr Man Therap 2020; 28:29. [PMID: 32552863 PMCID: PMC7304138 DOI: 10.1186/s12998-020-00322-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 05/12/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Little is known about the preferred treatment strategies of chiropractors in managing low back pain patients with prior lumbar fusions. There are several case reports which describe chiropractic care following surgical intervention, but there are no cohort or experimental studies published. Therefore, we sought to examine self-reported management approaches and practice patterns related to the management of patients with prior surgical lumbar fusion, among United States Veterans Affairs (VA) chiropractors. METHODS An electronic survey was administered nationwide to all chiropractors providing clinical care within VA. Questions were informed by a prior survey and piloted on a sample of chiropractors external to VA. Statistical analysis included respondent background information, and quantitative analysis of chiropractic referral patterns and practices. This survey collect information on 1) provider demographics, 2) VA referral patterns, and 3) attitudes, beliefs, practices and interventions utilized by VA chiropractors to manage patients with a history of surgical lumbar fusion. RESULTS The survey response rate was 46.3% (62/134). The respondents were broadly representative of VA chiropractic providers in age, gender, and years in practice. The majority of respondents (90.3%) reported seeing at least 1 post-fusion patient in the past month. The most common therapeutic approaches utilized by VA chiropractors were healthy lifestyle advice (94.9%), pain education (89.8%), exercise prescription (88.1%), stretching (66.1%) and soft tissue manual therapies (62.7%). A relatively smaller proportion described always or frequently incorporating lumbar (16.9%), thoracic (57.6%) or pelvic (39.0%) spinal manipulation. CONCLUSION This survey provides preliminary data on VA chiropractic services in the management of patients with prior lumbar fusion. These patients are often seen by VA chiropractors, and our findings support the need for further study to advance understanding of interventions utilized by chiropractors in this patient population.
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Affiliation(s)
- Clinton J Daniels
- Rehabilitation Care Services, VA Puget Sound Health Care System, 9600 Veterans Drive, Tacoma, WA, 98493, USA.
| | - Jordan A Gliedt
- Department of Neurosurgery, Medical College of Wisconsin, 9200 W. Wisconsin Ave., Milwaukee, WI, 53226, USA
| | - Pradeep Suri
- Rehabilitation Care Services, VA Puget Sound Health Care System, 9600 Veterans Drive, Tacoma, WA, 98493, USA.,Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA, 98108, USA.,Department of Rehabilitation Medicine, University of Washington, 325 9th Ave, Seattle, WA, 98104, USA
| | - Edward M Bednarz
- Rehabilitation Care Services, VA Puget Sound Health Care System, 9600 Veterans Drive, Tacoma, WA, 98493, USA
| | - Anthony J Lisi
- Chiropractic Service Chief, VA Connecticut Health Care System, 950 Campbell Ave, West Haven, CT, 06516, USA
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Lisi AJ, Salsbury SA, Hawk C, Vining RD, Wallace RB, Branson R, Long CR, Burgo-Black AL, Goertz CM. Chiropractic Integrated Care Pathway for Low Back Pain in Veterans: Results of a Delphi Consensus Process. J Manipulative Physiol Ther 2019; 41:137-148. [PMID: 29482827 PMCID: PMC6103526 DOI: 10.1016/j.jmpt.2017.10.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 10/25/2017] [Accepted: 10/26/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The purpose of this study was to develop an integrated care pathway for doctors of chiropractic, primary care providers, and mental health professionals who manage veterans with low back pain, with or without mental health comorbidity, within Department of Veterans Affairs health care facilities. METHODS The research method used was a consensus process. A multidisciplinary investigative team reviewed clinical guidelines and Veterans Affairs pain and mental health initiatives to develop seed statements and care algorithms to guide chiropractic management and collaborative care of veterans with low back pain. A 5-member advisory committee approved initial recommendations. Veterans Affairs-based panelists (n = 58) evaluated the pathway via e-mail using a modified RAND/UCLA methodology. Consensus was defined as agreement by 80% of panelists. RESULTS The modified Delphi process was conducted in July to December 2016. Most (93%) seed statements achieved consensus during the first round, with all statements reaching consensus after 2 rounds. The final care pathway addressed the topics of informed consent, clinical evaluation including history and examination, screening for red flags, documentation, diagnostic imaging, patient-reported outcomes, adverse event reporting, chiropractic treatment frequency and duration standards, tailored approaches to chiropractic care in veteran populations, and clinical presentation of common mental health conditions. Care algorithms outlined chiropractic case management and interprofessional collaboration and referrals between doctors of chiropractic and primary care and mental health providers. CONCLUSION This study offers an integrative care pathway that includes chiropractic care for veterans with low back pain.
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Affiliation(s)
- Anthony J Lisi
- Physical Medicine and Rehabilitation, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Stacie A Salsbury
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa
| | | | - Robert D Vining
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa
| | - Robert B Wallace
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
| | - Richard Branson
- Department of Physical Medicine and Rehabilitation, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Cynthia R Long
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa
| | | | - Christine M Goertz
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa..
