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Chiropractors' characteristics associated with their number of workers' compensation patients.

Introduction

"Work disability occurs when a worker is unable to stay at work or return to work because of an injury or disease" (1). Work disability is associated with many consequences for the worker, employer, healthcare system and compensation system. (2) There is increasing evidence that health care providers may influence work disability, both positively and negatively. (3) The most prevalent components of clinical return-to-work interventions for musculoskeletal disorders are physical exercises, education and behavioral treatments. (4) These components are considered the core components of return-to-work interventions. (5-9) Unfortunately, early aggressive care may delay recovery (10-14) from whiplash injuries and not listening carefully to the patient (particularly women) may delay return-to-work for occupational low back pain (15). Unnecessary diagnostic imaging tests are also frequently ordered. (16-20)

It has been demonstrated that general practitioners are less likely to implement evidence-based management of back pain than occupational physicians and occupational therapists. (21,22) The latter health care providers experience fewer barriers to guideline implementation because their tasks focus on disability prognosis, yellow flag management, and return to activity parameters. (22) However, little is known about the impact of doctors of chiropractic (DCs) on work disability and their adherence to guidelines. Chiropractic and medical care appear to have similar cost-effectiveness during the treatment of occupational low back pain (23,24) and chiropractic adherence to radiological guidelines appears to be increasing (25-28). The broad approaches described by DCs experienced in the treatment of occupational injuries are consistent with those proposed by evidence-based guidelines. (29) Barriers related to different provincial workers' compensation systems have previously been identified by Canadian DCs. (29) It has been hypothesized that DCs that treat a relatively high volume of workers' compensation cases may have different characteristics than the general chiropractic community. (29) In Quebec, the act regulating occupational injuries grants physicians the role of sole gatekeeper. (30) This is the only province where chiropractic care, to be reimbursed by the provincial workers' compensation board, must be prescribed by a medical doctor. It is thus reasonable to hypothesize that DCs from the province of Quebec treat fewer workers' compensation cases on average than DCs from other provinces.

Little is known about the characteristics of health care providers who tend to treat more workers' compensation cases. Identifying those characteristics is important for understanding the care seeking behaviours of injured workers. This research project aimed to perform a secondary data analysis from a nationwide survey to describe the characteristics of Canadian DCs who tend to treat more workers' compensation cases.

Specific objective

To identify DCs' characteristics that are associated with the number of workers' compensation patients they treat.

Methods

Study design

We performed a cross-sectional analysis using the 2011 survey of the Canadian Chiropractic Resources Databank (CCRD). (31) Members of the Canadian Chiropractic Association (CCA) were surveyed using a self-administered questionnaire (mail or online version). The University of Montreal Health Research Ethics Board approved this study (13-106-CERES-D).

Study Population

The study population included all Canadian DCs who were CCA members and had active practices in 2011. DCs practicing another profession (i.e., dentist, physician, nurse, occupational therapist, physiotherapist, psychologist or radiologist), or not in active practice (i.e., practicing less than 10 hours per week or 37 weeks yearly, retired and semi-retired) were excluded. During the 2011 iteration of the CCRD, 6,533 survey questionnaires were mailed to members of the CCA. The respondents were able to return the paper version of the questionnaire by mail or to complete the survey online. 1,889 questionnaires were returned by mail and 640 were completed online, resulting in a total of 2,529 completed questionnaires. The effective response rate was 38.7 percent. A total of 652 respondents were excluded because they were practicing another profession, not in active practice, or had missing answers for the main dependent variable. The current study included 1,877 respondents (Figure 1).

Source of data

The CCRD survey includes 81 questions detailing the practice and concerns of DCs and is used to inform the Canadian Chiropractic Association about services to provide to their membership. (31) For this project, we used information concerning professional activities, education, research and teaching activities, main sectors of activity, care provided to patients, chiropractic techniques used, type of conditions treated, and referral practices.

Description of study variables

Annual number of workers' compensation patients treated by a DC (dependent variable)

The annual number of workers' compensation pa tients treated by a DC was obtained by multiplying the respondent's answers to the following questions:

--The average number of new patients / week

--The average number of weeks practicing chiropractic per year

--The percentage of monthly income from the workers' compensation board.

DC characteristics (independent variables)

The survey administered by the CCRD includes multiple items that describe the practice of DCs. The questionnaire contained items classified into five category headings: background information (demographics), professional activity, education, training and affiliations, practice characteristics, finances and income (31). Pertinent themes were selected a priori and our hypotheses of the association between selected variables and the number of workers' compensation cases are listed in Appendix 1.

Analyses

We generated frequencies (categorical variables) or means and standard deviations (continuous variables) for variables that we determined as relevant a priori. To investigate non-responses to the survey, we compared the analyzed sample to the complete CCA membership for all available characteristics (i.e., sex, college of graduation, years of practice and province of exercise) using Student's t-tests and Pearson's chi-square test. Bivariate analyses were conducted between all the predetermined independent variables and the annual number of patients referred by MDs using Student's t-tests and ANOVA for categorical variables and Pearson's correlation coefficients for continuous variables. When appropriate, the Games-Howell for unequal variances post-hoc test was applied. (32) All comparisons were 2-tailed and considered statistically significant at p < 0.05.

