Factors influencing initial trial planning for low back pain among Veterans Health Administration chiropractors: A descriptive observational survey

Abstract: Objectives: The purpose of this study was to assess how chiropractors within the Veterans Health Administration (VHA) determine their perceived-optimal dosage (number of visits and trial duration) when planning initial trials of care for patients with low back pain, and to describe factors perceived to influence these decisions, as well as barriers and facilitators to implementation. Methods: A cross-sectional electronic survey was distributed to all chiropractors with an active VHA appointment as of July 1, 2024 (N = 384). The survey, based on prior qualitative interviews and pilot testing, included a clinical vignette and questions related to perceived-optimal visit number and duration, modifying factors, and implementation. Descriptive and inferential statistics (Pearson's chi-squares) were used to analyze responses in SAS 9.4. Results: A total of 181 VHA chiropractors completed the survey (47.1% response rate). The most frequently reported perceived-optimal initial trial was 6 visits over 6 weeks (21.5%). Respondents reported that increasing patient age, higher pain intensity, greater functional impairment, and shorter duration of symptoms would increase the planned visit dosage. There was considerable variation in chiropractors' perceptions of the ideal initial treatment trial. Most clinicians (62%) reported they were able to implement their preferred initial trial less than half of the time. The same barriers (including number of available chiropractic clinicians and treatment rooms) and facilitators (including the ability to collaborate with non-DC clinicians and the presence of clinical support staff) were reported by both the <25% and >= 75% optimal implementation groups. However, more chiropractors in the <25% optimal implementation group reported barriers than did those in the >= 75% optimal implementation group for the number of DC Clinicians (74% vs 39%, p = .0002), and clinical access parameters (67% vs 36%, p = .0002). Conclusions: This study revealed that VHA chiropractors reported variable perceived-optimal initial trial dosages and endorsed several clinical and system-level factors that influence trial planning. Reported barriers to implementation were common, particularly those related to staffing and space limitations, with more chiropractors in the low implementation group reporting barriers.