Changes in primary care physician's management of low back pain in a model of interprofessional collaborative care: an uncontrolled before-after study

'Specialist before physiotherapist': physicians' and physiotherapists' beliefs and management of chronic low back pain in Ghana - A qualitative study

PURPOSE

This study provides an understanding of the chronic low back pain (CLBP) beliefs and management practices of physicians/doctors and physiotherapists in Ghana, and the mechanisms underlying their beliefs and practices.

MATERIALS/METHODS

Thirty-three individual semi-structured interviews, involving eighteen physio-therapists and fifteen physicians involved with CLBP management, were carried out. Interviews were audio recorded, transcribed, and analysed using Straussian grounded theory principles and critical realist philosophy.

RESULTS

Five categories were derived: The predominance of bio-medical/mechanical beliefs, maladaptive beliefs, maladaptive practices, limited involvement of physiotherapists and other healthcare professionals (HCPs) and evidence-based beliefs and practices. The predominant mechanisms underlying the HCPs beliefs and practices were: the healthcare environment (professional roles/identity hinged around paternalistic and biomedical care, fragmented CLBP management, limited physiotherapy/HCPs' knowledge) and sociocultural environment (sociocultural/patients' expectations of passive therapy and paternalism).

CONCLUSION

The CLBP beliefs and practices of HCPs involved with CLBP in Ghana is modelled around a professional identity that is largely hinged on paternalism and bio-medical/mechanical understandings. Lack of collaboration and sociocultural expectations also play a significant role. There is the need for a reconstitution of Ghanaian HCPs' CLBP beliefs and management approaches to align with evidenced-based approaches (e.g., imaging should not be universally prescribed, biopsychosocial and patient-centred care).

The association between chiropractic integration in an Ontario community health centre and continued prescription opioid use for chronic non-cancer spinal pain: a sequential explanatory mixed methods study

BACKGROUND

Emerging evidence suggests that access to chiropractic care may reduce the likelihood of initiating an opioid prescription for spinal pain; however, the impact of chiropractic care for patients already prescribed opioids is uncertain. We undertook a sequential explanatory mixed methods study to evaluate the association between initiating chiropractic care and continued opioid use among adult patients attending an Ontario community health centre (CHC) and receiving opioid therapy for chronic non-cancer spinal pain.

METHODS

We conducted a retrospective cohort study of 210 patient records between January 1, 2014 and December 31, 2020. We used generalized estimating equations, adjusted for patient demographics, co-morbidities, visit frequency, and calendar year, to evaluate the association between receipt versus non-receipt of chiropractic services and continued opioid use (e.g., unique opioid fills, number of refills, and dosages) up to one year following the index chiropractic visit. We also completed follow-up interviews with 14 patients and nine general practitioners from the CHC and integrated these data with our quantitative findings.

RESULTS

Over 12-month follow-up, there were lower rates of opioid fills (incidence rate ratio [IRR] = 0.66; 95% confidence interval [CI], 0.52-0.83) and refills (IRR = 0.27; 95% CI, 0.17-0.42) among chiropractic recipients (n = 49) versus non-recipients (n = 161). Although patients who did and did not receive chiropractic care began the study with the same dose of opioids, recipients were less likely to be prescribed higher-dose opioids (i.e., ≥ 50 mg morphine equivalents daily) compared to non-recipients at three months (odds ratio [OR] = 0.14; 95% CI, 0.04-0.47), six months (OR = 0.14; 95% CI, 0.05-0.40), nine months (OR = 0.19; 95% CI, 0.07-0.57), and 12 months (OR = 0.22; 95% CI, 0.08-0.62). Interviews suggested that patient self-efficacy, limited effectiveness of opioids for chronic pain, stigma regarding use of opioids, and access to chiropractic treatment were important influencing factors.

CONCLUSION

We found that continued prescription opioid use among patients with chronic non-cancer spinal pain who received chiropractic care was lower than in patients who did not receive chiropractic care. Four themes emerged in our qualitative interviews to help provide a richer understanding of this association. Randomized controlled trials are needed to establish the effect of chiropractic care on opioid use for chronic spinal pain.

Association of Chiropractic Care With Receiving an Opioid Prescription for Noncancer Spinal Pain Within a Canadian Community Health Center: A Mixed Methods Analysis

OBJECTIVE

The purpose of this study was to examine the association between receipt of chiropractic services and initiating a prescription for opioids among adult patients with noncancer spinal pain in a Canadian community health center.

