INTRODUCTION
Musculoskeletal (MSK) pain disorders are a largely prevalent source of disability and financial burden both globally and nationally.1–3 United States (U.S.) Veterans experience more chronic pain than the United States general population.4 U.S. Veterans are highly impacted by MSK pain,5 and these conditions are a source of service-connected disability in 90% of Veterans of Iraq and Afghanistan.6
In 1998, the Veterans Health Administration (VHA) enacted the National Pain Management Strategy in response to the high rates and economic burden of pain and later enacted a Stepped Care Model for Pain Management (2009) as its standard for pain care nationally.7 Patient education in self-management strategies (SMS) is included as a first-line treatment in the Stepped Care Model. In addition to this directive, other best-practice initiatives and clinical practice guidelines consistently recommend clinicians provide advice and education to promote self-management to patients with MSK pain conditions.8–14 Many of these guidelines, such as a clinical practice guideline by the American College of Physicians, also recommend non-invasive treatment options – such as those provided by chiropractors – as first-line therapies for MSK pain.15
VHA continues to increase its delivery of non-pharmacological treatment options for MSK pain complaints, including expansion of chiropractic services.16–19 While efforts are continually made to assess the quality of VHA chiropractic care delivered to Veterans,20–22 it is unknown to what degree VHA chiropractors document the provision of SMS to patients. Assessments of delivery of SMS by providers using procedural (CPT®) coding may be limited given time requirements for billing patient education codes. Therefore, manual chart review of provider text may be needed to obtain a more comprehensive measurement of in-office discussion of self-management with patients.
Thus, the goal of this study was to assess the frequency with which VHA chiropractors document providing SMS to patients, and the degree to which patient visit characteristics are associated with delivery of SMS.
Methods
This study was part of a larger quality improvement project assessing various aspects of VHA chiropractic care using administrative data obtained from VHA’s Corporate Data Warehouse and manual EHR chart review. The larger quality improvement project has previously been described in detail.22 The project identified 1,000 on-station VHA chiropractic initial visits occurring in Fiscal Year 2018 (10/01/2017-9/30/2018) in patients with no chiropractic visits in the prior 12 months. All VHA facilities with on-station chiropractic clinics were eligible for inclusion. A team of investigators with collective substantial experience in clinical chiropractic care and VHA systems identified the clinical variables of interest to be abstracted. This team worked with an independent External Peer Review Process contractor, Quality Insights, Inc. (Charleston, WV), to develop the chart abstraction tool. Reviewers abstracted key variables of interest according to the chart abstraction tool from provider free text documentation of chiropractic visit notes and broader EHR elements. This process was piloted on a sample of 60 patients and visits to ensure the chart abstraction tool captured the intended clinical variables of interest.
Ethics
The Veterans Affairs Connecticut Healthcare System’s Research Office determined that this was a quality improvement project and thus exempt from Institutional Review Board review.
Demographics
Data on age, sex, race, and ethnicity of participants were collected using structured queries of VHA’s Corporate Data Warehouse.
Identification of MSK Pain Diagnoses
Abstractors used providers’ free text documentation of visit notes to identify and categorize MSK pain diagnoses at the identified initial visit into the following diagnostic categories: general low back pain (LBP), LBP with radiculopathy, general neck pain, neck pain with radiculopathy, thoracic pain, headache, upper extremity pain or condition, lower extremity pain or condition, generalized syndrome (chronic pain syndrome, fibromyalgia, myalgia, stiffness, muscle pain, unspecified pain, muscle spasm, muscle tension, stiffness), and other diagnoses. Participants were not limited in the number of diagnoses visit notes could include (i.e. a participant could have been diagnosed with both general LBP and thoracic pain diagnoses). However, participants could not have both a general LBP and LBP with radiculopathy diagnosis nor a general neck pain and neck pain with radiculopathy diagnosis. We also counted the number of MSK pain diagnoses per participant. We then categorized participants as having 0 to 1, 2, 3, and 4 or greater diagnoses.
Identification of Treatments Delivered
Abstractors used provider free-text documentation of visit notes to identify treatments received in initial visits as high-velocity low-amplitude (HVLA) manipulation, flexion-distraction manipulation, impulse instrument manipulation, drop-assisted manipulation, manual mobilization, manual traction, manual soft tissue, therapeutic exercise, in-office heat / cold, in-office e-stim / ultrasound, in-office laser, and acupuncture/dry needling. We then grouped these individual treatments into 5 categories including any CMT, any other manual therapies, therapeutic exercise, any modality, and acupuncture / dry needling. Documentation of receipt of treatments was not exclusive (i.e. a participant visit note could have documented receipt of any CMT, any other manual therapy, and therapeutic exercise). Treatments such as therapeutic exercises or any modality (e.g. heat / cold) were required to be specifically documented as delivered in-office (versus instruction to perform at-home).