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Rosenthal B, Gravrand H, Lisi AJ. Interprofessional collaboration among complementary and integrative health providers in private practice and community health centers. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.xjep.2019.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Lisi AJ, Scheinowitz M, Saporito R, Onorato A. A Pulsed Electromagnetic Field Therapy Device for Non-Specific Low Back Pain: A Pilot Randomized Controlled Trial. Pain Ther 2019; 8:133-140. [PMID: 30868475 PMCID: PMC6513933 DOI: 10.1007/s40122-019-0119-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Indexed: 12/19/2022] Open
Abstract
Introduction Low back pain (LBP) poses a significant burden of disease worldwide, and identifying safe and effective non-pharmacologic treatment options for LBP is a research priority. The aim of this study was to pilot a clinical trial of a portable pulsed electromagnetic field (PEMF) therapy device for subjects with mixed duration non-specific LBP. Methods This work was a randomized, double-blind, sham-controlled, parallel-group study conducted at a chiropractic school outpatient clinic. The primary end point was functional capacity measured by the Oswestry Disability Index (ODI) at baseline, 6 weeks, and 12 weeks. Analysis was conducted on the intent-to-treat population and as a trend of change in pain scores over time using the Freidman test of repeated measures. Results Forty-two participants were randomized to receive usual care plus PEMF therapy or usual care plus sham, and 25 completed the study. Significant improvements in ODI scores from baseline to week 6 were reported in the experimental group (χ2 = 14.68, p < 0.001, compared with patients in the sham group, χ2 = 4.00, p = 0.135, n.s.). This difference persisted at week-12 follow-up. Adverse events were rare and mild. Conclusion It is feasible to conduct a clinical trial of a PEMF therapy device for non-specific LBP. This work shows that the device was safe and provides preliminary evidence of effectiveness in improving function in patients with non-specific LBP. Trial Registration ClinicalTrials.gov identifier, NCT03053375. Funding Aerotel Ltd.
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Affiliation(s)
- Anthony J Lisi
- School of Chiropractic, University of Bridgeport, Bridgeport, CT, USA.
| | - Mickey Scheinowitz
- Aerotel, Ltd, Tel Aviv, Israel.,Sylvan Adams Sports Institute, Tel Aviv University, Tel Aviv, Israel
| | - Richard Saporito
- School of Chiropractic, University of Bridgeport, Bridgeport, CT, USA
| | - Anthony Onorato
- School of Chiropractic, University of Bridgeport, Bridgeport, CT, USA
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24
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Lisi AJ, Corcoran KL, DeRycke EC, Bastian LA, Becker WC, Edmond SN, Goertz CM, Goulet JL, Haskell SG, Higgins DM, Kawecki T, Kerns RD, Mattocks K, Ramsey C, Ruser CB, Brandt CA. Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care. Pain Medicine 2018; 19:S54-S60. [PMID: 30203014 DOI: 10.1093/pm/pny114] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Anthony J Lisi
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Kelsey L Corcoran
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Eric C DeRycke
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Lori A Bastian
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - William C Becker
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Sara N Edmond
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | | | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Sally G Haskell
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Diana M Higgins
- VA Boston Healthcare System, Boston, Massachusetts
- School of Medicine, Boston University, Boston, Massachusetts
| | - Todd Kawecki
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Robert D Kerns
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Kristin Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Christine Ramsey
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Christopher B Ruser
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Cynthia A Brandt
- Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, Yale University, New Haven, Connecticut
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25
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Lisi AJ, Salsbury SA, Twist EJ, Goertz CM. Chiropractic Integration into Private Sector Medical Facilities: A Multisite Qualitative Case Study. J Altern Complement Med 2018; 24:792-800. [PMID: 30016118 DOI: 10.1089/acm.2018.0218] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Anthony J Lisi
- 1 Pain Research, Informatics, Multi-Comorbidities and Education Center, VA Connecticut Healthcare System , West Haven, CT.,2 Yale Center for Medical Informatics, Yale School of Medicine , Yale University, New Haven, CT
| | - Stacie A Salsbury
- 3 Palmer Center for Chiropractic Research, Palmer College of Chiropractic , Davenport, IA
| | - Elissa J Twist
- 3 Palmer Center for Chiropractic Research, Palmer College of Chiropractic , Davenport, IA
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Lisi AJ, Brandt CA. Trends in the Use and Characteristics of Chiropractic Services in the Department of Veterans Affairs. J Manipulative Physiol Ther 2018; 39:381-386. [PMID: 27288324 DOI: 10.1016/j.jmpt.2016.04.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 04/06/2016] [Accepted: 04/07/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The purpose of this study was to analyze national trends and key features of the Department of Veterans Affairs' (VA's) chiropractic service delivery and chiropractic provider workforce since their initial inception. METHODS This was a serial cross-sectional analysis of the VA administrative data sampled from the first record of chiropractic services in VA through September 30, 2015. Data were obtained from VA's Corporate Data Warehouse and analyzed with descriptive statistics. RESULTS From October 1, 2004, through September 30, 2015, the annual number of patients seen in VA chiropractic clinics increased from 4052 to 37349 (821.7%), and the annual number of chiropractic visits increased from 20072 to 159366 (693.9%). The typical VA chiropractic patient is male, is between the ages of 45 and 64, is seen for low back and/or neck conditions, and receives chiropractic spinal manipulation and evaluation and management services. The total number of VA chiropractic clinics grew from 27 to 65 (9.4% annually), and the number of chiropractor employees grew from 13 to 86 (21.3% annually). The typical VA chiropractor employee is a 45.9-year-old man, has worked in VA for 4.5 years, and receives annual compensation of $97860. VA also purchased care from private sector chiropractors starting in 2000, growing to 159533 chiropractic visits for 19435 patients at a cost of $11155654 annually. CONCLUSIONS Use of chiropractic services and the chiropractic workforce in VA have grown substantially over more than a decade since their introduction.