Because our data were highly skewed and over dispersed (i.e., the variance was greater than the mean), a multivariate negative binomial regression was performed to identify factors associated with the number of workers' compensation cases. We did not include the number of new patients per week and the number of weeks of practice per year in our model because they were used to construct the dependent variable. All other independent variables with a P < 0.25 in bivariate analyses were entered into the multivariate negative binomial regression model. The least significant variables were removed from the model individually until all remaining variables had a P < 0.10 to form the preliminary model. We then attempted to reintroduce all the excluded variables individually. The final model was created by reintroducing variables into the model if they had a P < 0.10 or if their introduction altered the other variables' coefficients by more than 10%. We reported the incidence rate ratios (IRR) and their 95% confidence intervals for each independent variable included in the final model. The IRR values were obtained from the regression coefficients on an exponential scale. IRR values greater than 1 represent an increase in the annual number of workers' compensation cases and values lower than 1 represent a decrease. For continuous variables, the IRR represents the average change in the predicted annual number of workers' compensation patients for a one-unit increase of the independent variable. For categorical variables, the IRR represents the factor of change in the predicted annual number of workers' compensation patients attributable a given category of the independent variable under examination compared to the reference category. All analyses were performed using SPSS for Mac (version 21.0, IBM corporation, Armonk, NY, USA).

Results

On average, DCs received 10.3 (standard deviation (SD) = 17.6) workers' compensation cases per year. This finding represents 6.2% of all new patients treated by DCs on average in a year. The distribution of the workers' compensation cases was heavily skewed to the right (Figure 2), with 29.9% of DCs receiving no such cases and 5% receiving more than 40 per year. The results of the bivariate analyses examining the associations between DC characteristics and the number of workers' compensation cases are presented in Table 3. In this table, the numbers in the second column represent the average number of workers' compensation patient seen each year and SD for categorical variables and the Pearson's correlation coefficients for continuous variables.

Representativeness of the current study

The characteristics of the analyzed sample are presented in Table 1. When compared with the complete 2011 membership of the Canadian Chiropractic Association, the analyzed sample had similar distributions in terms of college of graduation, but the analyzed sample included slightly more males (2.9%), included slightly more experienced DCs (1.8 years) and had a significantly different provincial distribution (Table 2).

Association with the number of workers' compensation cases

Bivariate results

General information

Male DCs and DCs who perceived that there was an appropriate number of DCs in their area received significantly more workers' compensation cases. DCs from Saskatchewan, Manitoba and the Atlantic provinces received significantly more workers' compensation cases than DCs from the other provinces. DCs from British Columbia, Alberta and Ontario received significantly fewer workers' compensation cases than DCs from Saskatchewan, Manitoba and the Atlantic provinces, but significantly more cases than DCs from Quebec. DCs practicing in areas of more than 500,000 inhabitants received significantly less workers' compensation cases than those practicing in areas with populations between 10,000 and 49,999 inhabitants or between 100,000 and 499,999 inhabitants. Age and years of practice were not significantly associated with the number of workers' compensation cases. Post hoc specific comparisons did not reveal significant differences between the types of practice.

Professional activities

The number of hours of practice per week, the number of new patients per week and the number of treatments performed per week were all significantly, positively correlated with the number of workers' compensation cases. The number of weeks of practice per year was not significantly correlated with the number of workers' compensation cases.

Education, research and teaching

DCs who had graduated from the Canadian Memorial Chiropractic College (CMCC) received significantly more workers' compensation cases than those who had graduated from the Universite du Quebec a Trois-Rivieres (UQTR) and Palmer West (PCC-W). The amount of postgraduate education, continuing education, teaching, management training, practice management services, and research activities were not significantly associated with the number of workers' compensation cases.

Main sectors of activity

DCs reporting occupational/industrial practice, rehabilitation practice, or sports injury management as a main sector of activity received significantly more workers' compensation cases. DCs reporting maintenance/wellness activities or pediatric care as a main sector of activity received significantly fewer workers' compensation cases. Reporting that consulting/specialized assessment activities, geriatric care, nutritional activities, or pregnancy care was a main sector of activity was not significantly associated with the number of workers' compensation cases.

Care provided to patients

DCs that performed their own radiographs received significantly fewer workers' compensation cases than those who referred their patients to radiology clinics. The percentage of patients who were radiographed was significantly negatively correlated with the number of workers' compensation cases. Providing acupuncture, cryotherapy, diathermy, electrotherapy, exercises, heat packs, low volt, soft-tissue therapy, traction, flexion/distraction, ultrasound or patient education was associated with a significantly greater number of workers' compensation cases. The adjustment practice and providing laser therapy were not significantly associated with the number of workers' compensation cases.

Chiropractic techniques used

DCs reporting the use of the Diversified technique received significantly more workers' compensation cases. DCs reporting the use of the Hole-In-One technique received significantly fewer workers' compensation cases. The uses of the Thompson, Sacro-occipital, Gonstead, Activator or Cranio-Sacral techniques were not associated with the number of workers' compensation cases.

Types of conditions treated

The reported percentage of patients with neuromusculoskeletal conditions was significantly positively correlated with the number of workers' compensation cases. The reported percentage of patients with somatovisceral conditions was significantly negatively correlated with the number of workers' compensation cases. The reported percentage of patients with vascular conditions was not significantly associated with the number of workers' compensation cases.

Referral practice

The reported percentages of patients referred by their employer or by a physician were significantly positively correlated with the number of workers' compensation cases. The reported percentage of patients referred to other health care providers was not significantly correlated with the number of workers' compensation cases.

