This past year, the Ontario Chiropractic Association (OCA) received funding and support from the Ministry of Health and Long-Term Care to develop, implement and evaluate a consulting chiropractor role in primary care for low back pain.

This was part of the ministry's initiative to address barriers to the provision of high-quality and appropriate care for LBP in Ontario. This model of care is based on the introduction of an assessment clinic for LBP in a primary care physician's office. The consultant, a chiropractor, performs an assessment of approximately 30 minutes in length with a patient previously identified as having acute, recurrent or chronic LBP and referred to the clinic by the primary care provider.

It is important to note that the assessment clinic was not designed as a treatment model – but rather assessment and education. The outcome of the assessment is advice and decision support provided to the physician, and the inherent knowledge transfer that takes place between providers. The objective of the pilot project was to test the feasibility, acceptability and value of this model of care in the Ontario context. This project met the pre-pilot expectation in demonstrating the consulting chiropractors' ability to contribute positively to the care for patients with low back pain in physician primary care settings.

Four DCs were partnered with four group primary care practices for a six-month pilot phase. A total of nine hours was allocated per month per site for the assessment clinics, which took place in the primary care practice. Thirty-three physicians signed the consent form to participate in the pilot project.

A mixed-methods approach was used to capture the data required to meet the evaluation objectives of the project. Data was collected pre-pilot, during the pilot and post-pilot. Methods included semi-structured interviews, clinical practice guideline and reflective surveys with both the chiropractors and physicians. Some patient-level data was collected via graded chronic pain scale questionnaires, clinical notes and patient satisfaction surveys following each visit.

The consulting DCs appeared to influence the primary care physicians in their decision-making regarding the management of patient cases; specifically, the appropriateness of advanced imaging / referral to specialists and in their understanding of patient self-management / education strategies. There was strong evidence that physicians benefited from the knowledge transfer, as they reported higher levels of confidence in dealing with similar cases in the future. Most of the physicians valued the participation of and access to the chiropractors. An external agency was commissioned to develop the evaluation framework and conduct an independent evaluation of the project.

This model of care was built on the framework of evidence-based recommendations to the physicians. In addition, because of the co-location of the assessment clinics, there was an expanded opportunity to encourage collaborative care that focused on joint diagnosis and interprofessional patient care plans. Based on established clinical practice guidelines and evidence-informed criteria, the consulting DC provided advice to the physician on whether the patient was a potential surgical candidate with a recommendation for referral to a spine surgeon or other specialist; whether the patient had received appropriate and sufficient guideline-driven conservative care, and what treatment / referral options, if any, should be considered; and what, if any, advanced diagnostics should be ordered / considered.

Key Findings

Satisfaction

• High patient satisfaction (94 percent of patients said they were "very satisfied" or "satisfied") with care
• High provider satisfaction. All physicians made reference to the value in referring LBP patients to the consulting DC assessment
• Quicker access and faster diagnosis of patients
• The majority of physicians perceived the consulting chiropractor's assessment / management of LBP as being of higher quality than physicians

Knowledge Transfer

• Increased physicians' self-reported confidence in assessing and managing LBP patients (71 percent); knowledge of appropriate imaging and specialist referral for LBP patients; identification and management of yellow flags for LBP patients; understanding of the role of exercise and or physical activity for LBP patients (71 percent); and knowledge of community resources available to LBP patients
• Increased consulting chiropractors' understanding of the importance of streaming the information that is given to the PCPs; knowledge of medication management for LBP patients; and awareness of evidence-based Web sites and patient screening tools

Value

From the perspective of the physicians, quick turnaround between physician referrals to the assessment clinic resulted in several key benefits, including the following:

• Increased reassurance for the patient
• Increased patient confidence in diagnosis and treatment options
• Decrease in patients requesting specific referrals
• Decrease in referrals for imaging and specialists (71 percent of physicians reporting)

The majority of participating physicians identified that the clinical note(s) provided by the consulting DC was a key benefit to this model of care.  Effective communication between professional groups is an important facilitator to successful collaboration. Traditionally within primary care, this communication has relied on written formats: referral forms, feedback forms, case notes, care plans, letters, faxes and message books. Unfortunately, most physicians continue to cite that they rarely receive any communication following shared patient care from chiropractors. In consultation with family physicians, the OCA has developed a consultation note for this purpose. 

Some of the potential challenges of sharing patient information originate with how the information is captured in patient charts and clinical / consultation notes. The form creates common terminology on charting relevant to the data elements that are most relevant to the physician. The OCA encourages members to use this form to send clinical / consultation notes back to the physician, at a minimum, following the initial patient visit. This form has also been incorporated into the OCA's Patient Management Program (PMP), allowing users to access and complete this form electronically through the system, making the sharing of patient information much faster and more efficient.

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Submitted by the Ontario Chiropractic Association. For further information related to this project, contact Andrea Endicott, OCA senior health policy analyst, at , 416-860-7188 or toll-free 1-877-327-2273, ext. 7188.

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