Abstraction and Classification of Self-Management Characteristics
Abstractors were asked to identify all recommendations, education, or counseling that the chiropractor documented providing to the patient during the initial visit. These items were classified as ergonomic recommendations, use of heat or ice, instruction in home use of TENS/E-stim, advice to remain active, exercises and/or stretching given, and other SMS, which included self-massage, foam rolling, myofascial release, relaxation strategies, and at-home traction. Finally, we tabulated the visits including documentation of delivery of any self-management strategy.
Analysis
The demographic and clinical characteristics pertaining to initial visits were summarized as counts and percentages for categorical variables and as means with standard deviations for continuous variables. Chi-squared tests were used to assess bivariate relationships in categorical variables. Standard multivariable logistic regression analysis (significance at α = 0.05) was used to examine associations between participant demographic and initial visit characteristics and receipt of any SMS. The observations per variable included in the model (978 observations and 9 variables) exceeded the recommended number of 10 observations per variable for multivariable logistic regression as described by Peduzzi et al.23 All analyses were conducted using Microsoft Excel and Stata.24,25
Reporting
We report this study according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist/guidelines.26
Risk of Bias
The sample of 1,000 charts was identified using simple random sampling to avoid selection bias. To ensure completeness of data, we excluded cases where complete data were not available. To minimize selective reporting bias, all outcomes measured in the study were included in the manuscript, regardless of their direction or significance.
Results
One thousand initial chiropractic visit records were identified, originating from 69 of the 105 VHA facilities providing on-station chiropractic services during the study timeframe. The median count of records per facility was 12 (range: 1- 53). Of the 1000 initial chiropractic visit records, 22 were excluded due to lack of completing an index visit during the study timeframe. Ultimately, 978 index VHA chiropractic visits were included.
Participant Demographic and Visit Characteristics
The majority of participants were male (82%), 74% were white, and the mean age was 52.5 (standard deviation (SD): 15.6). LBP diagnoses were the most common (75.6% with any LBP diagnosis, 51.6% with general LBP, 23.9% with LBP with radiculopathy), followed by neck pain diagnoses (39.9% with any neck pain diagnosis, 35.9% with general neck pain, 4.0% with neck pain with radiculopathy), thoracic pain (25.5%) lower extremity pain (10.9%), generalized syndrome (10.9%), upper extremity pain (6.2%), and headache (4.7%). Other diagnoses (e.g. jaw pain) were present in 4.0% of participants. Most participants had more than 1 condition (91.2%). Approximately one-third (31.9%) of participants had 4 or more MSK pain diagnoses recorded in the provider text (Table 1). Treatment was provided in 797 (81.5%) of the 978 visits. CMT was the most common treatment delivered (65.4%), followed by other manual therapy (42.2%), therapeutic exercises (32.2%), any modality (12.0%), and acupuncture / dry needling (7.7%) (Tables 1 and 2).
Delivery of SMS
SMS were documented as delivered in 431 (44.1%) of participant visit notes. Advice to remain active was the most common form of self-management documented as delivered (18.0% of cases), followed by use of heat/ice (15.8%), exercises/stretches given (14.0%), ergonomic recommendations (13.8%), home use of TENS/E-stim (1.8%), and other SMS (1.7%), which included self-massage, foam rolling, myofascial release, relaxation strategies, and at-home mechanical traction.
Factors Associated with Documentation of Receipt of Any SMS
Veteran age, race, and ethnicity were not significantly associated with receipt of SMS (Table 3). There was no clear relationship between the type of diagnosis and documented delivery of SMS. We included the count of participant diagnoses in the multivariable logistic model instead, as the count of diagnoses demonstrated a stronger association in bivariate analyses and there was a high rate of comorbidity between diagnoses. Veterans with three MSK pain diagnoses were significantly more likely to receive SMS, while the associations with all other counts of MSK pain diagnoses were nonsignificant in both unadjusted and adjusted models. Documentation of receipt of each treatment type was significantly associated with documentation of receipt of any SMS in unadjusted analyses (Table 1). In adjusted analyses (Table 3), documentation of treatment with acupuncture/dry needling remained significantly associated with decreased odds (aOR: adjusted odds ratio) of receipt of SMS (aOR=0.50; 95% CI: 0.27, 0.91), while ‘other manual therapies’ (aOR: 1.41; 95% CI: 1.04, 1.92), ‘other modalities’ (aOR: 2.46; 95% CI: 1.54, 3.91) and ‘therapeutic exercise’ (aOR: 6.14; 95% CI: 4.47, 8.43) remained associated with increased odds. The association of CMT and SMS became nonsignificant in the adjusted model.