Multivariate results

Our final multivariate model (Table 4) included the following: type of clinic; population of practice area; province of practice; number of hours of practice per week; number of treatments per week; post graduate studies; management training; main sector of activity (occupational/industrial); providing radiographic examination at the clinic; care provided to patients (electrotherapy, soft-tissue therapy); chiropractic technique used (Sacro Occipital technique, Thompson, Cranio-sacral technique); percentage of patients with neuromusculoskeletal conditions; and the percentage of patients referred by their employer or a physician. All the independent variables of the final model influenced the dependent variable in the same direction as in the bivariate analyses; however, slight changes in their statistical significance were observed. Quebec DCs received significantly fewer workers' compensation cases than DCs of the other provinces, but the difference from Ontarians was not significant when controlling for all other variables. Sole practitioners received significantly less workers' compensation cases than DCs practicing with a group of DCs or in a multidisciplinary clinic (without an MD) when controlling for all other variables. Postgraduate studies, management training, and some chiropractic techniques (Sacro Occipital, Thompson and Cranio-sacral techniques) were not significant in the bivariate analyses but became significant in the multivariate model. Providing radiographic examination at the clinic was significantly associated with the number of workers' compensation cases in the bivariate analyses, but not in the multivariate model.

Discussion

Several of our intuitive a priori hypotheses were not confirmed: age, years of practice, number of DCs in relation to demand, post graduate studies, continued education, adjustment practice, involvement in research and teaching activities were not associated with the reported number of workers' compensation cases treated per year. CMCC graduates reported more workers' compensation cases than graduates from UQTR in the bivariate analysis, but the college of graduation was not statistically significant in the multivariate analysis. The difference observed in the bivariate analysis was most likely attributable to provincial differences because nearly all UQTR graduates are practicing in Quebec.

The results of our analysis indicate that three broad categories of factors may influence the number of workers' compensation cases that a DC reports, including the DC's interactions with other health care providers, a practice oriented toward the treatment of injured workers, and potential access to care.

Interactions with other health care providers

In both our bivariate and multivariate analyses, receiving more physician referrals was associated with a greater number of reported workers' compensation cases. This is consistent with the results of a previous American study that concluded that physicians were involved in the treatment of the majority of workers receiving care for occupational low back pain. (33) Sending the patient to another clinic for radiologic investigation was associated with a greater number of reported workers' compensation cases. This association may also indicate better physician-DC collaboration. Working in a multidisciplinary clinic without a physician was also associated with a greater number of reported workers' compensation cases when controlling for the amount of physician referrals. This result suggests that collaboration with other health care providers is also important during the care of injured workers. This result is supported by the literature, which views inter-professional collaboration as a cornerstone of successful return-to-work. (34-37) Surprisingly, referring more patients to other health care providers was not associated with the number of reported workers' compensation cases. This result is may be because in the context of occupational injuries, DCs may receive referral patients that are primarily within their scope of practice. DCs reporting maintenance and wellness care as a main sector of activity reported significantly fewer workers' compensation cases in all our analyses. This is potentially because they may be perceived as providers of excessive care by other health care providers (38,39) or by patients who want to rapidly return to work. DCs attending management training reported significantly fewer workers' compensation cases only when controlling for other variables in the final model. Their marketing strategy may be perceived to be aggressive, which can have a negative impact on physician referrals. (39) DCs interested in developing an occupational practice should develop good inter-professional relationships with physicians and other health care providers.

Practices oriented on the treatment of injured workers

It is not surprising that DCs with occupational/industrial and rehabilitation as main sectors of activity report more workers' compensation cases. Although sports injuries can be similar to occupational injuries, a pediatric-oriented practice is obviously different from an occupational practice. An explanation for the significantly lower number of reported workers' compensation cases associated with the completion of post graduate studies may be that these DCs specialize in a different field than occupational injury DCs. It is also not surprising that DCs that treat a higher percentage of patients with neuromusculoskeletal conditions report more injured workers because occupational injuries generally lie within their scope of practice. Occupational diseases are not within the scope of chiropractic practice and require medical care.

DCs that treat more injured workers also appear to provide care that respects radiographic guidelines, with less radiographic use associated with an increased number of reported workers' compensation cases. (27,28,40-42) Common components of clinical return-to-work interventions for musculoskeletal disorders (4), such as physical exercise and patient education, were also associated with higher numbers of reported workers' compensation cases. In fact, every additional treatment modality (with the exception of laser therapy) had a significant positive impact on the number of reported workers' compensation cases in the bivariate analyses. Electrotherapy and soft-tissue therapy met the inclusion criteria for the multivariate model. DCs that offer multimodal care may be perceived as having added value over those that provide only spinal manipulations. Although these results are interesting, clinician DCs should consider the best interests of their patients and remember that spinal traction, laser therapy, electrotherapy and ultrasound are not recommended by the National Institute for Health and Care Excellence (NICE) guidelines for the early management of persistent, non-specific low back pain. (43)

In our bivariate analyses, the Diversified technique had a significant positive impact on the number of reported workers' compensation cases while the Hole In One technique had a significant negative impact. In our multivariate analysis, the Thompson technique had a significant positive impact on the number of workers' compensation cases reported while Sacral Occipital Technique had a significant negative impact when controlling for all other variables. The Hole in One technique is a spinal manipulative technique specializing in the upper cervical area. Because cervical injury is only one type of occupational injury, this may explain why DCs using this technique report fewer workers' compensation cases. Additionally, DCs using the Thompson and Sacral Occipital techniques may provide different care to workers' compensation patients or patients may differently seek care from DCs that use these techniques. Further investigations will be necessary to understand the impact of chiropractic techniques on care seeking behaviors.

