Chiropractic Health Care Demonstration Project: an Update

At the direction of the U.S. Congress, and subsequent to the passage of the FY 1995 Defense Authorization Act, the Office of the assistant secretary of defense for health affairs (OASD(HA)) directed the surgeons general of the Army, Navy and Air Force to establish chiropractic services at ten military hospitals. The congressional mandate was to determine the "feasibility and advisability" of providing military beneficiaries with chiropractic care. "Feasibility" was defined as the ease with which the chiropractic providers could be integrated into the military health system; "advisability" was defined essentially as cost effectiveness. OASD(HA) was assigned the responsibility of carrying out the congressional mandate, with the assistance of a committee comprised of representatives from the three service medical departments, the chiropractic profession, the general accounting office, and the military coaliton. This committee was given the title of oversight advisory committee (OAC).

After two years of chiropractors working in military hospitals, it is clear that chiropractic providers can be integrated into the military health system. Advisability relative to cost remains to be evaluated, although administrative protocols were developed to measure both advisability and feasibility. The study protocols have depended almost exclusively on comparison of chiropractic patient data and traditional patient data. After 18 months, it is apparent that chiropractic patient data are abundant, but traditional patient data are insufficient for valid comparison. At this time, there are insignificant traditional data to establish a statistical significance. On the other hand, during this two-year period, the chiropractic providers have become productive members of the military hospital staffs. Chiropractic clinics have been providing services near maximum capacity at most sites for many months.

To enhance the project's credibility, OASD(HA) established three comparison sites. These sites were to evaluate traditional patient care for spine-related neuromusculoskeletal conditions without chiropractic services being an influence. The same administrative protocols were implemented, consistent with the ten chiropractic demonstration sites, with essentially the same results.

Several attempts were made to modify the project's administrative protocols. Part-time site evaluation technicians were hired and trained to ensure administration of questionnaires at all ten sites. Additionally, several changes were made in follow-up patient reporting procedures and patient access/screening methods. None of the changes resulted in a significant increase in traditional patient data.

At the two-year point, and after two meetings of the OAC, it has been determined that a major restructuring of the Chiropractic Health Care Demonstration Project is necessary. Coincidentally, and to the project's enhancement, the FY 1998 Defense Authorization Act mandated that three additional military hospitals be included in the project and that the project be extended through September 1999.

The three new sites -- National Naval Medical Center, Bethesda, Maryland; Walter Reed Army Medical Center, Washington, D.C.; and Wilford Hall Medical Center, San Antonio, Texas -- will participate in a randomized clinical trial. This trial will be of the "pragmatic study" design, with focus on cost analysis. The nature of the new sites will require a research-oriented individual to be present at each site to assist in project design, implementation and monitoring. A DC with a strong research background will be identified to assist the department of defense health affairs' staff and site personnel in the development of methodology for the trial. The tentative timeline indicates the three new sites will be functioning by May 1998, with data collection starting immediately.

At present the OAC is also considering a more focused approach to the project. Three of the original demonstration sites -- Fort Carson, Colorado Springs, Colorado; Scott Air Force Base, Belleville, Illinois; and Naval Air Station, Jacksonville, Florida -- have been chosen to continue the past study protocols, but will also add a full-time program manager in place of the part-time site evaluation technician. The goal will continue to be to enhance collection of traditional data. The seven remaining project sites will change to a primary care manager model, a process being implemented throughout the military health system. The chiropractic providers at these seven sites will perform in a referral mode, as do other specialty providers.

Many details remain to be worked out. Once the methodology of the randomized clinical trials is developed, and consensus reached among oversight advisory committee members, each site's institutional review board must approve the study. Two new chiropractic doctors and two chiropractic assistants will be hired for each of the three new sites. A great deal needs to be accomplished, and many individuals are working tirelessly to meet the demanding time line.

The Chiropractic Health Care Demonstration Project has already proven that DCs work well with other military health care providers and ancillary health care personnel. Many medical doctors, including doctors of osteopathy, refer patients on a daily basis for chiropractic services , and many military personnel desire, request and choose chiropractic services when given the opportunity. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently completed a review of one of the military sites with chiropractic services; both the chiropractic department and the hospital received high marks. Chiropractic services appear to be a very welcome addition to the military health care system.

Rick McMichael, DC
Canton, Ohio