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Affiliation(s)
- Anthony J Lisi
- Chiropractic Section Chief, VA Connecticut Healthcare System, West Haven, CT; Assistant Clinical Professor, Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, CT.
| | - Cynthia A Brandt
- Staff Physician, VA Connecticut Healthcare System, West Haven, CT; Professor, Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, CT
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27
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Bronston LJ, Austin-McClellan LE, Lisi AJ, Donovan KC, Engle WW. A Survey of American Chiropractic Association Members' Experiences, Attitudes, and Perceptions of Practice in Integrated Health Care Settings. J Chiropr Med 2015; 14:227-39. [PMID: 26793034 DOI: 10.1016/j.jcm.2015.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 06/17/2015] [Accepted: 06/18/2015] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The purpose of this study is to examine the self-report of experiences, attitudes, and perceived educational needs of American Chiropractic Association members regarding practice in integrated health care settings. METHODS This was a descriptive observational study of the American Chiropractic Association members. Participants completed an electronic survey reporting their current participation and interest in chiropractic integrated practice. RESULTS The survey was completed in 2011 by 1142 respondents, for a response rate of 11.8%. The majority of respondents (82.9%) did not currently practice in an integrated setting, whereas 17.1% did. Those practicing in various integrated medical settings reported delivering a range of diagnostic, therapeutic, and case management services. Participation in administrative and scholarly activities was less common. Respondents not practicing in integrated settings reported being interested in delivering a very similar array of clinical services. Doctors of chiropractic practicing in hospital or outpatient medical facilities reported frequent engagement in interprofessional collaboration. Both nonintegrated and integrated respondents reported very similar educational interests on a range of clinical topics. CONCLUSION The findings of this survey provide insight into the experiences, participation, and interests in integrated clinical practice for members of the American Chiropractic Association.
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Affiliation(s)
| | - Lauren E Austin-McClellan
- Adjunct Assistant Professor of Clinical Services, University of Bridgeport College of Chiropractic, Bridgeport, CT; Staff Chiropractor, VA Connecticut Healthcare System, West Haven, CT
| | - Anthony J Lisi
- Chiropractor, Aquidneck Chiropractic, Middletown, RI; Chiropractor, Engle Chiropractic Center, Denver, PA
| | - Kevin C Donovan
- Associate Professor of Clinical Sciences, University of Bridgeport College of Chiropractic, Bridgeport, CT
| | - Walter W Engle
- Chiropractic Section Chief, VA Connecticut Healthcare System, West Haven, CT
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Lisi AJ, Breuer P, Gallagher RM, Rodriguez E, Rossi MI, Schmader K, Scholten JD, Weiner DK. Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part II: Myofascial Pain. Pain Med 2015; 16:1282-9. [DOI: 10.1111/pme.12821] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 04/22/2015] [Accepted: 05/02/2015] [Indexed: 02/02/2023]
Affiliation(s)
- Anthony J. Lisi
- VA Connecticut Healthcare System
- Rehabilitation and Prosthetics Services; Veterans Health Administration
- University of Bridgeport College of Chiropractic
| | - Paula Breuer
- University of Pittsburgh Medical Center Centers for Rehab Services
| | - Rollin M. Gallagher
- Departments of Psychiatry
- Department of Anesthesiology; University of Pennsylvania
- Pain Service; Philadelphia VA Medical Center
| | - Eric Rodriguez
- Division of Geriatric Medicine; Department of Medicine; University of Pittsburgh School of Medicine
| | - Michelle I. Rossi
- Division of Geriatric Medicine; Department of Medicine; University of Pittsburgh School of Medicine
- Geriatric Research, Education & Clinical Center (GRECC), VA Pittsburgh Healthcare System
| | - Kenneth Schmader
- Durham VA Medical Center; GRECC
- Department of Medicine; Duke University Medical Center, Division of Geriatrics
| | - Joel D. Scholten
- Washington DC VA Medical Center
- Rehabilitation and Prosthetics Services; Veterans Health Administration
| | - Debra K. Weiner
- Division of Geriatric Medicine; Department of Medicine; University of Pittsburgh School of Medicine
- Geriatric Research, Education & Clinical Center (GRECC), VA Pittsburgh Healthcare System
- Department of Psychiatry
- Anesthesiology
- Clinical and Translational Science Institute, University of Pittsburgh; Pittsburgh PA
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Bednarz EM, Lisi AJ. A survey of interprofessional education in chiropractic continuing education in the United States. J Chiropr Educ 2014; 28:152-6. [PMID: 24918483 PMCID: PMC4211588 DOI: 10.7899/jce-13-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Objective : The purpose of this study is to describe the state of chiropractic continuing education vis-à-vis interprofessional education (IPE) with medical doctors (MD) in a survey of a sample of US doctors of chiropractic (DC) and through a review of policies. Methods : Forty-five chiropractors with experience in interprofessional settings completed an electronic survey of their experiences and perceptions regarding DC-MD IPE in chiropractic continuing education (CE). The licensing bodies of the 50 US states and the District of Columbia were queried to assess the applicability of continuing medical education (CME) to chiropractic relicensure. Results : The majority (89.1%) of survey respondents who attend CE-only events reported that they rarely to never experienced MD-IPE at these activities. Survey respondents commonly attended CME-only events, and 84.5% stated that they commonly to very commonly experienced MD-IPE at these activities. More than half (26 of 51) of the licensing bodies did not provide sufficient information to determine if CME was applicable to DC relicensure. Thirteen jurisdictions (25.5%) do not, and 12 jurisdictions (23.5%) do accept CME credits for chiropractic relicensure. Conclusion : The majority of integrated practice DCs we surveyed reported little to no IPE occurring at CE-only events, yet significant IPE occurring at CME events. However, we found only 23.5% of chiropractic licensing bodies allow CME credit to apply to chiropractic relicensure. These factors may hinder DC-MD IPE in continuing education.
