Identifying and Promoting Quality Low Back Pain Care by Chiropractors

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Abstract High-quality low back pain (LBP) care should include nonpharmacological interventions as the primary management strategy and serial pain assessment using validated patient reported outcome measures (PROMs). PROMs are standardized, validated questionnaires completed by patients to identify and quantify their perceptions of their health status. In addition to serving as a marker of high-quality LBP care, PROM use may impact pain-related clinical practice by facilitating shared decision making and communication between patients and healthcare professionals, enabling progress assessment to evaluate treatment plan appropriateness, and possibly positively influencing health status (including pain level and pain-related ability). However, little is known about the extent of translation of the recommended use of PROMs in usual practice by chiropractors. The goal of the research in this proposal is to describe the use of validated PROMs in LBP management in Veterans Health Administration (VHA) chiropractic clinics and perform feasibility pilot testing of a point-of-care CDS alert to facilitate use in the documentation workflow. An adaptation of the Technology Acceptance Model will be used as the theoretical basis for increasing use of PROMs by chiropractors through a technology-based intervention. In Aim 1, we will quantify the current national documentation of validated PROMs during LBP care by VHA chiropractors using natural language processing on electronic health record data. In Aim 2, we will survey VHA chiropractors to understand priorities and considerations in the documentation and clinical workflow for PROM use and clinical decision support. This “community-based” approach to stakeholder engagement will assess the acceptance, usability, and appropriateness of electronic health record based clinical decision support alert as an intervention to promote PROM use. In Aim 3, we will conduct a single-arm feasibility and acceptability pilot of the developed CDS alert in four VHA chiropractic clinics, measuring preliminary intervention adoption, feasibility, and acceptability as outcomes. The proposed research will evaluate the feasibility and refine methods in support of a full-scale pragmatic trial to assess the effects of a CDS alert intervention on high-quality LBP care delivery, including clinician use of PROMs as a quality marker, and on patient outcomes in chiropractic clinics and other care settings commonly managing LBP. As a career development award proposal, this project will prepare Dr. Coleman for a career as an independent scientist and inform future trials studying the use of point-of-care decision support tools to guide LBP management. He has assembled a team of mentors and collaborators with diverse expertise in medical informatics, clinical research, chiropractic care, and intervention development to guide his transition to an independent investigator. During this mentored award, he will acquire and enhance his knowledge and skills in clinical research, including pragmatic clinical trials and implementation science.