Year 2002 Survey of U.S. Chiropractors

1. Year 2002 Survey of U.S. Chiropractors Monica Smith, DC, PhD Palmer Center for Chiropractic Research,Davenport, IA, USA.

2. 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.

3. 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

4. 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

5. Methods: Survey Sampling Flowchart

6. Community Tracking Sites Palmer College ofChiropractic Florida

7. Preliminary Results: Response Rates SRS CTS Mail: = 27.4% 23.1% Mail & Phone: = 50.4% 46.8% • Mail survey completed • Mail survey sent – USPS Bad addresses • Mail survey completed & Phone follow-up • Mail survey sent – USPS Bad addresses – No yellow page listing

8. Preliminary Results: Practice markets / HPSAs SRSCTSHPSA Whole-Short HPSA in DC market 14% 6% 46% Whole- or Part-Short in DC market 87% 86% 93%

9. 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%

10. 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%

11. 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%

12. 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 often Routinely 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%

13. Preliminary Results: ID Adverse Rx Event Have you ever identified an adverse pharmaceutical event in one of your patients? Yes 61% How often Routinely 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%

14. Chiropractic Guidelines • I have read this guidelines document in sufficient depth to “know what it says” ReadWCA=1% ReadICA=3% 1% 13% 8% 9% Have NOT read WCA, ICA, nor Mercy =24% Read Mercy=41%

15. 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.

16. 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. Nutrition (N)

17. 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

18. 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.

19. 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.

20. Preventive/Other Guidelines PA 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%

21. 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

22. Feedback evidence from outcomes research to improve quality of care Structure of Care(Evidence-based “Best Practitioner”) Process of Care(Evidence-based “Best Practice”) Outcomes of Care(Patient values “Best Care” thatcan provide “Best Outcomes”) Past: The chain of measuring & ensuring quality in health care. Structure of Care(Training, Credentials) Process of Care(Clinical Practice) Outcomes of Care(Patient Improvement) (Practitioner-Centered) (Patient-Centered) Current and Future: The circle of quality assurance / improvement and accountability in health care.

23. Feedback evidence from outcomes research to improve quality of care Structure of Care(Evidence-based “Best Practitioner”) Process of Care(Evidence-based “Best Practice”) Outcomes of Care(Patient values “Best Care” thatcan provide “Best Outcomes”) 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)

24. 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

25. 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)

26. 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.

27. 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 ResearchThank you for your attention!