J Manipulative Physiol Ther. 2018 (Feb); 41 (2): 149155 ~ FULL TEXT
Stacie A. Salsbury, PhD, RN, Christine M. Goertz, DC, PhD, Elissa J. Twist, DC, MS, Anthony J. Lisi, DC
Palmer Center for Chiropractic Research,
Palmer College of Chiropractic,
OBJECTIVE: The purpose of this study was to describe the demographic, facility, and practice characteristics of doctors of chiropractic (DCs) working in private sector health care settings in the United States.
METHODS: We conducted an online, cross-sectional survey using a purposive sample of DCs (n = 50) working in integrated health care facilities. The 36-item survey collected demographic, facility, chiropractic, and interdisciplinary practice characteristics, which were analyzed with descriptive statistics.
RESULTS: The response rate was 76% (n = 38). Most respondents were men and mid-career professionals with a mean 21 years of experience in chiropractic. Doctors of chiropractic reported working in hospitals (40%), multispecialty offices (21%), ambulatory clinics (16%), or other (21%) health care settings. Most (68%) were employees and received salary compensation (59%). The median number of DCs per setting was 2 (range 18). Most DCs used the same health record as medical staff and worked in the same clinical setting. More than 60% reported co-management of patients with medical professionals. Integrated DCs most often received and made referrals to primary care, physical medicine, pain medicine, orthopedics, and physical or occupational therapy. Although in many facilities the DCs were exclusive providers of spinal manipulation (43%), in most, manipulative therapies also were delivered by physical therapists and osteopathic or medical physicians. Informal face-to-face consultations and shared health records were the most common communication methods.
CONCLUSIONS: Doctors of chiropractic are working in diverse medical settings within the private sector, in close proximity and collaboration with many provider types, suggesting a diverse role for chiropractors within conventional health care facilities.
KEYWORDS: Chiropractic; Delivery of Health Care; Integrative Medicine; Interprofessional Relations; Manipulation, Spinal; Private Sector
From the FULL TEXT Article:
Chiropractic care has been reported to have effectiveness for managing musculoskeletal disorders, particularly spine-related pain and disability. [1, 2] Over the past 2 decades, large public sector health care delivery systems in the United States, including the Department of Defense and Department of Veterans Affairs (VA), have integrated chiropractic care into their offered services.  Private sector medical settings, ranging from small primary care clinics to large health care systems in the United States, have introduced chiropractic care.  A survey by the National Board of Chiropractic Examiners Practice Analysis of Chiropractic reported that 9% of doctors of chiropractic (DCs) practice in settings other than chiropractic offices, including 7.8% who work in an integrated health care facility, with 3.6% of those surveyed identifying that they hold hospital staff privileges. 
The health care literature rarely describes characteristics of chiropractic practice in the US private sector; most reports are single-site case studies. [7, 8, 12, 13] Consequently, data are lacking on the structures and processes supporting the integration of chiropractic services into these health care facilities. Davis et al offered their experiences establishing chiropractic services in a primary care clinic in rural Vermont, noting the integrated model enhanced patient engagement, care coordination and referral between disciplines, and trust among providers.  Their practice model required considerable interprofessional education, was limited by insurance reimbursements, and necessitated negotiation of boundaries between chiropractic and physical therapy services.  Branson reflected on a 10year period of chiropractic integration into a private hospital system in an urban setting in Minnesota. 
The growing interest in complementary services within the community, long-term professional relationships, an increasing evidence-base for chiropractic care, availability of adequate physical space, and the creation of an interdisciplinary program for spine care served as key facilitators of chiropractic integration within that health system.  Pfefer et al described the integration of chiropractic care into a free safety-net clinic as a specialty service in suburban Kansas, noting the requirements for referral from clinic medical staff, difficulties with adding chiropractic forms to the electronic health record, and problems delivering health promotion counseling as a result of scheduling limitations.  Paskowski et al described the implementation of a hospital-based spine care pathway that included DCs on a multidisciplinary team in suburban Massachusetts.  Internal development that supported the project included the creation of an evidence-based pathway, buy-in from team members to adopt national back pain guidelines, initiation of clinical outcome measures across settings, and staff educational programs, with external development enhanced by educational outreach to primary care and specialty clinicians. 
A survey of American Chiropractic Association members indicated that 17% of 1,142 members reported working in integrated settings ranging from private group practices (59%), ambulatory care/outpatient clinics (15%), hospitals and medical centers (13%), and other types of facilities (11%), with 46% of these facilities located in the private sector.  Respondents reported that they served as musculoskeletal specialists and reported higher rates of referral to and from medical doctors (MDs) than those DCs who worked in nonintegrated settings. However, many DCs faced barriers to full participation in the health care team, which included not documenting care in the same clinical record or a lack of referrals from some medical providers. 
Health care systems are highly complex and differ considerably in their structures, processes, and outcomes. Thus, a better understanding of the existing models and characteristics of chiropractic practice in private medical settings is a key precursor to inclusion of chiropractic services in this sector and improved health care quality for persons with spine-related conditions.  Public sector settings, such as within the VA, have facility-level variations in chiropractic integration in terms of planning and implementation processes, clinic features, patient demography, and organizational supports.  Similar variations in the structures and processes of chiropractic service integration in community-based health care settings is anticipated, but these are not well documented in the literature. Therefore, the purpose of this study was to describe the demographic, facility, and practice characteristics of select DCs working in private sector health care settings in the United States.
