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Research Review By Dr. Michael Haneline©


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Date Posted:

November 2022

Study Title:

Association Between Characteristics of Danish Chiropractors and Number of Referred Patients from General Practitioners: A Cross-Sectional Study


Blanchette M, Engmark N, Sørensen M, Mior S & Stochkendahl M

Author's Affiliations:

Département de Chiropratique, Université du Québec à Trois-Riviéres, Trois-Riviéres, Quebec, Canada; Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; Department of Research and Innovation, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; Institute for Disability and Rehabilitation Research, Ontario Tech University, Toronto, Ontario, Canada; Chiropractic Knowledge Hub, Odense, Denmark.

Publication Information:

Journal of Manipulative & Physiological Therapeutics 2021; 44(8): 637-651. doi: 10.1016/j.jmpt.2022.01.002.

Background Information:

An emphasis on interprofessional practices and education has been growing worldwide (1), in part because it has been shown to improve patient functional status, produce greater provider compliance with clinical guidelines, and wiser use of health care resources (2). Chiropractors commonly collaborate with other health care professionals like general practitioners (GPs), a practice that is valued by patients and is one of the World Federation of Chiropractic’s 4 strategic pillars for the development of the profession (EPIC = Evidence-based, People-centered, Interprofessional and Collaborative care) (3).

The Canadian and Danish chiropractic associations previously developed a framework targeting cooperation between medical doctors and chiropractors in the delivery of care (4). Three domains for optimizing interprofessional collaboration are provided in the framework including communication, practice parameters, and service delivery:
  • Communication is essential because its lack may lead to unnecessary diagnostic testing and conflicting advice which may lead to fragmented patient care.
  • Practice parameters refers to a chiropractor’s scope and delivery of care in clinical practice, which most medical doctors in Canada consider as being effective for musculoskeletal conditions but not non-musculoskeletal conditions.
  • Service delivery has to do with access to care, affordability, provider reimbursement, and liability.
In a 2013 study, most chiropractors in Denmark (96%) considered interprofessional practice to be of great importance, and two-thirds of them considered their practice to be interprofessional (5). The study also revealed that chiropractors commonly collaborate with massage therapists, physical therapists, and acupuncturists, but only 1 out of 10 reported that medical doctors are active participants in interprofessional care. Earlier studies showed that only 11% of Danish chiropractic patients were referred by a GP in 1999 and 17% in 2002, indicating that collaboration between the professions was increasing.

The objectives of this study were to quantify the number of patients referred from GPs to Danish chiropractors per week and to identify characteristics of Danish chiropractors associated with the number of such referrals.

Pertinent Results:

The survey was completed by 364 out of 600 invited (and eligible) Danish chiropractors (61% response rate) and data from 286 respondents (47.7%) were analyzed. 64 of the chiropractors did not meet the inclusion criteria and 14 provided questionable answers, thus were excluded from the study.

An average of 2.5 (± 2.2) GP referrals per week were reported by the chiropractors in this study, which accounted for 31% of all new patients they received per week. A minority (11.2%) of chiropractors reported that they received no referrals from GPs and 2% reported 10 or more per week.

Results of the bivariable analysis showed that chiropractors who graduated from a program in the United Kingdom and/or having 21 to 30 years of experience (compared to 5 years or less) were associated with significantly fewer GP referrals, whereas more GP referrals were received in chiropractic clinics with more than 1 chiropractor. Other characteristics associated with receiving more GP referrals included: expertise in sports injuries, extremities, geriatric populations, and diagnostic ultrasound, as well as the use of shockwave therapy and having access to radiography and diagnostic ultrasound at the clinic.

Other characteristics that were associated with significantly fewer GP referrals included: chiropractors whose main focus of treatment was preventing and treating dysfunctions and subluxations and those collaborating with acupuncturists.

The multivariable analysis revealed the following predictors of the number of GP referrals: respondents’ number of years since graduation and having access to diagnostic ultrasound. The final statistical model showed the following factors as being statistically significantly associated with more GP referrals: having more than 1 chiropractor in the clinic, geriatric expertise, access to diagnostic ultrasound, having more new patients, and referring more patients to GPs.