METHODS

In this sequential explanatory mixed methods analysis, we conducted a retrospective study of 945 patient records (January 2014 to December 2020) and completed interviews with 14 patients and 9 general practitioners. We used Cox proportional hazards regression analyses, adjusted for patient demographics, comorbidities, visit frequency, and calendar year to evaluate the association between receipt of chiropractic care and time to first opioid prescription up to 1 year after presentation. Qualitative data were analyzed thematically and integrated with our quantitative findings.

RESULTS

There were 24% of patients (227 of 945) with noncancer spinal pain who received a prescription for opioids. The risk of initiating a prescription for opioids at 1 year after presentation was 52% lower in chiropractic recipients vs nonrecipients (hazard ratio [HR], 0.48; 99% confidence interval [CI], 0.29-0.77) and 71% lower in patients who received chiropractic services within 30 days of their index visit (HR, 0.29; 99% CI, 0.13-0.68). Patients whose index visit date was in a more recent calendar year were also less likely to receive opioids (HR, 0.86; 99% CI, 0.76-0.97). Interviews suggested that self-efficacy, access to chiropractic services, opioid stigma, and treatment impact were influencing factors.

CONCLUSION

Patients with noncancer spinal pain who received chiropractic care were less likely to obtain a prescription for opioids than patients who did not receive chiropractic care.

Association of chiropractic integration in an Ontario community health centre with prescription opioid use for chronic non-cancer pain: a mixed methods study protocol

INTRODUCTION

Emerging evidence from a number of primary care centres suggests that integration of chiropractic services into chronic pain management is associated with improved clinical outcomes and high patient satisfaction as well as with reductions in physician visits, specialist referrals use of advanced imaging and prescribing of analgesics. However, formal assessments of the integration of chiropractic services into primary care settings are sparse, and the impact of such integration on prescription opioid use in chronic pain management remains uncertain. To help address this knowledge gap, we will conduct a mixed methods health service evaluation of an integrated chiropractic back pain programme in an urban community health centre in Ontario, Canada. This centre provides services to vulnerable populations with high unemployment rates, multiple comorbidities and musculoskeletal disorders that are commonly managed with prescription opioids.

METHODS AND ANALYSIS

We will use a sequential explanatory mixed methods design, which consists of a quantitative phase followed by a qualitative phase. In the quantitative phase, we will conduct a retrospective chart review and evaluate whether receipt of chiropractic services is associated with reduced opioid use among patients already prescribed opioid therapy for chronic pain. We will measure opioid prescriptions (ie, opioid fills, number of refills and dosages) by reviewing electronic medical records of recipients and non-recipients of chiropractic services between 1 January 2014 and 31 December 2020 and use multivariable regression analysis to examine the association. In the qualitative phase, we will conduct in-depth, one-on-one interviews of patients and their general practitioners to explore perceptions of chiropractic integration and its impact on opioid use.

ETHICS AND DISSEMINATION

This study was approved by the Hamilton Integrated Research Ethics Board at McMaster University (approval number 2021-10930). The results will be disseminated via peer-reviewed publications, conference presentations and in-person or webinar presentations to community members and healthcare professionals.

Attitudes towards chiropractic: a repeated cross-sectional survey of Canadian family physicians

BACKGROUND

Many primary care patients receive both medical and chiropractic care; however, interprofessional relations between physicians and chiropractors are often suboptimal which may adversely affect care of shared patients. We surveyed Canadian family physicians in 2010 to explore their attitudes towards chiropractic and re-administered the same survey a decade later to explore for changes in attitudes.

METHODS

A 50-item survey administered to a random sample of Canadian family physicians in 2010, and again in 2019, that inquired about demographic variables, knowledge and use of chiropractic. Imbedded in our survey was a 20-item chiropractic attitude questionnaire (CAQ); scores could range from 0 to 80 with higher scores indicating more positive attitudes toward chiropractic. We constructed a multivariable regression model to explore factors associated with CAQ scores.