This survey is among the first descriptions of doctors of chiropractic who work in nongovernmental, private sector health care settings in the United States. Although the degree to which integration, or the delivery of care through a shared organizational framework,  occurred in these settings is not known, most respondents (60%) identified that their workplaces engaged in team-based approaches to patient care. Most DCs surveyed reported working in interprofessional practice settings in which they either co-managed patient care or collaborated with a diverse group of health care providers, which is similar to recent studies of chiropractic integration in military or VA hospital settings. [4, 15] These DCs most often consulted with or referred patients to primary care providers and other health professionals who focus on the management of pain and physical function. Because many were co-located, these DCs participated in such referrals on a daily or weekly basis, engaged in frequent face-to-face discussions with medical physicians and other health care providers, and shared electronic health records. Our findings diverge from previous surveys of interprofessional communication between DCs and MDs that have noted infrequent referrals (typically not more than 13 times per month)  and inconsistent exchange of health records. 
In contrast to a recent chiropractic practice analysis that reported nearly 75% of DCs are the sole proprietor of a chiropractic office,  most of the DCs who responded to our survey reported to supervisory staff who either were medical doctors or clinic administrators who were not themselves chiropractors. Our findings here are important because a recent systematic review of graduate program standards in 4 regional councils of chiropractic education (United States, Australia, Canada, and Europe) reported few competencies for interprofessional collaboration, professional interactions within the broader health care system, or use of health information systems and similar technologies.  Prelicensure training and continuing education programs might introduce or strengthen chiropractor competency in these areas to facilitate interprofessional collaboration among DCs and medical providers working within or outside integrated health care settings. 
Doctors of chiropractic practicing in integrated settings primarily provided care to patients with musculoskeletal conditions of the low back and neck, headache, and other musculoskeletal complaints and reported little treatment of viscerosomatic complaints. These findings are similar to the most recent Practice Analysis of Chiropractic,  chiropractic delivery in military and veteran hospitals,  and are the reasons most patients seek out chiropractic care in all settings.  Although DCs provide a range of examination and management services, our study only assessed the delivery of spinal manipulation, a treatment commonly identified with the chiropractic profession. Interestingly, most respondents reported that spinal manipulation also was provided by physical therapists, osteopathic physicians, and medical doctors at their facilities. Future studies might explore how health care professionals negotiate the delivery of spinal manipulation, mobilization, other manual therapies, and exercise to patients who are receiving care from providers with varying scopes of practice within the organization. 
Our sample of mid-career chiropractic professionals was similar in demographic characteristics to those in a recent US practice analysis.  Of note, the median annual salary ($112,500) reported by respondents greatly exceeded the 2016 median pay projections of the US Depart of Labor Bureau of Labor Statistics ($67,520) and the 2015 VA average annual salary ($97,860) reported by Lisi and Brandt.  Respondents also engaged in educational training of medical and chiropractic students, committee work, research, and administrative functions, which may differ from the work of solo practitioners in private chiropractic clinics. Future studies might explore the motivating factors (personal, professional, financial, etc) that lead DCs to shift their workplaces from private practices to integrated health care settings.
Limitations and Future Studies
The generalizability of our results to chiropractors working in integrated settings is limited because of the purposive sampling framework of the survey, which may have resulted in selection bias. The study had a small sample size, and so results cannot necessarily be extrapolated to the whole. The high number of participants located in the northeastern United States, the region from which the most respondents were recruited, resulted in overrepresentation in this region. There also seems to be an overrepresentation of Palmer graduates. Because this was a survey, it is also possible that respondents were not accurate in reporting their information.
Future studies may aim to describe the interprofessional collaborations of DCs working in integrated settings in more diverse settings both in the United States and worldwide and to seek a more generalizable sample to better represent this population of chiropractors. Our survey provided fairly constrained choices for the health care facilities in which respondents work, with the majority affiliated with physical medicine, rehabilitation, or physical therapy settings, and allowed for limited information on some aspects of clinical practice (total number of patient visits each week vs number of patient seen each week). Follow-up studies may wish to more fully describe the provider setting and practice characteristics. In addition, researchers might seek out practitioners who work in other medical departments such as in emergency services or urgent care clinics. Although our response rate (76%) exceeds published data  on chiropractor responses to research surveys (53%), nearly a quarter of those invited to participate declined to do so.
Survey nonrespondents may have not been interested in the topic, had not enough time for the survey or, perhaps, were not allowed to divulge proprietary information about their employment settings, any of which would affect the accuracy of the data obtained in this study. Lastly, the findings of this survey focus solely on the perspectives of DCs; exploratory research of the views of collaborating providers, patients, and administrators may help to elicit a better understanding of the benefits and challenges of such integrated practice models. Future research is needed to explore the administrative structures and clinical processes of chiropractors working in medical settings and identify the impact of such on patient and systems outcomes.
This preliminary study indicated that a group of DCs practicing in integrated, private sector medical settings reported higher rates of bidirectional patient referrals, interprofessional communication, and interdisciplinary collaboration than previous surveys of chiropractors working outside of medical settings.
In this sample, DCs reported working in a variety of integrated health care
settings within the US private sector, including hospitals, multispecialty
clinics, ambulatory clinics, and other facilities.
Most DCs reported referral and co-management with many types of health care
professionals, most commonly those working in primary care or those treating
chronic pain patients.
Shared electronic health records and face-to-face informal consultations were
the most used methods for interprofessional communication.
Doctors of chiropractic working in integrated health care settings may not be
the sole providers of spinal manipulative therapy in their facilities.
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