Clinical Application & Conclusions:

Several characteristics were identified as being positively associated with the number of GP referrals, including access to chiropractic care (number of chiropractors in the clinic and number of new patients per week), the type of care provided (geriatric expertise and access to diagnostic ultrasound), and interprofessional communication (number of patients referred to GP). Even though chiropractic practice in Denmark is somewhat different from other countries and jurisdictions, emulating these characteristics may result in increased GP referrals to chiropractors outside Denmark.

In this study, communication was found to be an important predictor of referrals by GPs to chiropractors. For example, chiropractors in Denmark commonly send written reports back to the GP when they received a referral or when they referred a patient to the GP. Chiropractors who referred more patients to GPs also received more referrals from GPs compared to chiropractors who made fewer referrals to GPs.

Having expertise in sports injuries or extremities and geriatric care, as well as specializing in sports injuries and having access to imaging modalities at the clinic were positively associated with the number of GP referrals. The only treatment modality that was positively associated with GP referrals was shockwave therapy.

Study Methods:

This study utilized a cross-sectional survey research design that targeted members of the Danish Chiropractic Association. Passive, retired, students or living abroad members were not eligible to participate. Respondents were also excluded if they did not work in a private clinic, did not have patient contact, or had missing or inappropriate responses. All eligible Danish chiropractors (n = 1160, prior to exclusion criteria application) were invited to participate in the study by email, with 2 weekly reminders sent to non-responders.

The study’s survey questionnaire was adopted and revised from a previous Canadian survey and was assessed for face validity and pilot-tested by 5 Danish chiropractors. The survey comprised 27 questions divided into 5 domains: 1) description of the chiropractors, 2) description of the clinics, 3) clinical day, 4) new patients, and 5) collaborative practices.

The primary dependent variable in this study was the weekly number of referred patients from GPs with responses derived from the following 2 questions:
  • On average how many new patients each week are referred to you from GPs through RefHost? (Note: RefHost is the common online communication platform for health care providers in Denmark)
  • On average how many new patients each week have an oral recommendation from their GP to visit at chiropractor?
A new patient was defined as someone the chiropractor had never been seen before, or someone who had not visited the clinic in the previous 3 years.

Study Strengths / Weaknesses:

This was a well-done survey study that identified several attributes of chiropractors regarding referral patterns from GPs. However, only Danish chiropractors participated in this study, and they reported an average of 2.5 medical referrals per week, which is substantially higher than a previous study done in Canada (6). Consequently, generalizing the findings of this study outside Denmark is problematic, given the uniqueness of the chiropractic profession in that country. For instance, the government provides reimbursement for a portion of chiropractic services rendered to patients. Also, the Danish chiropractic educational program is part of the health faculty of a state-funded university which facilitates communication between chiropractic and medical students, likely leading to better interprofessional relations in practice.

The characteristics of survey responders may have been different from non-responders, but since the response rate was higher than most other similar studies, any such effect would likely have been small.

The psychometric properties of the questionnaire that was used in this study were not adequately tested, which limits the reliability of the data that were collected. Recall bias may also have influenced the reliability of the data as number of referrals were provided by the respondents and not verified.

The cross-sectional design that was used in this study does not permit establishing causality between the associations that were identified.

Additional References:

  1. World Health Organization. Framework for Action on Interprofessional Education & Collaborative Practice. Geneva, Switzerland: World Health Organization; 2010.
  2. Reeves S, Pelone F, Harrison R, Goldman J, Zwarenstein M. Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database Syst Rev 2017; 6: (6) CD000072.
  3. Gurden M, Morelli M, Sharp G et al. Evaluation of a general practitioner referral service for manual treatment of back and neck pain. Prim Health Care Res Dev 2012; 13(3): 204-210.
  4. Mior S, Barnsley J, Boon H, Ashbury F, Haig R. Designing a framework for the delivery of collaborative musculoskeletal care involving chiropractors and physicians in community-based primary care. J Interprof Care 2010; 24(6): 678-689.
  5. Myburgh C, Christensen H, Fogh-Schultz A. Chiropractor perceptions and practices regarding interprofessional service delivery in the Danish primary care context. J Interprof Care 2014; 28(2): 166-7.
  6. Blanchette M, Rivard M, Dionne C, Cassidy J. Chiropractors’ characteristics associated with physician referrals: results from a survey of Canadian chiropractors. J Manipulative Physiol Ther 2015; 38(6): 395-406.

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