Year 2002 Survey of U.S. Chiropractors

Monica Smith, DC, PhD

Palmer Center for Chiropractic Research,Davenport, IA, USA.

Study Purpose

DCs may be serving to help fill the gap in health care system capacity in primary care shortage areas. Need more information about the actual or potential contribution of the chiropractic profession to this nation’s primary healthcare workforce capacity.

Survey Items/Instrument

Define chiropractic practice markets (also map to HPSAs and other market characteristics)

Demographics, Guidelines, Information Technology

Practice patterns of chiropractors relative to primary and coordinated care: Differential diagnosis Making referrals to other health professionals Monitoring patients for adverse Rx events

Methods Survey questions pilot-tested on a sample of 104 “key

informants” drawn from the leadership rosters of the Congress of Chiropractic State Associations (COCSA), the Federation of Chiropractic Licensing Boards (FCLB), and the National Board of Chiropractic Examiners (NBCE).

Data linked by respondent's primary location state and county to the HRSA Bureau of Health Profession’s Area Resource File (HRSA-BHPr ARF) to provide additional measures of each respondent chiropractor’s practice market environment such as HPSA designation, health care system factors, and population density.

Initial mailing, 2 follow-up mailings, phone follow-up

Methods: Survey Sampling FlowchartN = 67,217

Universe of all U.S. DCs holding active state board license in CY2001, reconciled to remove dual license holders

N = 64,717

N = 62,186

N = 61,286

Remaining, not sampled

CCGPP Sample #1

Simple Random Samplen=2500

SRS

CCGPP Sample #2

Clustered Random Sample drawn from sites of Community Tracking Study

n=2531

CTS

CCGPP Sample #3

Stratified Random Sample drawn from 3 HPSA strata

n=900

HPSA

Community Tracking SitesSites Selected for the Community Tracking Study (CTS) and Chiropractic Colleges

Site IntensityHigh-IntensityLow-Intensity (Metro)Low-Intensity (Non-metro)

Copyright 1999 Palmer Center for Chiropractic Research, Palmer College of ChiropracticSources: Site and County Crosswalk File, Community Tracking Study, Center for Studying Health System Change

Logan College of Chiropractic

Texas Chiropractic College

Cleveland Chiropractic College

Los Angeles College of Chiropractic

Western States Chiropractic College

Life Chiropractic College West

Palmer College of Chiropractic West

University of Bridgeport, College of Chiropractic

Life University, School of Chiropractic

The National College of Chiropractic

Palmer College of Chiropractic

Northwestern College of Chiropractic

Cleveland Chiropractic College - Kansas City

Sherman College of Straight Chiropractic

Parker College of Chiropractic

New York Chiropractic College

Palmer College ofChiropractic Florida

Preliminary Results: Response Rates

SRS CTS

Mail: = 27.4% 23.1%

Mail & Phone: = 50.4% 46.8%

Mail survey completedMail survey sent – USPS Bad addresses

Mail survey completed & Phone follow-upMail survey sent – USPS Bad addresses – No yellow page listing

Preliminary Results: Practice markets / HPSAs

SRS CTS HPSA

Whole-Short HPSA in DC market 14% 6% 46%

Whole- or Part-Short in DC market 87% 86% 93%

Preliminary Results: Demographics

Male 80%

White 94%

Age Average 44

25-35 21%

36-45 35%

46-55 33%

>55 11%

Years in Practice Average 16

1-10 36%

11-20 36%

21-30 20%

>30 8%

Preliminary Results: Demographics

Full Time 84%

Solo 67%

1 site 90%

Same location 2 yrs 84%

Satisfied 88%

Chiro Specialized Credentials 32%

Other Specialized Credentials 42%

National and/or State Assoc 66%

Preliminary Results: Differential Dx

In the examination and assessment of a patient’s

condition do you perform:

Differential Diagnosis only 5%

Chiropractic Analysis only 15%

Both 80%

Preliminary Results: ID Serious Condition

Have you ever been first health care provider to identify a serious condition requiring referral for medical care?

Yes 84%

How oftenRoutinely 3%Frequently 9%Sometimes 39%Seldom 47%Never 2%

How often past 2 yrs 0 times 8%1-5 times 44%6-10 times 23%11-20 times 9%21-30 times 8%>30 times 8%

Preliminary Results: ID Adverse Rx Event

Have you ever identified an adverse pharmaceutical event in one of your patients?

Yes 61%

How oftenRoutinely 1%Frequently 17%Sometimes 35%Seldom 40%Never 7%

How often past 2 yrs 0 times 5%1-5 times 41%6-10 times 17%11-20 times 15%21-30 times 9%>30 times 13%

Chiropractic Guidelines I have read this guidelines document in

sufficient depth to “know what it says”

ReadWCA =1%

Read Mercy =41%

ReadICA =3%

1%

13%

9%8%

Have NOTread WCA, ICA,nor Mercy =24%

Physical Activity (PA)

Health care providers should routinely assess patients’ physical activity practices and counsel them in engaging in a program of regular physical activity that is tailored to their health status and lifestyle. Women should receive counseling regarding the use of weight-bearing exercise to help prevent postmenopausal osteoporosis. All Americans should engage in regular physical activity at a level appropriate to their capacity, needs, and interest. Children and adults should set a goal of accumulating at least 30 minutes of moderate-intensity physical activity on most, and preferably all, days of the week. Clinicians may find useful the basics of Physical Activity Counseling in the AHCPR-published Clinician’s Handbook of Preventive Services.

