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Acupuncture and Chiropractic Care: Utilization and Electronic Medical Record Capture
Charles Elder, MD, MPH; Lynn DeBar, PhD, MPH; Cheryl Ritenbaugh, PhD, MPH; William Vollmer, PhD; Richard A. Deyo, MD, MPH; John Dickerson, PhD; and Lindsay Kindler, PhD, RN
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Acupuncture and Chiropractic Care: Utilization and Electronic Medical Record Capture

Charles Elder, MD, MPH; Lynn DeBar, PhD, MPH; Cheryl Ritenbaugh, PhD, MPH; William Vollmer, PhD; Richard A. Deyo, MD, MPH; John Dickerson, PhD; and Lindsay Kindler, PhD, RN
Most patients with chronic musculoskeletal pain use acupuncture or chiropractic care. A substantial percentage of this utilization, however, is not captured by the electronic medical record.
For chiropractic care, data were captured for 887 patients. Of these, 381 (43%) utilized chiropractic services entirely out of plan, and thus were not captured by the EMR. Overall, 478 (54%) participants used at least some type of chiropractic care out of plan; 323 patients (36%) utilized a chiropractor based solely upon self-referral benefit coverage; and only 78 patients (9%) did so based solely upon clinician referral. Of the 408 patients who used chiropractic care in 2011 using a self-referral benefit, 77 (19%) supplemented their self-referral health plan benefit with additional out-of-plan utilization.

Thus, for acupuncture, most utilization was based upon clinician referral. In contrast, for chiropractic care, relatively little utilization was based upon clinician referral, with the great majority of patients accessing care out of plan only, through self-referral, or both.

Utilization and Benefit Coverage

For this set of analyses, data are included for the subset of patients indicating 2011 utilization. “Out of plan only” describes participants in area C of the Venn diagrams of Figures 1 and 2. “Clinician referral” describes participants in areas A + F of the Venn diagrams: those who used the clinician referral mechanism for at least some of their care. “Self-referral” describes participants in areas B + G of the Venn diagrams: those who used the self-referral mechanism for at least some of their care. The small number of patients in areas D and E were dropped.

There were no differences among the 3 groups (ie, out-of-plan only, clinician referral, and self-referral) with respect to gender, ethnicity, or smoking status. For chiropractic, there was a tendency for those accessing care out of plan only to be older (mean age = 58 years; SD = 13; P <.01), to use long-term opioids (16%; P = .03), and to have more pain diagnoses (mean = 4.2; SD = 2.1; P = .01). For acupuncture, there was a tendency for those using a clinician referral mechanism to exhibit these same characteristics (mean age = 59 years, SD = 13, P <.01; long-term opioid use = 21%, P = .02; mean number of pain diagnoses = 4.0, SD = 2.1, P = .01). Acupuncture patients receiving clinician referral care were also less educated compared with those using self-referral or out-of-plan only care (high school/GED or less = 20%, some college = 44%, college graduate or more = 36%; P <.01).

For chiropractic users, the most commonly used additional CAM modality was massage (55% for out-of-plan only, 57% for clinician referral, and 53% for self-referral). However, there were no significant differences among the 3 utilization groups with respect to self-reported use of any of the additional CAM modalities, including massage, yoga, tai chi/qigong, supplements, meditation, physical activity, diet, or other. For acupuncture users, the most commonly used additional CAM modality was also massage (52% for out-of-plan only, 46% for clinician referral, and 56% for self-referral). Acupuncture users accessing care through self-referral were more likely than clinician referral or out-of-plan only users to report use of dietary (23%; P = .02) or other (24%; P = .03) modalities.

Participants accessing acupuncture via clinician referral were significantly more likely than those accessing acupuncture via self-referral or out of plan only to self-report pain in the back (73%; P = .01), muscles (41%; P = .03), or pain due to arthritis (54%; P <.01). For chiropractic care, those obtaining care out-of-plan only were significantly more likely to report extremity pain (59%; P = .02).


The use of acupuncture and chiropractic care among HMO chronic pain patients responding to our survey was substantial. Those using neither acupuncture nor chiropractic care (42%) were in the minority. The data also suggest that a substantial percentage of acupuncture and chiropractic use is not documented by the EMR, and/or is not reported by patients to their HMO clinicians.

While investigators may use clinical and administrative databases to enhance study design, results suggest that EMR data fail to detect a substantial percentage of acupuncture and chiropractic utilization, even in an integrated delivery system with allowable referrals to acupuncture and chiropractic care, as well as a state-of-the-art EMR system. Any EMR-based analysis of acupuncture and chiropractic use would require additional survey or other data collection to capture the full spectrum of care.

Clinicians should assume that a substantial percentage of their patients with chronic musculoskeletal pain are receiving acupuncture and chiropractic care. For both acupuncture and chiropractic users, the most commonly endorsed answer to the question, “Did you share information about acupuncture/chiropractic use with your HMO clinician?” was “No, but would tell if asked.” This finding serves to emphasize the importance of clinicians raising this topic in routine encounters with chronic pain patients. Engaging the patient in a discussion about acupuncture and chiropractic use can provide information for optimizing care. Such discussions can reinforce a patient’s self-management efforts and potentially provide insight into the types of patients who may be, or should be, using acupuncture and/or chiropractic services. Clinicians should also consider direct communication with acupuncturists and chiropractors about patients they are co-managing. This may allow better coordination of care and will potentially improve outcomes.