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Coulis CM, Lisi AJ. Chiropractic management of postoperative spine pain: a report of 3 cases. J Chiropr Med 2014; 12:168-75. [PMID: 24396317 DOI: 10.1016/j.jcm.2013.10.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 08/20/2013] [Accepted: 08/21/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The purpose of this case series is to describe chiropractic care including spinal manipulation for 3 patients with postsurgical spine pain. CLINICAL FEATURES Three patients with postsurgical spine pain (1 cervical fusion, 1 lumbar discectomy, and 1 lumbar laminectomy) presented for chiropractic treatment at a major US medical center. Treatment included spinal manipulation and/or flexion-distraction mobilization based on patient response to joint loading strategies. INTERVENTION AND OUTCOMES Two patients were treated with high-velocity, low-amplitude spinal manipulation; and 1 patient was treated with flexion-distraction mobilization. Treatment frequency and duration were 4 treatments over 4 weeks for case 1, 17 treatments over 7 years for case 2, and 5 treatments over 5 weeks for case 3. Subjective improvement was noted using numeric pain scores and functional changes; and upon completion, the patients reported being "satisfied" with their overall outcome. One episode of transient benign soreness was noted by 1 patient. No additional adverse events or effects were noted. CONCLUSION In these 3 cases, patients with postsurgical spine pain responded positively to chiropractic care. Spinal manipulation/mobilization was tolerated without significant adverse effects.
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Affiliation(s)
- Christopher M Coulis
- Staff Chiropractor, VA Connecticut Healthcare System, West Haven, CT ; Adjunct Assistant Professor, University of Bridgeport College of Chiropractic, Bridgeport, CT
| | - Anthony J Lisi
- Chief, Chiropractic Service, VA Connecticut Healthcare System, West Haven, CT ; Associate Professor, University of Bridgeport College of Chiropractic, Bridgeport, CT
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Kreiner DS, Hwang SW, Easa JE, Resnick DK, Baisden JL, Bess S, Cho CH, DePalma MJ, Dougherty P, Fernand R, Ghiselli G, Hanna AS, Lamer T, Lisi AJ, Mazanec DJ, Meagher RJ, Nucci RC, Patel RD, Sembrano JN, Sharma AK, Summers JT, Taleghani CK, Tontz WL, Toton JF. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J 2014; 14:180-91. [PMID: 24239490 DOI: 10.1016/j.spinee.2013.08.003] [Citation(s) in RCA: 322] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 08/14/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The objective of the North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of lumbar disc herniation with radiculopathy. The guideline is intended to reflect contemporary treatment concepts for symptomatic lumbar disc herniation with radiculopathy as reflected in the highest quality clinical literature available on this subject as of July 2011. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder. PURPOSE To provide an evidence-based educational tool to assist spine specialists in the diagnosis and treatment of lumbar disc herniation with radiculopathy. STUDY DESIGN Systematic review and evidence-based clinical guideline. METHODS This guideline is a product of the Lumbar Disc Herniation with Radiculopathy Work Group of NASS' Evidence-Based Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. A literature search addressing each question and using a specific search protocol was performed on English-language references found in Medline, Embase (Drugs and Pharmacology), and four additional evidence-based databases to identify articles. The relevant literature was then independently rated using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were developed via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Level I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline. RESULTS Twenty-nine clinical questions were formulated and addressed, and the answers are summarized in this article. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence. CONCLUSIONS The clinical guideline has been created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with symptomatic lumbar disc herniation with radiculopathy. The entire guideline document, including the evidentiary tables, suggestions for future research, and all the references, is available electronically on the NASS Web site at http://www.spine.org/Pages/PracticePolicy/ClinicalCare/ClinicalGuidlines/Default.aspx and will remain updated on a timely schedule.