DCs that report more workers' compensation cases also report more employer referrals. This observation is interesting because an American study revealed that employers selected the majority of providers for workers who receive care. (33) Employers were more likely to choose physicians, while workers were more likely than employers to select DCs (33).

Our results suggest that DCs that consider occupational/industrial care as a primary sector of activity, stimulate employer referrals and offer care adapted to the needs of injured workers (multimodal care, avoiding excessive radiographic imaging); therefore, these DCs tend to report more workers' compensation cases.

Potential access to care

In both our bivariate and multivariate analyses, the practice area population, practice province and number of practicing hours per week were significantly associated with the reported number of workers' compensation cases. The number of practicing hours per week as well as practicing in a group of DCs (compared with solo practice) increases the number of hours when injured workers are able to seek care. Our results indicate that DCs in larger cities (more than 500,000 inhabitants) report less workers' compensation cases. Usually, Canadians in rural areas experience more difficulty when seeking immediate care. (44) A possible explanation for these results may be that injured workers in smaller towns have access to a limited number of providers and seek more care from their local DCs, while the opposite situation is present in metropolitan centers. When DCs perceive that there is an appropriate number of DCs in their area, they report significantly more workers' compensation cases than when they perceive that there are too many DCs, which also supports the previous hypothesis. As expected, Quebecers report significantly fewer workers' compensation cases than DCs from the other provinces in all our analyses. Physicians, the sole gatekeepers to the Quebec worker's compensation system (30), are acting as a barrier to chiropractic care. In general, the residents of eastern Canadian provinces are more likely to report difficulty accessing routine and immediate care than residents of western provinces (44). This may explain why DCs in the Atlantic provinces receive the highest number of workers' compensation cases. Our results suggest that DCs offering more office hours and practicing in areas with limited access to other health care resources report more workers' compensation cases.

Strengths and Limitations

The main strength of this study is the large sample size, which provides sufficient statistical power for modeling all the investigated DC characteristics. The use of an appropriate regression model (negative binomial) also enabled us to deal with the highly skewed distribution of the annual number of workers' compensation cases.

Our results obtained from the secondary analysis of the CCRD cross-sectional survey should be interpreted with caution. As with every cross-sectional study, the temporality of the exposure-outcome relationship cannot be firmly established. A prospective study would provide better evidence regarding the temporality of the observed associations between the different independent variables and the amount of workers' compensation board cases. The low response rate, 38.7%, has important implications. It is possible that non-responders may have systematically differed from responders and that our results may have limited the generalizability to DCs outside of the analyzed group. Additionally, the proportion of respondents differed between the provinces. The DCs in our analysis had an average 1.8 years more practice experience and were 2.9% more often males than the complete CCA membership. Although these differences are relatively small, they are significant and may have biased the magnitude of the observed associations. It is also possible that DCs that chose to be CCA members have different profiles than non-members. However, in order to reverse the direction of the observed associations, the non-respondents would need to show an inverse relationship between the dependent and the independents variables. The CCRD survey was not designed for the purpose of this study and the metric properties of the questionnaire are unknown. Our composite dependent variable might not reflect the exact number of workers' compensation case seen by DCs. Furthermore, our model only included data available in the CCRD and it is possible that other variables, such as the incidence of occupational injuries in the area of practice, may be of interest.

Nonetheless, we believe our results provide valuable information regarding DC characteristics associated with the amount of workers' compensation cases. Additional qualitative research would be useful to better identify the relevant factors that influence the type of care sought by injured workers and to understand the mechanism underlying the choice of healthcare provider.

Conclusion

The reported number of workers' compensation cases substantially varies among Canadian DCs, with nearly one-third of DCs' receiving no cases and a few DCs receiving many cases. Canadian DCs with practices oriented toward the treatment of injured workers that collaborate with other health care providers and facilitate workers' access to care reported more workers' compensation patients.

Appendix 1 List of a priori hypotheses regarding the
association between relevant CCRD variables and the number
of workers' compensation patients seen per year

Variable                Hypothesis

General information

Sex                     Women see less workers' compensation patients
                        since they were under represented in a previous
                        study (29).

Age, years of           Older DCs receive fewer workers' compensation
practice                patients because they adhere less to new
                        guidelines (21).

Type of practice        DCs in multidisciplinary clinics receive more
                        workers' compensation patients

Practice province       Quebecers receive fewer workers compensation
                        patients because they require prior medical
                        referral.

Practice area           DCs in smaller towns receive more workers'
population              compensation patients.

Number of DCs in        DCs that practice in areas with a high
relation to demand      concentration of DCs are expected to receive
                        fewer workers' compensation patients

Professional activities

Number of hours of      No association is expected
practice/week

Number of weeks of      No association is expected
practice / year

Number of treatments    DCs who receive a high volume of patients are
/ week                  expected to receive fewer workers compensation
                        patients Or DCs treating more patients are more
                        successful at attracting workers' compensation
                        patients

Education, research and teaching

College of              DCs graduating from a "straight" college receive
graduation              fewer workers' compensation patients.

Post graduate           DCs with post graduate qualifications receive
studies                 more workers' compensation patients

Number of hours of      DCs that are more up-to-date receive more
continued education     workers' compensation patients

Management training     DCs who receive a high volume of patients are
in the last 3 years     expected to receive fewer workers' compensation
                        patients Or DCs treating more patients are more
                        successful at attracting workers' compensation
                        patients

Research involvement    DCs implicated in research receive more workers'
                        compensation patients

Involvement in          DCs implicated in teaching activities receive
teaching activities     more workers' compensation patients

Main sectors of activity

Type of practice        DCs who provide more specialized care receive
                        more workers' compensation patients

Care provided to patients

Radiographs             DCs who prescribe radiographs out of their
                        clinic receive more workers' compensation
                        patients. DCs  who perform a higher percentage
                        of radiographs receive less workers'
                        compensation patients.