RESULTS

Among eligible physicians, 251 of 685 in 2010 (37% response rate) and 162 of 2429 in 2019 (7% response rate) provided a completed survey. Approximately half of respondents (48%) endorsed a positive impression of chiropractic, 27% were uncertain, and 25% held negative views. Most respondents (72%) referred at least some patients for chiropractic care, mainly due to patient request or lack of response to medical care. Most physicians believed that chiropractors provide effective therapy for some musculoskeletal complaints (84%) and disagreed that chiropractic care was beneficial for non-musculoskeletal conditions (77%). The majority agreed that chiropractic care was a useful supplement to conventional care (65%) but most respondents (59%) also indicated that practice diversity among chiropractors presented a barrier to interprofessional collaboration. In our adjusted regression model, attitudes towards chiropractic showed trivial improvement from 2010 to 2019 (0.31 points on the 80-point CAQ; 95%CI 0.001 to 0.62). More negative attitudes were associated with older age (- 1.55 points for each 10-year increment from age 28; 95%CI - 2.67 to - 0.44), belief that adverse events are common with chiropractic care (- 1.41 points; 95% CI - 2.59 to - 0.23) and reported use of the research literature (- 6.04 points; 95% CI - 8.47 to - 3.61) or medical school (- 5.03 points; 95% CI  - 7.89 to - 2.18) as sources of knowledge on chiropractic. More positive attitudes were associated with endorsing a relationship with a specific chiropractor (5.24 points; 95% CI 2.85 to 7.64), family and friends (4.06 points; 95% CI 1.53 to 6.60), or personal treatment experience (4.63 points; 95% CI 2.14 to 7.11) as sources of information regarding chiropractic.

CONCLUSIONS

Although generally positive, Canadian family physicians' attitudes towards chiropractic are diverse, and most physicians felt that practice diversity among chiropractors was a barrier to interprofessional collaboration.

Interprofessioal collaboration among Speech Language Pathologists and Nurses in Acute Care in Pakistan

OBJECTIVE

To find out inter-professional collaboration among speech-language pathologists and nurses in acute care in Pakistan.

METHODS

This was a cross sectional study which was conducted in all government and private hospitals of Islamabad and Rawalpindi having facility of ICUs after taking consent from authorities. The duration of study was six months from October 2018 to February 2019. A total number of 350 participants (200 nurses, 150 speech language pathologists) working in ICU of different private and government hospitals of Pakistan were included in the study. Standardized questionnaire of ": assessment of inter-professioal collaboration scale": (AITCS) was circulated to nurses and speech language pathologists (SLPS) working in ICU with its subscale's partnership, coordination, cooperation and shared decision making on a 5-point likert scale. Data was analyzed using SPSS version 21.Measure of mean was obtained by independent sample t-test. P- Value less than 0.05 was considered as significant.

RESULTS

Statistical analysis showed measures of mean differences obtained by t-test revealed significant differences at p<0.001 level between partnership scores of SLPS and nurses. This reveals good partnership between two disciplines. Measures of mean differences obtained by t-test revealed significant differences at p<0.001 level between partnership scores of SLPS and nurses. Both do not value each other in cooperation. Measures of mean differences obtained by t-test showed significant differences at p<0.001 level amongst coordination scores of SLPS and nurses. Both have good coordination. Measures of mean differences obtained by t-test revealed significant differences at p<0.001 level amongst shared decision-making scores of SLPS and nurses. Both are involved in shared decision making.

CONCLUSION

Results show significant difference in partnership, coordination, and shared decision making. There is no significant difference in cooperation.

Chiropractic integration within a community health centre: a cost description and partial analysis of cost-utility from the perspective of the institution

OBJECTIVE

To evaluate costs and consequences of a new back pain service provided by chiropractors integrated into a Community Health Centre in Cambridge, Ontario. The study sample included 95 consecutive patients presenting between January 2014 to January 2016 with a mixture of sub-acute and chronic back pain.

METHODS

A secondary cost-utility analysis was performed and conducted from the perspective of the healthcare institution. Cost-utility was calculated as cost per quality-adjusted life year (QALY) gained over a time horizon of 90 days.

RESULTS

According to the EuroQol 5 Domain questionnaire, nearly 70% of patients improved. The mean number of treatment sessions was 8.4, and an average of 0.21 QALYs were gained at an average cost per QALY of $1,042. Seventy-seven percent of patients did not visit their primary care provider over the 90-day period, representing potential cost savings to the institution of between $2,022.23 and $6,135.82.

CONCLUSION

Adding chiropractic care to usual medical care was associated with improved outcomes at a reasonable cost in a sample of complex patients with sub-acute and chronic back pain. Future comparative cost-effectiveness studies are needed.