Our data suggest that, to a substantial extent, insurance benefits influence who uses acupuncture and chiropractic care, and under what circumstances. For acupuncture, the majority of utilization was based upon clinician referral. In contrast, for chiropractic care, relatively little utilization was based upon clinician referral, with the great majority of patients accessing care out of plan (with no insurance coverage), through self-referral, or both. Chiropractic care may be commonly used for chronic pain by patients, but at KPNW, medical necessity criteria limit clinician referrals for chiropractic care to acute pain. In addition, Washington patients all have a self-referral insurance rider for chiropractic care, but not for acupuncture, making it easier for Washington members to access chiropractic services by self-referral. At the same time, patients seeking chiropractic care may be dissuaded from using HMO benefits when the fee per visit for obtaining chiropractic care out of plan is only marginally higher than their HMO co-pay.

For chiropractic services, there is a tendency for “out-of-plan only” users to be older, to use long-term opioids, and to have more pain diagnoses. For acupuncture, there is a tendency for those using the clinician referral mechanism to exhibit these same characteristics. This is consistent with the acupuncture referral guidelines, which allow for care only in the setting of chronic, as opposed to acute, pain. Chiropractic benefits for self-referral are limited in the dollar amount allowed, and for clinician referral, are constrained by referral guidelines allowing use only for acute pain. Those who desire ongoing maintenance treatments will go out of plan due to necessity.

The substantial percentage of participants indicating out-of-plan use suggests that many chronic pain patients are determined to use acupuncture and chiropractic care, regardless of their insurance coverage. In this context, and in the face of the high prevalence of acupuncture and chiropractic use, policy makers may need to consider better ways of covering and integrating acupuncture and chiropractic care into conventional delivery systems.15,16 Many chronic pain patients may consider acupuncture and chiropractic coverage important when selecting a health insurance plan. In addition, better acupuncture and chiropractic integration could offer potential opportunities for improved management algorithms and more efficient utilization of resources.17,18 The potential for these 2 types of care to serve as noninvasive alternatives to pharmacologic and procedural interventions, or as tools to facilitate the reduction of chronic pharmacotherapy, would seem to warrant further investigation.19,20

Strengths and Limitations

The study’s strengths include a large sample size, as well as the availability of a comprehensive EMR system. Multiple pathways to acupuncture and chiropractic care exist within the HMO, which we were able to electronically track and compare. In addition, we were able to supplement EMR data with survey data to gain a more complete picture of overall acupuncture and chiropractic utilization. Limitations include a relatively low survey response rate. We did not attempt to contact nonresponders to determine possible reasons for this. Furthermore, survey responders may not accurately represent the broader group of patients who suffer from chronic pain. Comparing survey responders who self-reported chronic pain with nonresponders, using EMR demographic and diagnostic data (6 comparisons), we found that responders were more likely to be female or Caucasian and were less likely to smoke, and more likely to have had an acupuncture referral (P for all <.01). It is likewise unclear to what extent any findings or conclusions may be applicable to other healthcare venues beyond an HMO setting, or beyond KPNW.


In our analyses, a majority of HMO participants with chronic musculoskeletal pain have used acupuncture, chiropractic care, or both. While benefit structure may materially influence utilization patterns, many patients with chronic musculoskeletal pain use acupuncture and chiropractic care without regard to their insurance coverage. A substantial percentage of acupuncture and chiropractic use thus occurs beyond detection of EMR systems, and many patients do not report their acupuncture and chiropractic utilization to their HMO clinicians.

Author Affiliations: Kaiser Permanente Center for Health Research (CE, LD, WV, JD, LK), Portland, OR; University of Arizona (CR), Tucson, AZ; Oregon Health and Science University (RAD), Portland, OR.

Source of Funding: The project was supported by a grant (R01 AT005896) from the National Center for Complementary and Integrative Health, National Institutes of Health.

Author Disclosures: Dr Deyo has received federally funded grants and has grants pending from PCORI and NIH. Drs Elder, Kindler, Vollmer, DeBar, and Ritenbaugh and Mr Dickerson report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (CE, LD, CR, WV, LK, RAD); acquisition of data (CE, LD, JD); analysis and interpretation of data (CE, LD, CR, WV, JD, RAD); drafting of the manuscript (CE, LD, CR, RAD); critical revision of the manuscript for important intellectual content (CE, LD, CR, WV, RAD); statistical analysis (CE, WV, JD); provision of patients or study materials (LK); obtaining funding (LD, CR, WV); administrative, technical, or logistic support (LK).

Address correspondence to: Charles Elder, MD, Kaiser Permanente Northwest, Center for Health Research, 3800 N Interstate Ave, Portland, OR 97227. E-mail:


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