1. Bridging the Gaps and Enhancing Interprofessional Integration Process of Integrating Evidence (PIE) for CAM Educators Jason Busse, DC, PhD McMaster University Depts. of Anesthesia & Clinical Epidemiology & Biostatistics

2. Interprofessional Integration In 2006 the Chiropractic Strategic Planning Conference proposed a set of recommendations for advancing the chiropractic profession in North America: - interdisciplinary clinical training - integration of chiropractic into mainstream healthcare - increased interprofessional collaboration Advancing these initiatives requires endorsement from healthcare professionals that attend to patients that also seek chiropractic care

3. Canadian Utilization of Chiropractic Canadian DC use relatively stable: Lifetime 36% in 1997 40% in 2006 In last 12-Month 13% in 1997 15% in 2006

4. 2008 OCA Membership Survey 2775 members were surveyed (34% response rate) “Over 95% of those who responded to the survey support greater integration into the health care system for our profession.” “The majority (67%) felt that the practices of their peers are in some way negatively influencing perceptions of the profession.”

5. What Do Mainstream Healthcare Providers Think About Chiropractic? 487 surgeons completed the survey (response rate, 49%)

6. Attitudes Towards Chiropractic North American orthopedic surgeons’ attitudes toward chiropractic were diverse: 45% endorsing a negative impression 29% holding favorable views 26% being neutral Approximately half of respondents referred patients for chiropractic care each year, mainly due to patient request.

7. Attitudes Towards Chiropractic Specific attitudes: Effective therapy for some musculoskeletal complaints (82%) Not effective for nonmusculoskeletal conditions (90%) Chiropractors provide unnecessary treatment (73%) Engage in overly-aggressive marketing (63%)

8. Attitudes Towards Chiropractic In our adjusted generalized linear model: Negative factors older age endorsement of the research literature, the media, or medical school as a source of information regarding chiropractic Positive factors endorsing a relationship with a specific chiropractor as a source of information regarding chiropractic

9. Survey of Family Physicians 1000 surveys sent to a random sample of Family Physicians 634 Responses 251 Completed surveys 238 non-respondents (after 3 waves) 128 fax numbers not in service 196 not interested 187 were not eligible

10. Demographic Characteristics 60% female 59% have practiced for >20 years % of patients with MSK complaints: 10% to 20%: 18.5% 21% to 30%:28.5% 31% to 40%:23.7% 41% to 70%:23.2%

11. GP Attitudes Towards DCs Canadian Family Physician's attitudes toward chiropractic were less diverse: 47% endorsing a positive impression 27% being neutral 26% holding negative views The majority (74%) of respondents referred patients for chiropractic care each year.

12. GP Attitudes Towards DCs 86% endorsed that chiropractors provide effective therapy for some musculoskeletal complaints 79% disagreed that chiropractors could provide effective relief for non-musculoskeletal conditions The majority agreed that chiropractic care was a useful supplement to conventional care (65%).

13. GP Attitudes Towards Chiropractic In our adjusted generalized linear model: Negative factors belief that adverse events are common endorsement of the research literature or medical school as a source of information regarding chiropractic Positive factors endorsing a relationship with a specific chiropractor, family or friends, or personal treatment experience as a source of information regarding chiropractic

14. Family Physician's Attitudes Towards Chiropractic Does diversity within the chiropractic profession present a barrier to collaboration? Yes-62.8% Unsure-24.4% No-12.8%

15. Diversity Within Chiropractic “I have a good relationship with one chiropractor who I trust with my patients……I am often reluctant to send patients to chiropractors elsewhere because the treatment and information given and practices vary considerably.”

16. Research is Influential, but Negatively so… “There was an article on Medscape a few months ago where patients were examined for known damage after neck manipulation that led to CVA/death. This did little to help my mostly negative feelings and approaches towards chiropractic medicine”

17. The Result may Depend on the Research that is Read

18. Promoting Integration Build relationships with mainstream providers Provide education to clinicians-in-training Encourage and promote high quality research Be bold in what we hypothesize, and conservative in what we claim

20. The Problem 30% of surgeons turned away >20% of referrals without a consultation 32% had to screen 11-20 pts for a single surgical candidate; 10% had to screen >20

21. Surgeon’s Interest in pre-Screening Most surgeon’s reported wait times of >6 months for assessment & surgery 78% were interested in working with a DC or PT to screen LBP patients referred for assessment 75% would be comfortable not seeing ruled out pts.

22. 78% of Spine Surgeons require Imaging to Accompany all Spine-Related Referrals

23. Adjusted Spine Imaging Rates for Ontario (2001-2011) 40M to 63M over 10 years

24. Promoting Integration There are enormous inefficiencies in the current system There are considerable wasted resources There is an opportunity for chiropractors and other CAM providers to play a key role in addressing these issues.

25. Thank You!