The state of the science of interprofessional collaborative practice: A scoping review of the patient health-related outcomes based literature published between 2010 and 2018

INTRODUCTION

If interprofessional collaborative practice is to be an important component of healthcare reform, then an evidentiary base connecting interprofessional education to interprofessional practice with significantly improved health and healthcare outcomes is an unconditional necessity. This study is a scoping review of the current peer reviewed literature linking interprofessional collaborative care and interprofessional collaborative practice to clearly identified healthcare and/or patient health-related outcomes. The research question for this review was: What does the evidence from the past decade reveal about the impact of Interprofessional collaborative practice on patient-related outcomes in the US healthcare system?

MATERIALS AND METHODS

A modified preferred reporting items for systematic reviews and meta-analyses (PRISMA) approach was followed.

RESULTS

Of an initial 375 articles retrieved 20 met review criteria. The most common professions represented in the studies reviewed were physicians, pharmacists and nurses. Primary care was the most common care delivery setting and measures related to chronic disease the most commonly measured outcomes. No study identified negative impacts of interprofessional collaborative practice. Eight outcome categories emerged from a content analysis of the findings of the reviewed studies.

CONCLUSIONS

The results suggest a need for more research on the measurable impact of interprofessional collaborative practice and/or care on patient health-related outcomes to further document its benefits and to explore the models, systems and nature of collaborations that best improve population health, increase patient satisfaction, and reduce cost of care.

Management of Back Pain-related Disorders in a Community With Limited Access to Health Care Services: A Description of Integration of Chiropractors as Service Providers

OBJECTIVE

The purpose of this study was to evaluate a chiropractic service for back pain patients integrated within a publicly funded, multidisciplinary, primary care community health center in Cambridge, Ontario, Canada.

METHODS

Patients consulting for back pain of any duration were referred by their medical doctor or nurse practitioner for chiropractic treatment at the community health center. Patients completed questionnaires at baseline and at discharge from the service. Data were collected prospectively on consecutive patients between January 2014 and January 2016.

RESULTS

Questionnaire data were obtained from 93 patients. The mean age of the sample was 49.0 ± 16.27 years, and 66% were unemployed. More than three-quarters (77%) had had their back pain for more than a month, and 68% described it as constant. According to the Bournemouth Questionnaire, Bothersomeness, and global improvement scales, a majority (63%, 74%, and 93%, respectively) reported improvement at discharge, and most (82%) reported a significant reduction in pain medication. More than three-quarters (77%) did not visit their primary care provider while under chiropractic care, and almost all (93%) were satisfied with the service. According to the EuroQol 5 Domain questionnaire, more than one-third of patients (39%) also reported improvement in their general health state at discharge.

CONCLUSION

Implementation of an integrated chiropractic service was associated with high levels of improvement and patient satisfaction in a sample of patients of low socioeconomic status with subacute and chronic back pain.

The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults: Results From the 2012 National Health Interview Survey

STUDY DESIGN

Secondary analysis of a national survey.

OBJECTIVE

The aim of this study was to investigate the prevalence, patterns, and predictors of chiropractic utilization in the US general population.

SUMMARY OF BACKGROUND DATA

Chiropractic is one of the largest manual therapy professions in the United States and internationally. Very few details have been reported about the use of chiropractic care in the United States in recent years.

METHODS

Cross-sectional data from the 2012 National Health Interview Survey (n = 34,525) were analyzed to examine the lifetime and 12-month prevalence and utilization patterns of chiropractic use, profile of chiropractic users, and health-related predictors of chiropractic consultations.

RESULTS

Lifetime and 12-month prevalence of chiropractic use were 24.0% and 8.4%, respectively. There is a growing trend of chiropractic use among US adults from 2002 to 2012. Back pain (63.0%) and neck pain (30.2%) were the most prevalent health problems for chiropractic consultations and the majority of users reported chiropractic helping a great deal with their health problem and improving overall health or well-being. A substantial number of chiropractic users had received prescription (23.0%) and/or over-the-counter medications (35.0%) for the same health problem for which chiropractic was sought and 63.8% reported chiropractic care combined with medical treatment as helpful. Both adults older than 30 years (compared to younger adults), and those diagnosed with spinal pain (compared to those without spinal pain) were more likely to have consulted a chiropractor in the past 12 months.

CONCLUSION

A substantial proportion of US adults utilized chiropractic services during the past 12 months and reported associated positive outcomes for overall well-being and/or specific health problems for which concurrent conventional care was common. Studies on the current patient integration of chiropractic and conventional health services are warranted.

LEVEL OF EVIDENCE

3.