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Affiliation(s)
- D Scott Kreiner
- Ahwatukee Sports and Spine, 4530 E. Muirwood Dr, Suite 110, Phoenix, AZ 85048-7693, USA.
| | - Steven W Hwang
- Department of Neurosurgery, Tufts Medical Center, 800 Washington St, Boston, MA 02111-1552, USA
| | - John E Easa
- The College of Human Medicine, Michigan State University, 12662 Riley St, Suite 120, Holland, MI 49424-8023, USA
| | - Daniel K Resnick
- Department Neurosurgery, University of Wisconsin Medical School, K4/834 Clinical Science Center, 600 Highland, Madison, WI 53792-0001, USA
| | - Jamie L Baisden
- Department of Neurosurgery, Medical College of Wisconsin, 9200 W. Wisconsin Ave., Milwaukee, WI 53226-3522, USA
| | - Shay Bess
- Rocky Mountain Scoliosis and Spine, 2055 High St, Suite 130, Denver, CO 80205-5504, USA
| | - Charles H Cho
- Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115-6110, USA
| | | | | | | | - Gary Ghiselli
- Denver Spine, 7800 E. Orchard Rd, Suite 100, Greenwood Village, CO 80111-2584, USA
| | | | - Tim Lamer
- Mayo Clinic Rochester, 200 1st St SW, Eisenberg 8G, Rochester, MN 55905-0001, USA
| | - Anthony J Lisi
- VACT Healthcare System, 950 Campbell Ave., Bldg 2, Floor 4, West Haven, CT 06516-2770, USA
| | - Daniel J Mazanec
- Cleveland Clinic Spine Institute, 9500 Euclid Ave., C21, Cleveland, OH 44195-0001, USA
| | | | | | - Rakesh D Patel
- University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5000, USA
| | - Jonathan N Sembrano
- University of Minnesota, 2450 Riverside Ave. S., Suite R200, Minneapolis, MN 55454-1450, USA
| | - Anil K Sharma
- Spine and Pain Medicine, 2 Mockingbird Drive, Colts Neck, NJ 07722-2228, USA
| | - Jeffrey T Summers
- NewSouth NeuroSpine, 2470 Flowood Drive, Flowood, MS 39232-9019, USA
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Lisi AJ, Goertz C, Lawrence DJ, Satyanarayana P. Characteristics of Veterans Health Administration chiropractors and chiropractic clinics. ACTA ACUST UNITED AC 2010; 46:997-1002. [PMID: 20157856 DOI: 10.1682/jrrd.2009.01.0002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Chiropractic services have been delivered on station at select Veterans Health Administration (VHA) medical facilities since late 2004. No published data describing the characteristics of VHA chiropractic physicians (chiropractors) and chiropractic clinics exist at a national level. This study was designed to examine elements of the structures of chiropractic services in VHA settings. Web-based survey methods were used to question all chiropractors in VHA facilities (N = 36). Data were obtained from 33 providers, yielding a 91.6% response rate. Most respondents were full-time VHA employees, while others were part-time employees or contractors. Differences were found in prior training, integrated practice, and academic or research experience. Of the respondents, 88% ranked low back pain as the most common patient complaint seen in practice and 79% ranked cervical pain the second most common complaint. Of the new patient consultations, 67.6% originated from primary care, 9.4% from pain management, and 6.2% from physiatry. Most respondents were similar in their reported use of diagnostic and therapeutic procedures, but their reported rates of participation in various facility activities were different. Further work is needed for researchers and policy makers to more fully understand the integration and delivery of chiropractic services in VHA settings.
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Affiliation(s)
- Anthony J Lisi
- Veterans Health Administration, Office of Rehabilitation Services, Washington, DC, USA.
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Lisi AJ. Management of Operation Iraqi Freedom and Operation Enduring Freedom veterans in a Veterans Health Administration chiropractic clinic: A case series. ACTA ACUST UNITED AC 2010; 47:1-6. [DOI: 10.1682/jrrd.2009.07.0095] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Funk MF, Lisi AJ. Conflict of interest policies among institutions and organizations offering chiropractic continuing education. J Manipulative Physiol Ther 2009; 32:303-8. [PMID: 19447267 DOI: 10.1016/j.jmpt.2009.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Revised: 01/07/2009] [Accepted: 01/21/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The purpose of this study is to document and describe the policies governing conflict of interest (COI) among select organizations and institutions offering chiropractic continuing education. METHODS Surveys were sent to the following: all North American chiropractic colleges; major national chiropractic organizations; and state chiropractic organizations in states with more than 3500 licensed Doctors of Chiropractic. Each organization or institution was surveyed regarding written and verbal COI policies. RESULTS Half of the respondents in this survey indicated that they had written policies for management of COI, whereas half did not. None included most of the common elements typically outlined in continuing medical education COI policies. Content varied among the policies available for review. Relevant financial interest is the issue most often defined, and respondents generally prohibit presenters from selling products or services directly during presentations. CONCLUSIONS Overall, these results suggest that processes for managing COI in chiropractic CE are less robust than those previously described for continuing medical education. This study provides preliminary insight into the status of COI management in chiropractic CE.