Type of care            DCs who provide complimentary therapies and soft
provided                tissue mobilization receive more workers'
                        compensation patients. DCs who prescribe more
                        therapeutic exercise receive more workers'
                        compensation patients.

Adjustment practice     DCs who only treat the cervical spine receive
                        less workers' compensation patients.

Types of conditions treated

Condition treated       DCs treating more viscerosomatic conditions
                        receive less workers' compensation patients.

Referral Practice

Percentage of           DCs receiving more referrals from physicians and
patients referred       employers receive more workers' compensation
                        patients. DCs who refer more patients receive
                        more workers' compensation patients.


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(41.) Ammendolia C, Cote P, Hogg-Johnson S, Bombardier C. Utilization and costs of lumbar and full spine radiography by Ontario chiropractors from 1994 to 2001. Spine J. 2009;9(7):556-563.

(42.) Ammendolia C, Hogg-Johnson S, Pennick V, Glazier R, Bombardier C. Implementing evidence-based guidelines for radiography in acute low back pain: a pilot study in a chiropractic community. J Manipulative Physiol Ther. 2004;27(3):170-179.

(43.) Savigny P, Watson P, Underwood M. Early management of persistent non-specific low back pain: summary of NICE guidance. BMJ. 2009;338:b1805.

(44.) Sanmartin C, Ross N. Experiencing difficulties accessing first-contact health services in Canada: Canadians without regular doctors and recent immigrants have difficulties accessing first-contact healthcare services. Reports of difficulties in accessing care vary by age, sex and region. Healthcare Policy. 2006;1(2):103-119.

Marc-Andre Blanchette, DC, MSc [1]

J. David Cassidy, PhD, DrMedSc [2,3,4,5]

Michele Rivard, ScD [6,7]

Clermont E. Dionne, PhD [8,9]

[1] Public Health PhD Program, School of Public Health, University of Montreal, Montreal, QC, Canada

[2] Institute of Sports Science and Clinical Biomechanics, Faculty of Health, University of Southern Denmark, Odense, Denmark;

[3] Division of Health Care and Outcomes Research, Toronto Western Research Institute, University Health Network, University of Toronto, Toronto, ON, Canada;

[4] Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada;

[5] Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada

[6] Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, QC, Canada;

[7] Public Health Research Institute, University of Montreal, Montreal, QC, Canada

[8] Department of Rehabilitation, Faculty of Medicine, Universite Laval, Quebec City, QC, Canada;

[9] Axe Sante des populations et pratiques optimales en sante, Centre de recherche du CHU de Quebec (CHUQ), Quebec City, QC, Canada

Corresponding author: Marc-Andre Blanchette, DC, MSc

marc-andre.blanchette@umontreal.ca

Funding support: Dr. Blanchette is supported by a PhD fellowship from CIHR. This work was supported by the Work Disability Prevention Canadian Institutes of Health Research (CIHR) Strategic Training Program Grant (FRN: 53909).

Disclosure: This study is based on data provided by the Canadian Chiropractic Association. The interpretations and conclusions contained herein are those of the authors and do not necessarily represent those of the Canadian Chiropractic Association.

Table 1.

Descriptive statistics of DC characteristics (n=1877)

General information

Sex; n (%)                                   Male    1,313    (70.0%)
                                           Female      564    (30.0%)

Age (years): mean (SD)                                43.7    (10.8)
Years of practice: mean (SD)                          16.5    (10.9)

Type of practice; n (%)         Solo practitioner      646    (34.4%)
                                     Group of DCs      379    (20.2%)
                                Multidisciplinary      741    (39.5%)
                                       without MD
                                Multidisciplinary       91    (4.8%)
                                          with MD
                                          Missing       20    (1.1%)

Practice province; n (%)         British Columbia      303    (16.1%)
                                          Alberta      270    (14.4%)
                                     Saskatchewan       79    (4.2%)
                                         Manitoba       85    (4.5%)
                                          Ontario      793    (42.2%)
                                           Quebec      260    (13.9%)
                               Atlantic provinces       87    (4.6%)

Primary practice community           Under 10,000      232    (12.4%)
  population; n (%)                Between 10,000      367    (19.6%)
                                       and 49,999
                                   Between 50,000      285    (15.2%)
                                       and 99,999
                                  Between 100,000      488    (26.0%)
                                      and 499,999
                                     Over 500,000      490    (26.1%)
                                          Missing       15    (0.8%)

Views on adequacy of supply                            100    (5.3%)
  of DCs in community; n (%)             Too many      717    (38.2%)
  Too few                        The right number      763    (40.6%)
                                    I do not know      297    (15.8%)

Professional activities
Number of hours of practice                           37.5    (10.1)
  per week: mean (SD)
Number of weeks of practice                           48.8    (2.0)
  per year: mean (SD)
Number of new patients per                             3.4    (2.6)
  week: mean (SD)
Number of treatments per                               105    (74)
  week: mean (SD)

Education, research
  and teaching

Chiropractic college of                      CMCC    1,111    (59.2%)
  graduation; n (%)                          UQTR      125    (6.7%)
                                            PCC-D      151    (8.0%)
                                            PCC-W       68    (3.6%)
                                           LoganU       41    (2.2%)
                                              WSU       83    (4.4%)
                                             NUHS       52    (2.8%)
                                            NSHSU       51    (2.7%)
                                            LCC-W       24    (1.3%)
                                               LU       23    (1.2%)
                                           Others      146    (7.8%)
                                          Missing        2    (0.1%)