Collaborative care for a patient with complex low back pain and long-term tobacco use: a case report

Few examples of interprofessional collaboration by chiropractors and other healthcare professionals are available. This case report describes an older adult with complex low back pain and longstanding tobacco use who received collaborative healthcare while enrolled in a clinical trial. This 65 year-old female retired office worker presented with chronic back pain. Imaging findings included disc extrusion and spinal stenosis. Multiple co-morbidities and the complex nature of this case substantiated the need for multidisciplinary collaboration. A doctor of chiropractic and a doctor of osteopathy provided collaborative care based on patient goal setting and supported by structured interdisciplinary communication, including record sharing and telephone consultations. Chiropractic and medical interventions included spinal manipulation, exercise, tobacco reduction counseling, analgesic use, nicotine replacement, dietary and ergonomic recommendations, and stress reduction strategies. Collaborative care facilitated active involvement of the patient and resulted in decreased radicular symptoms, improvements in activities of daily living, and tobacco use reduction.

Interprofessional collaboration in research, education, and clinical practice: working together for a better future

Interprofessional collaboration occurs when 2 or more professions work together to achieve common goals and is often used as a means for solving a variety of problems and complex issues. The benefits of collaboration allow participants to achieve together more than they can individually, serve larger groups of people, and grow on individual and organizational levels. This editorial provides an overview of interprofessional collaboration in the areas of clinical practice, education, and research; discusses barriers to collaboration; and suggests potential means to overcome them.

Assessing the change in attitudes, knowledge, and perspectives of medical students towards chiropractic after an educational intervention

Objective : We assessed the change in attitudes, knowledge, and perspectives of medical students towards chiropractic after a 1-hour educational intervention. Methods : A mixed-methods approach was used with a 52-item cross-sectional paper survey and 1 focus group of third-year medical students. The views of these medical students towards chiropractic were assessed previously in their second-year of medical school. ANOVA and the Wilcoxon rank-sum test were used to assess between-group differences between the medical students' views before and after the educational intervention. The constant comparative method for analyzing qualitative data was used to identify emergent themes from the focus group transcript. Results : Of 112 third-year medical students, 58 completed the survey (51.7% response rate). The focus group consisted of 6 medical students. Self-reported understanding of chiropractic and number of attitude-positive responses were significantly higher in the group after the educational session. The average number of correct responses assessing knowledge on chiropractic also was significantly higher. Focus group themes were that medical students wanted exposure to chiropractic in clinical settings, had negative attitudes towards chiropractic formed from hidden curriculum, had concerns regarding evidence and safety of chiropractic, and thought that timing of the session on chiropractic was too late in the curriculum. Conclusions : The attitudes and knowledge of medical students towards chiropractic improved immediately after a 1-hour educational intervention. Formally educating medical students on chiropractic may help minimize hidden curriculum issues regarding chiropractic, as identified by the medical students, and facilitate collaboration between medical and chiropractic providers.

Quality of life in patients referring to private osteopathic clinical practice: a prospective observational study

BACKGROUND

Health improvement is one of the main priorities of both public and private health systems. In recent years, more attention has been given to the use of complementary and alternative medicines, including osteopathic manipulative treatment (OMT), as possible effective interventions in increasing patients' health reported outcomes. With regard to OMT, very little research was focused on its effectiveness in enhancing health in the general population.

OBJECTIVES

To explore the extent to which OMT is effective in improving quality of life in referring patients.

DESIGN

Cohort study.

SETTING

Private osteopathic clinical practices in Italy.

INTERVENTIONS

25 osteopaths from Central and Southern Italy participated in the study. Self-referred patients, with a diagnosed musculo-skeletal disorder and older than 18 years of age, who did not undergo any OMT session in the previous 12 months and/or contemporarily additional manual therapies were enrolled.

MAIN OUTCOME MEASURES

Changing from baseline SF36 general health sub-domain scores was used as the study primary outcomes.

RESULTS

1000 patients with primary diagnosis of musculo-skeletal disorder were initially enrolled. 988 patients completed the study. After 4 weeks, mean general health score was 14.7 points higher (95% CI 13.9-15.6; Cohen's d=0.84). Similarly, physical and mental component scores increased (11.5; 95% CI 10.8-12.1; d=0.87 and 9.6; 95% CI 8.6-10.5; d=0.61 respectively). No association between SF36 domains and socio-demographic exposures was found to be statistically significant.

CONCLUSIONS

Positive changes on various quality of life dimensions were reported by patients receiving osteopathic treatment. The trial was registered on clinicaltrials.gov (identifier NCT01965678).