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Affiliation(s)
- Matthew F Funk
- Assistant Professor of Clinical Services, University of Bridgeport College of Chiropractic, Bridgeport, CT 06604, USA.
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Green BN, Johnson CD, Lisi AJ, Tucker J. Chiropractic practice in military and veterans health care: The state of the literature. J Can Chiropr Assoc 2009; 53:194-204. [PMID: 19714234 PMCID: PMC2732257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To summarize scholarly literature that describes practice, utilization, and/or policy of chiropractic services within international active duty and/or veteran health care environments. DATA SOURCES PubMed, the Cumulative Index to Nursing and Allied Health Literature, and the Index to Chiropractic Literature were searched from their starting dates through June 2009. REVIEW METHODS All authors independently reviewed each of the articles to verify that each met the inclusion criteria. Citations of included papers and other pertinent findings were logged in a summary table. RESULTS Thirteen articles were included in this study. Integration of chiropractic care into military or veteran health care systems has been described in 3 systems: the United States Department of Defense, the United States Department of Veterans Affairs, and the Canadian Forces. CONCLUSION Chiropractic services seem to be included successfully within military and veteran health care facilities. However, there is a great need for additional written evaluation of the processes, policies, practices, and effectiveness of chiropractic services in these environments.
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Affiliation(s)
- Bart N Green
- Chiropractic Division, Department of Physical and Occupational Therapy, Naval Medical Center San Diego, MCAS Miramar Branch Medical Clinic, PO Box 452002, San Diego, CA 92145-2002.
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Lisi AJ. Managing conflicts of interest in continuing medical education: a comparison of policies. J Chiropr Educ 2009; 23:36-39. [PMID: 19390681 PMCID: PMC2670233 DOI: 10.7899/1042-5055-23.1.36] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Revised: 07/07/2008] [Accepted: 08/12/2008] [Indexed: 05/27/2023]
Abstract
BACKGROUND Altruism is a central underpinning of professional behavior; however physicians may face instances in which their secondary (financial) interest is in competition with their primary (patient health, research integrity, professional education) interests. Most medical institutions have developed policies to manage conflicts of interest, but chiropractic institutions, organizations and providers may not be well-acquainted with such policies. PURPOSE To compare the policies of the Department of Veterans Affairs (VA) and the North American Spine Society (NASS) regarding management of conflicts of interest in continuing medical education (CME). METHODS A qualitative review of published policies of the VA and NASS was performed. The policies of each organization were retrieved and reviewed, and data were entered into a spreadsheet for comparison. Content experts at each organization were contacted to provide additional information. RESULTS The VA and NASS provide explicit, similar policies to manage conflicts of interest in CME. Proposed speakers are required to disclose the nature and value of financial relationships relevant to content of their planned talk/presentation. Procedures for committee review, mitigation of conflict, or prohibiting the participation of a given speaker have been described. Disclosure must be made to the attendees of an educational activity in printed materials and at the time of presentation. CONCLUSION The VA and NASS appear similar in their policies to manage conflicts of interest in CME. The policies of the VA and NASS may provide examples for the chiropractic profession to consider in relation to chiropractic continuing education.
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Affiliation(s)
- Anthony J. Lisi
- Address correspondence to: Anthony J. Lisi, D.C., Associate Professor of Clinical Sciences, University of Bridgeport College of Chiropractic, Staff Chiropractor, VA Connecticut Healthcare System, 950 Campbell Avenue, Building 2, Floor 4, West Haven, CT 06516,
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Johnson C, Baird R, Dougherty PE, Globe G, Green BN, Haneline M, Hawk C, Injeyan HS, Killinger L, Kopansky-Giles D, Lisi AJ, Mior SA, Smith M. Chiropractic and Public Health: Current State and Future Vision. J Manipulative Physiol Ther 2008; 31:397-410. [DOI: 10.1016/j.jmpt.2008.07.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW. Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research. J Altern Complement Med 2007; 13:491-512. [PMID: 17604553 DOI: 10.1089/acm.2007.7088] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES (1) To evaluate the evidence on the effect of chiropractic care, rather than spinal manipulation only, on patients with nonmusculoskeletal conditions; and (2) to identify shortcomings in the evidence base on this topic, from a Whole Systems Research perspective. DESIGN Systematic review. METHODS Databases included were PubMed, Ovid, Mantis, Index to Chiropractic Literature, and CINAHL. Search restrictions were human subjects, peer-reviewed journal, English language, and publication before May 2005. All randomized controlled trials (RCTs) were evaluated using the Scottish Intercollegiate Guidelines Network (SIGN) and Jadad checklists; a checklist developed from the CONSORT (Consolidated Standards of Reporting Trials) guidelines; and one developed by the authors to evaluate studies in terms of Whole Systems Research (WSR) considerations. RESULTS The search yielded 179 papers addressing 50 different nonmusculoskeletal conditions. There were 122 case reports or case series, 47 experimental designs, including 14 RCTs, 9 systematic reviews, and 1 a large cohort study. The 14 RCTs addressed 10 conditions. Six RCTs were rated "high" on the 3 conventional checklists; one of these 6 was rated "high" in terms of WSR considerations. CONCLUSIONS (1) Adverse effects should be routinely reported. For the few studies that did report, adverse effects of spinal manipulation for all ages and conditions were rare, transient, and not severe. (2) Evidence from controlled studies and usual practice supports chiropractic care (the entire clinical encounter) as providing benefit to patients with asthma, cervicogenic vertigo, and infantile colic. Evidence was promising for potential benefit of manual procedures for children with otitis media and elderly patients with pneumonia. (3) The RCT design is not necessarily incompatible with WSR. RCTs could improve generalizability by basing protocols on usual practice. (4) Case reports could contribute more to WSR by increasing their emphasis on patient characteristics and patient-based outcomes. (5) Chiropractic investigators, practitioners, and funding agencies should increase their attention to observational designs.