Nutrition (N)

Clinicians should routinely provide nutritional assessment and counseling to their patients, especially targeting obesity (for all patients over 2 years) and calcium intake (for females 11 years and over). Obese patients should be counseled to replace calories from fat with increased dietary fiber, and age-appropriate females counseled with regard to adequate calcium intake. It is reasonable for physicians to provide general dietary advice, while for patients at increased risk, such as alcoholics and the elderly living alone, it is prudent to consider referral to a clinical nutritionist or other professional with specialized nutritional expertise. Women of childbearing age who are capable of becoming pregnant should consume 0.4 mg of folic acid per day. Clinicians may find useful the basics of Nutrition Counseling in the AHCPR-published Clinician’s Handbook of Preventive Services.

Polypharmacy (PP)

Clinicians should assess the use of prescription and nonprescription medications of older adult patients at each periodic health evaluation (annually or as appropriate). Clinicians should maintain a drug profile on older adults to evaluate/monitor for unnecessary and excessive drug use. Clinicians may find useful the basics of Polypharmacy Counseling in the AHCPR-published Clinician’s Handbook of Preventive Services

Smoking Cessation (SC)

For patients who smoke, clinicians should provide smoking cessation counseling, consider over-the-counter or prescription drug therapy with nicotine products, and referral as appropriate to smoking cessation programs. Counseling should be done on a regular basis to smokers, as multiple messages are often needed, and the harmful effect of smoking on children’s health be emphasized to smoking parents. Smoking should be prohibited in health-care facilities. Clinicians may find useful the basics of Smoking Cessation Counseling in the AHCPR-published Clinician’s Handbook of Preventive Services.

HTN Medication (HTN)

National guidelines of the Joint National Committee on detection, evaluation, and treatment of high blood pressure recommend consideration of antihypertensive medication step-down and withdrawal in patients with well-controlled hypertension. The rationale for this recommendation is that medications can be expensive, can cause bothersome side effects and undesirable metabolic changes, and may paradoxically increase the risk of clinical cardiovascular events in certain patients. In addition, in many persons, hypertension occurs as a result of excess sodium intake or heavy body weight, and can therefore potentially be reversed through patient lifestyle changes.

Preventive/Other GuidelinesPA Nutr Poly HTN Smok

Rx Cess

Scientifically Sound 94% 81% 77% 89% 87%

Consistent Practice 93% 85% 58% 92% 74%

+ Impact Reimburse 73% 46% 22% 53% 33%

+ Impact Inclusion 68% 60% 32% 56% 44%

Beneficial Position 85% 83% 48% 82% 67%

Consist State Laws 83% 80% 28% 59% 52%

Next Generation Standards/Guidelines for Quality Chiropractic Care

A useful model for organizing our thoughts about ensuring Quality Care Provision through Established Standards for Best Practices

Past: The chain of measuring & ensuring quality in health care.

Current and Future: The circle of quality assurance / improvement and accountability in health care.

Structure of Care(Training, Credentials)

Outcomes of Care(Patient Improvement)

Process of Care(Clinical Practice)

(Practitioner-Centered) (Patient-Centered)

Process of Care(Evidence-based “Best Practice”)

Outcomes of Care(Patient values “Best Care” thatcan provide “Best Outcomes”)

Structure of Care(Evidence-based “Best Practitioner”)

Feedback evidence from outcomes research to improve quality of care

Within Chiropractic Practice Chiropractic-specific techs/procedures Other clinical activities relevant to chiropractic care (Dx, Tx, Prev) Empowering patient as informed, active participant in decisions about care

Across Providers/Settings: Coordinated / Integrated Care* “Best Practitioners” and “Best Practices” Bi-directional Consultation, Referral, Co-Management DCs as well-educated “Patient Advocates” capable of helping their

patients to navigate safely through a complex and intimidating health care system

(*e.g. see Tamblyn et al, “Association between licensure examination scores and practice in primary care”. JAMA Dec. 18, 2002, Vol. 288, No. 23)

Process of Care(Evidence-based “Best Practice”)

Outcomes of Care(Patient values “Best Care” thatcan provide “Best Outcomes”)

Structure of Care(Evidence-based “Best Practitioner”)

Feedback evidence from outcomes research to improve quality of care

Chiropractic Workforce Research Heterogeneity among DC profession

Which dimensions? Source/Cause of heterogeneity?

Standards for Best Chiropractic Care Practices NMS/Biomechanical (subluxation) Other Dx, Tx (e.g. “visceral”) Prevention (wholistic, wellness-oriented) Patient as informed participant in decisions

Standards Best Coordinated/Integrated Care Practices Information Technology (tools for change, change agents)

Clinical Decision Support Systems (DVA, DoD, Multidis) Established DCs –- HIPAA (billing clinical apps) New DCs –- Clinical Informatics Curricula

Further Implications for Workforce Research

Conceptual, Methodological, Logistical Issues Market area query (up to 5 counties)

HPSA-stratified sampling (via ID contiguous)

HPSA: Whole vs. Part vs. No short

Rural and HPSA

Link to external datasets (ARF, CTS)

Secondary analyses of this and other workforce data (e.g. data archive)

Implications for Education/Practice/Policy

DCs contribute to this nation’s primary health workforce needs, particularly in rural and underserved areas.

Key to enhancing the actual and potential roles of DCs in primary healthcare delivery lies in documenting, understanding, and improving both chiropractic practice and cross-disciplinary professional interactions.

DCs and the chiropractic profession must be cognizant of how patients within a DC’s service area utilize chiropractic as a component of their overall care, and must assume the necessary responsibility for ensuring that underserved or vulnerable population groups receive appropriate and adequate care.

Project Funding: Council on Chiropractic Guidelines and Practice Parameters

(CCGPP) and Palmer Center for Chiropractic Research (PCCR)

Funding for this presentation: Palmer Center for Chiropractic Research

Thank you for your attention!