Discussion
Summary of Main Findings
Documentation of delivery of SMS was present in 44% of VHA chiropractic initial visit notes, with advice to remain active being the most common strategy delivered. The majority of demographic and clinical variables did not demonstrate meaningful associations with documented delivery of SMS. There was an increase in associated odds of SMS in participants with three MSK diagnoses which did not hold for the group with four or greater diagnoses. The type of treatment documented as provided was frequently associated with documentation of delivery of SMS. Therapeutic exercise was associated with the greatest odds of delivery of SMS while there was an inverse association between acupuncture/dry needling and SMS.
Interpretation
Demographic variables were not significantly associated with SMS. However, in future work with a set of more nuanced and comprehensive predictors, demographics should be examined to see what associations are present. Treatment/intervention choice, which is in-part provider-driven,27–29 was frequently associated with documented delivery of SMS. Provider characteristics, such as years of practice and involvement in teaching, have been significantly associated with delivery of advice and education in chiropractic settings.30 As such, it is possible that documented delivery of SMS is most strongly explained by individual provider characteristics.
The odds of documented delivery of SMS associated with provision of therapeutic exercises were much greater than in other treatments. These data may suggest providers who deliver therapeutic exercises are more likely to provide SMS. A previous study found chiropractors who had been in practice less than five years were more likely to prescribe therapeutic exercises and provide advice and education.30 However, it is also possible that participants’ clinical presentations may have driven the selection of delivery of therapeutic exercises and SMS in consultation visits. The same study found the presence of medical comorbidities and patient BMI to be associated with likelihood of delivery of therapeutic exercises. It is unclear why participants in our study receiving acupuncture/dry needling were less likely to receive SMS while all other treatments were associated with increased odds. However, the number of participants receiving this intervention was fewer than any other in this study. The association between treatment with acupuncture/dry needling and delivery of SMS warrants further investigation. Participants who did not receive treatment in initial visits were significantly less likely to receive SMS. This may have been impacted by unmeasured variables such as time constraints, additional diagnostic workup being deemed necessary by the provider before provision of treatment, or providers deeming chiropractic care to be inappropriate. Future sampling should consider the requirement of at least one follow-up visit with the chiropractic clinic to control for these factors.
While participants having 3 MSK pain diagnoses was significant in the multivariable regression model, we were unable to determine meaningful differences between these participants and the rest of the sample population. Diagnoses were only captured in initial visits. Including assessments of subsequent visits may have impacted the count of diagnoses per participant. Additionally, the count of diagnoses was established by abstracting provider free text rather than documented diagnostic coding. As such, the relationship between the number of diagnoses present and delivery of SMS should be assessed in a complete episode of care.
Published data assessing delivery of SMS in chiropractic settings are limited. However, some data exist assessing delivery of advice and education in these settings. An observational study of chiropractors in Australia and Canada by Jenkins et al. and a scoping review including an assessment of care provided by chiropractors by Bealiveau et al. found advice and education were delivered in 25% and 31% of chiropractic visits, respectively.30,31 It’s important to note that these studies broadly assessed advice and education – where education may not have consisted of SMS – compared to the present study which specifically assessed SMS. Additionally, our study was limited to consultation visits – which may be more likely to contain provider advice and education in chiropractic settings30 – whereas the studies by Jenkins et al. and Beliveau et al. were not limited to these.
Limitations and Directions for Future Work
As with all EHR assessments, this study relied on the accuracy of clinicians’ documentation of patient encounters. It is possible that clinicians provided education on self-management that went undocumented and thus was not included as a result in this assessment. The chart abstraction process did not determine the specific conditions for which SMS were provided. Generalizability of results may be limited as random sampling was not stratified by chiropractic clinic capacity. Unmeasured clinical variables, such as pain interference and severity, may have impacted results. This assessment was performed on initial VHA chiropractic visits and therefore would not have captured delivery of SMS at subsequent visits. Future work should assess these variables over the course of a complete episode of care.
Conclusion
VHA chiropractors documented delivering SMS in 44.1% of consultation visits. The type of treatment documented as provided was frequently associated with documentation of delivery of SMS, while other demographic and clinical characteristics did not have meaningful associations. More work is needed to better understand documented delivery of SMS over the course of a complete episode of care and associations with VHA chiropractic patient outcomes.