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Affiliation(s)
- Cheryl Hawk
- Cleveland Chiropractic College, Kansas City, Missouri 64131, USA.
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Lisi AJ. Chiropractic Management of Cow's Milk Protein Intolerance in Infants With Sleep Dysfunction Syndrome: A Therapeutic Trial. J Manipulative Physiol Ther 2007; 30:247. [PMID: 17416280 DOI: 10.1016/j.jmpt.2007.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Indexed: 11/26/2022]
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Lisi AJ, O'Neill CW, Lindsey DP, Cooperstein R, Cooperstein E, Zucherman JF. Measurement of in vivo lumbar intervertebral disc pressure during spinal manipulation: a feasibility study. J Appl Biomech 2007; 22:234-9. [PMID: 17215555 DOI: 10.1123/jab.22.3.234] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This paper presents the first reported measurements of lumbar intervertebral disc pressure in vivo during spinal manipulation. A pressure transducer was inserted into the nucleus pulposus of one normal-appearing lumbar disc in an asymptomatic adult volunteer. Pressures were recorded during several body positions and maneuvers, then during spinal manipulation, and lastly during a repetition of the preintervention body positions. Baseline pressures in the prone and side-lying positions measured 110 kPa and 150 kPa, respectively. During the manipulation, pressure rose to a peak of 890 kPa over 250 ms. Immediately following, pressures in the prone and side-lying positions measured 150 kPa and 165 kPa, respectively. These data do not support the hypotheses that manipulation can reduce a herniation by decreasing intradiscal pressure, or cause a herniation by raising pressure to failure levels. Further work may lead to a better understanding of this treatment method.
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Affiliation(s)
- Anthony J Lisi
- Palmer Center for Chiropractic Research, Davenport, IA, USA
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Abstract
Low back pain is a common complaint in pregnancy, with a reported prevalence of 57% to 69% and incidence of 61%. Although such pain can result in significant disability, it has been shown that as few as 32% of women report symptoms to their prenatal provider, and only 25% of providers recommend treatment. Chiropractors sometimes manage low back pain in pregnant women; however, scarce data exist regarding such treatment. This retrospective case series was undertaken to describe the results of a group of pregnant women with low back pain who underwent chiropractic treatment including spinal manipulation. Seventeen cases met all inclusion criteria. The overall group average Numerical Rating Scale pain score decreased from 5.9 (range 2-10) at initial presentation to 1.5 (range 0-5) at termination of care. Sixteen of 17 (94.1%) cases demonstrated clinically important improvement. The average time to initial clinically important pain relief was 4.5 (range 0-13) days after initial presentation, and the average number of visits undergone up to that point was 1.8 (range 1-5). No adverse effects were reported in any of the 17 cases. The results suggest that chiropractic treatment was safe in these cases and support the hypothesis that it may be effective for reducing pain intensity.
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Lisi AJ, Holmes EJ, Ammendolia C. High-Velocity Low-Amplitude Spinal Manipulation for Symptomatic Lumbar Disk Disease: A Systematic Review of the Literature. J Manipulative Physiol Ther 2005; 28:429-42. [PMID: 16096043 DOI: 10.1016/j.jmpt.2005.06.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2004] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The aim of the study was to review the evidence for high-velocity low-amplitude spinal manipulation (HVLASM) for symptomatic lumbar disk disease (SLDD). METHODS A systematic review of the literature was performed. The Cochrane Central Register of Controlled Trials, Medline, Cumulative Index to Nursing and Allied Health Literature, and Mantis were searched. Evidence-based operational definitions of SLDD, HVLASM, and outcomes measures were established. Articles were assessed using these inclusion criteria: (1) published in English, (2) measured at least one outcome in subjects with SLDD undergoing HVLASM, (3) descriptions were sufficiently clear to meet all 3 categories of our operational definitions. Articles that met the inclusion criteria were assessed by 2 independent reviewers and assigned quality ratings based on previously published guidelines. RESULTS Sixteen studies met the inclusion criteria, representing 203 total subjects. Of these, 172 subjects received HVLASM as active treatment, and 31 received other treatments as comparison subjects. Improvements in patient-based and physiological outcomes were reported among subjects receiving HVLASM; however, no conclusions regarding safety and effectiveness could be drawn from this review because the overall body of evidence uncovered was lacking in quality and quantity. CONCLUSION HVLASM for SLDD has been reasonably described in the literature; however, the evidence is limited, and definitive conclusions on safety and effectiveness cannot be made at this time. The reviewed evidence supports the hypothesis that HVLASM may be effective in the treatment of SLDD and does not support the hypothesis that HVLASM is inherently unsafe in SLDD cases. It appears that patients with lumbar disk pathology do undergo manipulative treatment in practice. Consequently, this should be an area of research importance. More high-quality clinical trials using valid and reliable diagnostic criteria and outcomes measures are needed.
