A Systems Approach for Assessing Low Back Pain Care Quality in Veterans Health Administration Chiropractic Visits: A Cross-Sectional Analysis

The Chiro.Org Blog

SOURCE:   J Manipulative Physiol Ther 2023 (Dec 22) [EPUB]


Ryan D. Muller, DC, MS • Sarah E. Graham, DC • Xiwen Zhao, MSPH • Anna R. Sites, MSN, RN • Kelsey L. Corcoran, DC • Anthony J. Lisi, DC

VA Connecticut Healthcare System,
West Haven, Connecticut;
Yale School of Medicine,
Yale University,
New Haven, Connecticut.

Objective:   The purpose of this study was to explore a systemwide process for assessing components of low back pain (LBP) care quality in Veterans Health Administration (VHA) chiropractic visits using electronic health record (EHR) data.

thods:   MeWe performed a cross-sectional quality improvement project. We randomly sampled 1000 on-station VHA chiropractic initial visits occurring from October 1, 2017, to September 30, 2018, for patients with no such visits within the prior 12 months. Characteristics of LBP visits were extracted from VHA national EHR data via structured data queries and manual chart review. We developed quality indicators for history and/or examination and treatment procedures using previously published literature and calculated frequencies of visits meeting these indicators.

There is more like this @

LOW BACK PAIN Section and


Visits meeting our history and/or examination and treatment indicators were classified as “high-quality” visits. We performed a regression analysis to assess associations between demographic/clinical characteristics and visits meeting our quality criteria.

Results:   There were 592 LBP visits identified. Medical history, physical examination, and neurologic examination were documented in 76%, 77%, and 63% of all LBP visits, respectively. Recommended treatments, such as any manipulation, disease-specific education/advice, and therapeutic exercise, occurred in 75%, 69%, and 40% of chronic visits (n = 383), respectively. In acute/subacute visits (n = 37), any manipulation (92%), manual soft tissue therapy (57%), and disease-specific advice/education (54%) occurred most frequently. Female patients and those with a neck pain comorbid diagnosis were significantly less likely to have a “high-quality” visit, while other regression associations were non-significant.

Conclusion:   This study explored a systemwide process for assessing components of care quality in VHA chiropractic visits for LBP. These results produced a potential framework for uniform assessment of care quality in VHA chiropractic visits for LBP and highlight potential areas for improvements in LBP care quality assessments.

Keywords:   Chiropractic; Low Back Pain; Quality Assurance, Health Care; Veterans Health.

From the FULL TEXT Article:


Low back pain (LBP) causes more years lived with disability (YLDs) worldwide than any other condition and has a global point prevalence of 7.5%. [1] Low back pain is the leading cause of YLDs in the United States (US) population. [2] An estimated $135.5 billion was spent on care for low back and neck pain in the US in 2016, with costs increasing by 6.7% annually from 1996 to 2016. [3, 4] United States veterans are particularly affected by LBP, as it is the second most common musculoskeletal disorder that affects veterans receiving care in the Veterans Health Administration (VHA). [5]

The VHA has been increasing its delivery of evidence-based, non-pharmacologic treatment options for LBP and other pain conditions by expanding Veteran access to a number of treatment approaches, including chiropractic care. [6, 7] Use of chiropractic care in the VHA, most commonly for LBP, has been increasing rapidly, yet little is known about the quality of delivered services. [8, 9]

Appropriate diagnostic workup is an important component of care for patients with LBP. [10] Previous investigators have identified quality indicators, such as key history and examination procedures, that, when present in clinical documentation, serve as markers of a desired LBP workup. [11, 12] However, health care providers’ adherence to some of these elements of quality, such as documenting a thorough neurologic examination and screening for serious diseases, has been shown to be poor. [11]

Providing appropriate management options is also critical in caring for patients with LBP. [13] Evidence from physical therapy and primary care settings, as well as analyses of health care claims data, suggest that guideline-adherent management of patients with LBP may result in better patient outcomes, reduced risk of recurrence, and lower associated medical costs. [14–17] As such, researchers have used clinical practice guidelines (CPGs) as references to assess how often recommended treatment options for LBP are provided in health care settings. [14, 15, 18, 19] Current CPGs recommend non-pharmacologic treatments as first-line therapies in the management LBP. [13, 20, 21] Despite evidence in favor of guideline-adherent care, discrepancies remain between CPG recommendations and the treatments provided to patients with LBP in practice. [18, 19, 22, 23]

Read the rest of this Full Text article now!