Transcript Survey of Chiropractors in U.S. Health Profession Shortage Areas

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
 Making
diagnosis
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 Flowchart
N = 67,217
Universe of all U.S. DCs holding
active state board license in
CY2001, reconciled to remove
dual license holders
CCGPP Sample #1
SRS
Simple Random Sample
n=2500
N = 64,717
CCGPP Sample #2
CTS
Clustered Random Sample drawn from
sites of Community Tracking Study
n=2531
N = 62,186
CCGPP Sample #3
HPSA
Stratified Random Sample drawn from
3 HPSA strata
n=900
N = 61,286
Remaining, not sampled
Community Tracking Sites
Sites Selected for the Community Tracking Study (CTS)
and Chiropractic Colleges
Western States
Chiropractic College
Northwestern College of Chiropractic
Palmer College of Chiropractic
The National College of Chiropractic
Life Chiropractic
College West
New York
Chiropractic College
University of Bridgeport,
College of Chiropractic
Palmer College of
Chiropractic West
Sherman College of
Straight Chiropractic
Cleveland Chiropractic College
Life University,
School of Chiropractic
Los Angeles College of Chiropractic
Palmer College of
Chiropractic Florida
Site Intensity
High-Intensity
Low-Intensity (Metro)
Low-Intensity (Non-metro)
Sources: Site and County Crosswalk File, Community Tracking Study, Center for Studying Health System Change
Logan College of Chiropractic
Cleveland Chiropractic College - Kansas City
Texas Chiropractic College
Parker College of Chiropractic
Copyright 1999 Palmer Center for Chiropractic Research, Palmer College of Chiropractic
Preliminary Results: Response Rates
SRS
Mail:
CTS
= 27.4%
23.1%
= 50.4%
46.8%
Mail survey completed
Mail survey sent – USPS Bad
addresses
Mail & Phone:
Mail survey completed & Phone follow-up
Mail 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
Years in Practice
Average
16
25-35
21%
1-10
36%
36-45
35%
11-20
36%
46-55
33%
21-30
20%
>55
11%
>30
8%
Preliminary Results: Demographics
Full Time
Solo
1 site
Same location 2 yrs
Satisfied
Chiro Specialized Credentials
Other Specialized Credentials
National and/or State Assoc
84%
67%
90%
84%
88%
32%
42%
66%
Preliminary Results: Differential Dx
In the examination and assessment of a patient’s
condition do you perform:
Differential Diagnosis only
Chiropractic Analysis only
Both
5%
15%
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
How often
Routinely
Frequently
Sometimes
Seldom
Never
How often past 2 yrs
0 times
1-5 times
6-10 times
11-20 times
21-30 times
>30 times
84%
3%
9%
39%
47%
2%
8%
44%
23%
9%
8%
8%
Preliminary Results: ID Adverse Rx Event
Have you ever identified an adverse pharmaceutical event in one
of your patients?
Yes
How often
Routinely
Frequently
Sometimes
Seldom
Never
How often past 2 yrs
0 times
1-5 times
6-10 times
11-20 times
21-30 times
>30 times
61%
1%
17%
35%
40%
7%
5%
41%
17%
15%
9%
13%
Chiropractic Guidelines
 I have read this guidelines document in
sufficient depth to “know what it says”
Read
WCA =1%
1%
Read
ICA =3%
13%
8%
9%
Read Mercy =41%
Have NOT
read 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 weightbearing 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 moderateintensity 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-thecounter 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 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%
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.
Structure of Care
(Training, Credentials)
Process of Care
(Clinical Practice)
(Practitioner-Centered)
Outcomes of Care
(Patient Improvement)
(Patient-Centered)
Current and Future: The circle of quality assurance /
improvement and accountability in health care.
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” that
can provide “Best Outcomes”)
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” that
can 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)
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!