Postgraduate education;                                232    (12.4%)
  n (%)
Number of hours of continued                          26.8    (39.2)
  education per year:
  mean (SD)
Involved in research; n (%)        Yes, currently      126    (6.7%)
                                  Not now, but in      193    (10.3%)
                                 the last 3 years
                                               No    1,542    (82.2%)
                                          Missing       15    (0.8%)
Involved in teaching; n (%)                            116    (6.2%)
Practice management seminar                            561    (29.9%)
  in the last 3 years; n (%)
Client of chiropractic                                 143    (7.6%)
  practice management
  service; n (%)

Main sectors of activity

Consulting/ specialized                                246    (13.1%)
  assessment; n (%)
Geriatrics; n (%)                                      224    (11.9%)
Maintenance/ wellness; n (%)                         1,111    (59.2%)
Nutrition; n (%)                                       154    (8.2%)
Occupational/ Industrial;                               60    (3.2%)
  n (%)
Pediatrics; n (%)                                      243    (12.9%)
Pregnancy; n (%)                                       137    (7.3%)
Rehabilitation; n (%)                                  306    (16.3%)
Sports Injuries; n (%)                                 539    (28.7%)
Care provided to patients
DC takes his/her own                                   435    (23.2%)
  radiographs; n (%)
Percentage of patients                                34.8    (31.9)
  radiographed: mean (SD)
Acupuncture; n (%)                                     386    (20.6%)
Cryotherapy; n (%)                                     908    (48.4%)
Diathermy; n (%)                                        56    (3.0%)
Electrotherapy; n (%)                                  792    (42.2%)
Exercises; n (%)                                     1,595    (85.0%)
Heat Packs; n (%)                                      552    (29.4%)
Laser; n (%)                                           469    (25.0%)
Low volt therapy; n (%)                                192    (10.2)
Patient education; n (%)                             1,530    (81.5%)
Soft-tissue therapy; n (%)                           1,537    (81.9%)
Traction, flexion/                                     746    (49.7%)
  distraction; n (%)
Ultrasounds; n (%)                                     683    (36.4%)
Adjustment practice; n (%)        Full spine only      114    (6.1%)
                                   Full spine and    1,728    (92.8%)
                                      extremities
                                         Cervical       12    (0.6%)
                                       spine only
                                            Other       20    (1.1%)
                                          Missing        3    (0.2%)
Chiropractic technique used
Diversified; n (%)                                   1,746    (93.0%)
Sacral Occipital                                       222    (11.8%)
  technique; n (%)
Hole In One; n (%)                                      54    (2.9%)
Gonstead; n (%)                                        199    (10.6%)
Thompson; n (%)                                        519    (27.7%)
Activator; n (%)                                       988    (52.6%)
Cranio-sacral technique;                               154    (8.2%)
  n (%)
Type of condition treated
Percentage of patients with                           91.0    (14.0)
  neuromusculoskeletal
  conditions: mean (SD)
Percentage of patients with                            7.0    (11.1)
  somatovisceral conditions:
  mean (SD)
Percentage of patients with                            1.2    (5.4)
  vascular related
  conditions: mean (SD)

Referral practice
Percentage of patients                                14.9    (15.7)
  referred to other health
  care providers: mean (SD)
Percentage of patients                                 1.7    (5.4)
  referred by their
  employer: mean (SD)
Percentage of patients                                 8.1    (13.0)
  referred by a physician:
  mean (SD)

Missing value were always less than 4%

CMCC     = Canadian Memorial Chiropractic College

UQTR     = Universite du Quebec a Trois-Rivieres
PCC-D    = Palmer College of Chiropractic, Davenport

PCC-W    = Palmer College of Chiropractic, West
LoganU   = Logan University

WSU      = Western States University
NUHS     = National University of Health Sciences

NWHSU    = Northwestern Health Sciences University

LCC-W    = Life Chiropractic College, West
LU       = Life University

Table 2. Comparison on the analyzed sample population with
all Canadian Chiropractic Association (CCA) members

                Variables       Analyzed           CCA         p-value
                                 Sample          Members
                              (n = 1,877)      (n = 6,713)

Sex; n (%)          Male     1,313 (70.0%)    4,273 (67.1%)     0.021
                   Female     564 (30.0%)     2,093 (32.9%)
              Missing (n)          0               347

Years of practice;            16.5 (10.9)      14.7 (11.1)     <0.001
  mean (SD)
              Missing (n)          5               856

Practice province; n (%)
         British Columbia     303 (16.1%)      914 (14.5%)     <0.001
                  Alberta     270 (14.4%)      904 (14.3%)
             Saskatchewan      79 (4.2%)        177 (2.8%)
                 Manitoba      85 (4.5%)        222 (3.5%)
                  Ontario     793 (42.2%)     3,026 (47.9%)
                   Quebec     260 (13.9%)      829 (13.1%)
       Atlantic provinces      87 (4.6%)        247 (3.9%)
              Missing (n)          0               394