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Affiliation(s)
- Anthony J Lisi
- Veterans Affairs Connecticut Healthcare System, West Haven, Conn 06516, USA.
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Lisi AJ, Bhardwaj MK. Chiropractic High-Velocity Low-Amplitude Spinal Manipulation in the Treatment of a Case of Postsurgical Chronic Cauda Equina Syndrome. J Manipulative Physiol Ther 2004; 27:574-8. [PMID: 15614245 DOI: 10.1016/j.jmpt.2004.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To present an evidence-based case report on the use of chiropractic high-velocity low-amplitude spinal manipulation in the treatment a postsurgical, chronic cauda equina syndrome patient. CLINICAL FEATURES A 35-year-old woman presented with complaints of midback pain, low-back pain, buttock pain, saddle anesthesia, and bladder and bowel incontinence, all of 6 months duration. The patient was 6 months post emergency surgery for acute cauda equina syndrome due to lumbar disc herniation. She had been released from neurosurgical care with the current symptoms considered to be residual and nonprogressive. INTERVENTION AND OUTCOME The patient was treated with high-velocity low-amplitude spinal manipulation and ancillary myofascial release. After 4 treatments, the patient reported full resolution of midback, low back, and buttock pain. The patient was seen another 4 times with no improvement in her neurologic symptoms. No adverse effects were noted. CONCLUSION This appears to be the first published case of chiropractic high-velocity low-amplitude spinal manipulation being used for a patient with chronic cauda equina syndrome. It seems that this type of spinal manipulation was safe and effective for reducing back pain and had no effect on neurologic deficits in this case.
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Affiliation(s)
- Anthony J Lisi
- VA Connecticut Healthcare System, West Haven, Connecticut 06516, USA.
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Lisi AJ, Thomas GP. Cervical spine geometry correlated to cervical degenerative disease in a symptomatic group. J Manipulative Physiol Ther 2004; 27:220-1; author reply 221. [PMID: 15129205 DOI: 10.1016/j.jmpt.2003.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Lisi AJ, Cooperstein R, Morschhauser E. An exploratory study of provocation testing with padded wedges: can prone blocking demonstrate a directional preference? J Manipulative Physiol Ther 2004; 27:103-8. [PMID: 14970811 DOI: 10.1016/j.jmpt.2003.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Currently, no traditional chiropractic examination method to determine a spinal listing offers demonstrated guidance in treatment decisions for low back pain (LBP) patients. Development of an examination that bypasses the difficulty of accurately and reliably identifying a listing, yet provides guidance on manipulative vectors, could be very valuable to clinicians and patients. OBJECTIVE To explore 2 potential protocols for provocation testing and assessment of directional preference using padded wedges. METHODS Two groups of 20 subjects were examined while lying prone on various positions of padded wedges. In the first group, pain pressure threshold (PPT) was measured at 4 anatomic points; in the second group, tenderness was measured at 1 anatomic point. We investigated whether either method could demonstrate a directional preference response. RESULTS When tenderness was measured at 1 anatomic point, 70% of subjects demonstrated a directional response, and only 1 subject exhibited an increase in baseline tenderness at the end of the procedure. When PPT was measured at 4 anatomic points, 40% of subjects demonstrated a directional response, but 12 subjects exhibited decreased PPT at the end of the procedure. CONCLUSION Measuring changes in tenderness at 1 anatomic point in response to various padded wedge patterns appears promising as an examination procedure to determine directional preference.
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Affiliation(s)
- Anthony J Lisi
- University of Bridgeport College of Chiropractic, Conn. 06601, USA.
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Abstract
OBJECTIVE To describe 3 cases of discogenic low back pain and leg pain in which the centralization phenomenon was used in determining chiropractic treatment and prognosis. CLINICAL FEATURES Three men with low back pain and sciatica, positive straight leg raise, mild neurologic deficits, and evidence of discogenic disease requested chiropractic treatment. Two of the patients exhibited centralization of pain on provocation testing; the third did not. INTERVENTION AND OUTCOME All patients were treated with chiropractic side-posture manipulation, ancillary therapies, and pain medications. The 2 subjects whose pain centralized had excellent outcomes to treatment. The one whose pain did not centralize had a poor outcome and eventually required surgery. CONCLUSION Assessment of the centralization phenomenon provided valuable diagnostic and prognostic information regarding chiropractic side-posture manipulation in this case series.
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Affiliation(s)
- A J Lisi
- Department of Technique, Palmer College of Chiropractic West, San Jose, Calif. 95134, USA.
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