Chiropractic College of
  graduation; n (%)
                     CMCC    1,111 (59.3%)    3,718 (58.4%)     0.495
                     UQTR      125 (6.7%)       395 (6.2%)
                    PCC-D      151 (8.1%)       515 (8.1%)
                    PCC-W      68 (3.6%)        192 (3.0%)
                   LoganU      41 (2.2%)        140 (2.2%)
                      WSU      83 (4.4%)        307 (4.8%)
                     NUHS      52 (2.8%)        214 (3.4%)
                    NSHSU      51 (2.7%)        155 (2.4%)
                    LCC-W      24 (1.3%)        62 (1.0%)
                       LU      23 (1.2%)        85 (1.3%)
                   Others      146 (7.8%)       583 (9.2%)
              Missing (n)          2               347

CMCC     = Canadian Memorial Chiropractic
           College
UQTR     = Universite du Quebec a Trois-Rivieres
PCC-D    = Palmer College of Chiropractic, Davenport
PCC-W    = Palmer College of Chiropractic, West
LoganU   = Logan University
WSU      = Western States University
NUHS     = National University of Health
           Sciences
NWHSU    = Northwestern Health Sciences University
LCC-W    = Life Chiropractic College, West
LU       = Life University

Table 3.
DC characteristics associated with the number of workers' compensation
patients seen per year in bivariate analyses

Variables                                    Association      p-value
                                               with the
                                             annual number
                                              of workers'
                                             compensation
                                              patients;
                                               mean (SD)

General information

Sex                                   Male   11.5 (19.4)       <0.001
                                    Female    7.5 (12.3)

Age (years) (P)                               r = -0.018       0.442

Years of practice (P)                         r = -0.021       0.370

Type of practice         Sole practitioner       9 (18)       0.030 *
                              Group of DCs      11 (19)
              Multidisciplinary without MD      11 (15)
                 Multidisciplinary with MD      14 (29)

Practice province         British Columbia       8 (12)      <0.001 (a)
                                   Alberta       9 (17)
                              Saskatchewan      28 (28)
                                  Manitoba      19 (19)
                                   Ontario       9 (17)
                                    Quebec       5 (10)
                        Atlantic provinces      22 (30)

Practice area population      Under 10,000      11 (18)      0.003 (b)
                 Between 10,000 and 49,999      12 (18)
                 Between 50,000 and 99,999      10 (14)
               Between 100,000 and 499,999      12 (21)
                              Over 500,000       8 (15)

Number of DCs in relation to the
demand                             Too few      12 (23)      0.001 (c)
                                  Too many       9 (17)
                          The right number      12 (19)
                             I do not know       8 (12)

Professional activities

Number of hours of practice per week (P)       r = 0.158       <0.001

Number of weeks of practice per year (P)       r = 0.030       0.192

Number of new patients per week (P)            r = 0.485       <0.001

Number of treatments per week (P)              r = 0.212       <0.001

Education, research and teaching

College of graduation                 CMCC      11 (18)      0.004 (d)
                                      UQTR       5 (12)
                                     PCC-D       9 (18)
                                     PCC-W       7 (8)
                                    LoganU      16 (22)
                                       WSU      13 (20)
                                      NUHS      12 (20)
                                     NSHSU      14 (18)
                                     LCC-W      13 (20)
                                        LU       7 (9)
                                    Others       9 (13)

Post graduate studies                  Yes       9 (14)         0.224
                                        No      11 (18)

Number of hours of continued education (P)    r = -0.019       0.416

Involved in research        Yes, currently      13 (30)        0.112
          Not now, but in the last 3 years      10 (16)
                                        No      10 (17)

Involved in teaching                   Yes      12 (27)        0.330
                                        No      10 (17)

Management training in the last 3
years                                  Yes       9 (18)         0.191
                                        No      11 (18)

Client of chiropractic practice
management service                     Yes       8 (16)         0.164
                                        No      10 (18)

Main sectors of activity

Consulting/ specialized assessment     Yes      10 (18)        0.900
                                        No      10 (18)

Geriatrics                             Yes      10 (15)        0.921
                                        No      10 (18)

Maintenance/ wellness                  Yes       9 (16)         0.011
                                        No      12 (19)

Nutrition                              Yes      10 (18)        0.932
                                        No      10 (17)

Occupational/ Industrial               Yes      18 (21)        0.009
                                        No      10 (17)

Pediatrics                             Yes       8 (15)         0.037
                                        No      11 (18)

Pregnancy                              Yes       9 (16)         0.345
                                        No      10 (18)

Rehabilitation                         Yes      13 (19)        0.002
                                        No      10 (17)

Sports Injuries                        Yes      12 (20)        0.005
                                        No      10 (17)

Care provided to patients

Do you take your own radiographs       Yes       8 (14)         <0.001
                                        No      11 (19)

Percentage of patients radiographed (P)       r = -0.073       0.002

Acupuncture                            Yes      14 (25)        0.001
                                        No       9 (15)

Cryotherapy                            Yes      12 (17)        0.001
                                        No       9 (18)

Diathermy                              Yes      16 (17)        0.016
                                        No      10 (18)

Electrotherapy                         Yes      13 (19)        <0.001
                                        No       9 (16)

Exercises                              Yes      11 (18)        0.003
                                        No       8 (14)

Heat Packs                             Yes      13 (21)        <0.001
                                        No       9 (16)

Laser                                  Yes      12 (17)        0.062
                                        No      10 (18)

Low volt therapy                       Yes      14 (22)        0.013
                                        No      10 (17)

Patient education                      Yes      11 (18)        0.042
                                        No       9 (16)

Soft-tissue therapy                    Yes      11 (18)        0.037
                                        No       8 (16)

Traction, flexion/distraction          Yes      12 (19)        0.001
                                        No       9 (17)

Ultrasounds                            Yes      13 (18)        <0.001
                                        No       9 (17)

Adjustment practice Full spine only             11 (16)        0.522
Full spine and extremities                      10 (18)
Cervical spine only                              4 (8)
Other                                            7 (9)

Chiropractic technique used

Diversified                            Yes      11 (18)        0.034
                                        No       7 (20)

Sacral Occipital technique             Yes       8 (14)         0.093
                                        No      11 (18)

Hole In One                            Yes       6 (9)         0.002
                                        No      10 (18)

Gonstead                               Yes      12 (20)        0.166
                                        No      10 (17)

Thompson                               Yes      11 (18)        0.207
                                        No      10 (18)

Activator                              Yes      10 (17)        0.826
                                        No      10 (19)

Cranio-sacral technique                Yes       9 (15)         0.197
                                        No      10 (18)

Types of conditions treated

Percentage of patients with
neuromusculoskeletal condition (P)             r = 0.068       0.003

Percentage of patients with somatovisceral
conditions (P)                                r = -0.058       0.012

Percentage of patients with vascular
related conditions (P)                        r = -0.014       0.560

Referral practice

Percentage of patients referred to other
health care providers (P)                      r = 0.025       0.283

Percentage of patients referred by their
employer (P)                                   r = 0.080       0.001

Percentage of patients referred by a
physician (P)                                  r = 0.218       <0.001

CMCC   = Canadian Memorial Chiropractic
         College

UQTR   = Universite du Quebec a Trois-Rivieres

PCC-D  = Palmer College of Chiropractic,
         Davenport

PCC-W  = Palmer College of Chiropractic, West

LoganU = Logan University

WSU    = Western States University

NUHS   = National University of Health
         Sciences

NWHSU  = Northwestern Health Sciences
         University

LCC-W  = Life Chiropractic College, West

LU     = Life University

(P) Pearson correlation coefficient

(a) Saskatchewan, Manitoba and the Atlantic provinces are
significantly higher than the other provinces. British Columbia,
Alberta and Ontario are significantly lower than Saskatchewan,
Manitoba and the Atlantic provinces, but significantly higher
than Quebec.

(b) "Over 500,000" is significantly lower than "Between
10,000-49,999" and "Between 100,000-499,999"

(c) "The right number of DCs" is significantly higher than "Too
many DCs" and "I do not know"

(d) CMCC is significantly higher than UQTR and PCC-W

* No significant differences after the post hoc testing.

Table 4.
Variables associated with the annual number of workers'
compensation patients in the multivariate negative
binomial regression model (n=1,733)

                                    IRR        Wald's 95%      p-value
                                               confidence
                                                interval
                                               of the IRR

(Constant)                         0.60      (0.30 to 1.19)     0.143

General information

Type of clinic

Sole practitioner                Reference         --            --
Group of DCs                       1.23      (1.04 to 1.54)     0.018
Multidisciplinary without MD       1.19      (1.01 to 1.40)     0.039
Multidisciplinary with MD          1.35      (0.96 to 1.89)     0.082
Population of practice area
Under 10,000                       1.19      (0.94 to 1.51)     0.157
Between 10,000 and 49,999          1.37      (1.10 to 1.69)     0.004
Between 50,000 and 99,999          1.19      (0.96 to 1.48)     0.122
Between 100,000 and 499,999        1.36      (1.11 to 1.67)     0.003
Over 500,000                     Reference         --            --
Practice province
Quebec                           Reference         --            --
British-Columbia                   1.63      (1.23 to 2.15)     0.001
Alberta                            1.52      (1.13 to 2.05)     0.005
Saskatchewan                       4.34      (2.89 to 6.52)    <0.001
Manitoba                           2.67      (1.81 to 3.90)    <0.001
Ontario                            1.23      (0.96 to 1.58)     0.106
Atlantic provinces                 3.04      (2.07 to 4.46)    <0.001

Professional activity
Number of hours of practice        1.02      (1.01 to 1.03)    <0.001
  per week
Number of treatments per week      1.01      (1.00 to 1.01)    <0.001

Education, research and
  teaching
Post graduate studies              0.78      (0.63 to 0.96)     0.017
Management training in the         0.76      (0.65 to 0.89)    <0.001
  last 3 years

Main sectors of activity
Occupational/ Industrial           1.59      1(1.09 to 2.32)    0.017

Care provided to patients
DC performs his own                0.85      (0.70 to 1.03)     0.098
  radiographs
Electrotherapy                     1.30      (1.12 to 1.52)     0.001
Soft-tissue therapy                1.21      (1.01 to 1.47)     0.044

Chiropractic techniques used
Sacral Occipital technique         0.78      (0.62 to 0.98)     0.030
Thompson                           1.21      (1.04 to 1.42)     0.017
Cranio-sacral technique            0.79      (0.60 to 1.02)     0.073

Types of conditions treated
Percentage of patients with        1.01      (1.00 to 1.01)     0.009
  neuromusculoskeletal
  conditions

Referral practice
Percentage of patients             1.02      (1.01 to 1.04)     0.003
  referred by their employer
Percentage of patients             1.02      (1.01 to 1.03)    <0.001
  referred by a physician

IRR = incidence rate ratio
Pearson's chi-square = 2,264
Pearson's chi-square/degree of freedom = 1.329
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Author:Blanchette, Marc-Andre; Cassidy, J. David; Rivard, Michele; Dionne, Clermont E.
Publication:Journal of the Canadian Chiropractic Association
Article Type:Report
Date:Jul 1, 2015
Words:8325
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